Continuing the Conversation: A Multi-site RCT Using Narrative Communication to Support Hypertension Self-Management among African-American Veterans

背景：为了回应退伍军人事务部HSR&D医疗公平和健康差距主要优先领域，我们 建议继续对话，这是一种使用叙述性沟通来支持和维持的RCT测试 非裔美国退伍军人的高血压(HTN)自我管理。与其他种族和民族相比， 非西班牙裔非裔美国人HTN发病更早，患病率更高，而且不成比例 更高的并发症风险，导致更高的心血管发病率和死亡率。在之前的工作中，我们使用了 在退伍军人事务部以外的非裔美国人中讲故事，显著改善了血压。我们翻译了 这些发现交给退伍军人管理局，开发和测试视频记录的老兵叙事，我们向非洲人展示- 美国退伍军人。我们在改变HTN管理行为的意图上表现出显著的差异 然而，在观看视频后立即对血压的影响并不持续，六个月的结果 与对照组相比仅显示出轻微的好处(p=0.06)。我们的发现强调了需要纵向支持来维持 讲故事的效果。我们建议的研究通过短信提供纵向支持，整合了来自 参与者选择同伴叙事作为维持HTN自我管理的动力和参与度的一种手段。 创新性：尽管医学文献中的短信研究层出不穷，但很少有人能做到严谨 随机试验。在技术辅助干预和试验中，非裔美国人的代表性一直不足 在退伍军人中进行HTN自我管理的短信尚未进行。我们的建议，“继续对话，”是 一种将同行叙事交流与技术相结合的新颖方式。同时使用信息学工具(短信)作为 支持自我管理的渠道本身并不新鲜，通过纵向短信对叙事的延伸是一种 创新机制，支持和维持HTN的自我管理行为。我们的具体目标包括： 目的1.完善并试行持续对话(CTC)干预。在此之前，我们创建了录像 非裔美国退伍军人在HTN讲述的故事，描述他们的自我管理策略。我们将通过以下方式提炼CTC 改编这些视频的内容以创建与叙事一致的文本，我们将试行CTC。 目的2.通过随机对照试验检测CTC。CTC通过展示老兵故事来开始对话 视频给参与者，然后邀请参与者选择一种首选的叙事。然后我们“继续对话”。 通过6个月的与叙事一致的文本消息提供纵向支持。消息涵盖关键的HTN内容， 提供教育、提醒和每周评估，并包括从选定的叙述中引述的语录。 控制参与者每周都会收到针对相同关键HTN自我管理行为的评估文本。 目的3.评价CTC的有效性和中介因素，并进行成本分析。我们假设，对于反恐委员会来说 干预组与对照组比较：(H1)血压从基线到6个月的差值(主要 结果)与对照的改变相比，CTC干预更倾向于CTC干预。(H2)：自我效能感与HTN管理 在6个月的随访中，CTC干预组的行为将比对照组更多。 方法：在一项随机对照试验中，将招募600名HTN控制不良的非裔美国退伍军人 来自2个在HTN控制方面存在已知差异的退伍军人事务部医疗保健站点。我们将使用站内随机化(CTC与 控制)。结果将包括血压、自我效能和HTN管理行为。纵向文本是 旨在将讲故事的人带回退伍军人的日常生活中，提醒并加强我们退伍军人的参与 将会影响他们的血压和他们的生活的无数日常决定。将对等内容合并到文本中 这种方式的信息具有很高的创新性，为支持我们的退伍军人提供了一种很有前途的方法。 下一步：在这次试验期间和之后，我们将向我们的运营合作伙伴互联办公室提供材料 CARE(OCC)，用于向国家领导委员会(包括VISN主任)进行演示，并探索其他途径 以供传播。我们将与OCC合作创建基于电子健康记录的转诊工具，以鼓励临床 团队招募患者，并将探索退伍军人可以发起登记请求的机制。

Background: In response to the VA HSR&D Healthcare Equity and Health Disparities major priority domain, we propose Continuing the Conversation, an RCT testing use of narrative communication to support and sustain hypertension (HTN) self-management among African-American Veterans. Compared to other racial and ethnic groups, non-Hispanic African Americans have an earlier onset and higher prevalence of HTN as well as a disproportionately higher risk of complications, leading to higher rates of cardiovascular morbidity and mortality. In previous work, we used storytelling in African Americans outside the VA, yielding significant improvements in blood pressure. We translated these findings to the VA, developing and testing video-recorded Veteran narratives which we showed to African- American Veterans. We demonstrated significant differences in intention to change HTN management behavior immediately after video viewing; however, effects on blood pressure were not sustained, and six-month outcomes revealed only modest benefit over control (p = 0.06). Our findings highlight the need for longitudinal support to sustain the storytelling effect. Our proposed study provides longitudinal support via text messages, incorporating content from the participant’s chosen peer narrative as a means of sustaining motivation and engagement in HTN self-management. Innovativeness: Despite the proliferation of texting studies in the medical literature, very few have been rigorous randomized trials. African-Americans have been under-represented in technology-assisted interventions, and trials using texting for HTN self-management in Veterans have not been conducted. Our proposal, “Continuing the Conversation,” is a novel integration of peer narrative communication into technology. While use of an informatics tools (texting) as a channel to support self-management is not novel per se, the extension of a narrative via longitudinal texting is an innovative mechanism for supporting and sustaining HTN self-management behaviors. Our Specific aims include: Aim 1. Refine and Pilot the Continuing the Conversation (CTC) intervention. Previously, we created video-recorded stories told by African-American Veterans with HTN, describing their self-management strategies. We will refine CTC by adapting content from these videos to create narrative-aligned texts and we will pilot CTC. Aim 2. Test CTC by conducting a randomized controlled trial. CTC ‘begins the conversation’ by showing Veteran Story videos to participants, then inviting participants to select a preferred narrative. We then ‘continue the conversation,’ offering longitudinal support via 6 months of narrative-aligned text messages. Messages cover key HTN content, providing education, reminders and weekly assessments, and include quotations derived from the chosen narrative. Control participants receive weekly assessment texts addressing the same key HTN self-management behaviors. Aim 3. Evaluate CTC effectiveness, and mediating factors, and conduct a cost analysis. We hypothesize that, for the CTC Intervention group as compared to the control: (H1)the difference in blood pressure from baseline to 6 months (primary outcome) will favor CTC intervention compared with the change in control. (H2): Self-efficacy and HTN management behaviors during 6-month follow-up will be greater for those in the CTC intervention group than control. Methods: In a randomized controlled trial, 600 African-American Veterans with poorly controlled HTN will be recruited from 2 VA healthcare sites with known disparities in HTN control. We will use within-site randomization (CTC vs. Control). Outcomes will include blood pressure, self-efficacy and HTN management behaviors. Longitudinal texts are designed to bring the storyteller back into the Veteran’s everyday life, reminding and reinforcing as our Veterans engage in the numerous daily decisions that will impact their blood pressure and their lives. Incorporating peer content into text messages in this way is highly innovative and offers a promising approach to supporting our Veterans. Next Steps: During and following this trial, we will provide materials to our operational partner, the Office of Connected Care (OCC), for presentations to National Leadership Council including to VISN Directors and also explore other avenues for dissemination. We will work with OCC to create an Electronic Health Record-based referral tool to encourage clinical teams to enroll patients and will explore mechanisms by which Veterans can initiate the request for enrollment.