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

背景：为了响应VA HSR&D医疗保健公平和健康差异主要优先领域，我们 建议继续对话，一项RCT测试使用叙事沟通来支持和维持 高血压（HTN）自我管理在非洲裔美国退伍军人。与其他种族和民族相比， 非西班牙裔非洲裔美国人的HTN发病较早，患病率较高， 并发症风险较高，导致心血管发病率和死亡率较高。在以前的工作中，我们使用 在弗吉尼亚州以外的非洲裔美国人中讲故事，血压得到显著改善。我们翻译 这些发现的VA，开发和测试视频记录退伍军人的叙述，我们显示给非洲- 美国退伍军人我们证明了改变HTN管理行为的意图存在显着差异 观看视频后立即;然而，对血压的影响并不持久，6个月的结果 仅显示出相对于对照的适度益处（p = 0.06）。我们的研究结果强调了纵向支持的必要性， 讲故事的效果。我们提出的研究通过短信提供纵向支持， 参与者选择的同伴叙述作为维持HTN自我管理动机和参与的手段。 创新性：尽管在医学文献中短信研究激增，但很少有严谨的研究。 随机试验非裔美国人在技术辅助干预和使用 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 一种新颖的将同伴叙事交流融入技术的方法。虽然使用信息学工具（发短信）作为 支持自我管理的渠道本身并不新颖，通过纵向短信扩展叙述是一种 支持和维持HTN自我管理行为的创新机制。我们的具体目标包括： 目标1.完善和试点继续对话（CTC）干预。此前，我们制作了视频记录 由非裔美国退伍军人与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完善CTC： 改编这些视频的内容，以创建叙事一致的文本，我们将试点CTC。 目标二。通过进行随机对照试验来测试CTC。CTC通过展示退伍军人的故事“开始对话” 视频给参与者，然后邀请参与者选择一个首选的叙述。然后我们“继续谈话”， 通过6个月的叙事性短信提供纵向支持。消息涵盖关键HTN内容， 提供教育、提醒和每周评估，并包括从所选叙述中得出的引文。 对照组参与者每周接受评估文本，解决相同的关键HTN自我管理行为。 目标3。评估CTC的有效性和中介因素，并进行成本分析。我们假设，对于CTC来说， 干预组与对照组相比：（H1）从基线到6个月的血压差异（主要 结果）将有利于CTC干预相比，控制的变化。(H2)自我效能和HTN管理 在6个月的随访期间，CTC干预组的行为将高于对照组。 方法：在一项随机对照试验中，将招募600名患有控制不良HTN的非洲裔美国退伍军人 来自2个已知HTN控制不一致的VA医疗中心。我们将使用研究中心内随机化（CTC与 对照）。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，提醒和加强我们的退伍军人参与 影响他们的血压和生活的许多日常决定。将对等内容转换为文本 这种方式的信息是高度创新的，并提供了一个有前途的方法来支持我们的退伍军人。 下一步：在试验期间和试验结束后，我们将向我们的运营合作伙伴办公室提供材料， 护理（OCC），用于向国家领导理事会（包括VISN董事）进行演示，并探索其他途径 用于传播。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招募请求的机制。

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.