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

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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.