Using values affirmation to reduce the effects of perceived discrimination on hypertension disparities

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PROJECT SUMMARY / ABSTRACT Over 80% of African Americans report experiences of discrimination in the past year; perceived discrimination is linked to health disparities including poor adherence. Poor adherence may contribute to the high prevalence of uncontrolled hypertension in African Americans. We propose an innovative approach using values affirmation to overcome the threat of discrimination to increase patient activation, improve adherence and thereby reduce disparities in hypertension outcomes. Our proposal is based upon our pilot study demonstrating a brief values affirmation exercise done immediately before a clinic visit resulted in improved communication between African American patients and providers during the visit and suggested improved medication adherence 6-months after the visit. We propose to advance our prior work and fill gaps in the evidence by conducting a randomized controlled trial comparing a values affirmation exercise to a control exercise among 1100 patients with hypertension from three health systems. The primary outcome is 6-month change in adherence to antihypertensive therapies with the secondary outcome of change in blood pressure. We will also explore possible mechanisms of the intervention effect and formally evaluate for dissemination.  In aim 1, we will compare the effects of the values affirmation exercise to a control exercise on antihypertensive medication adherence in African American patients across three clinical settings. We hypothesize patients randomized to values affirmation will have greater adherence change at 6-months compared to controls and the effect will be partially moderated by patient factors (prior experiences of discrimination), independent of provider factors (implicit racial bias, past disparities training, self- efficacy caring for minority patients) and mediated by patient activation.  In aim 2, we will compare the effects of values affirmation exercise in African American patients to its effects in white patients with hypertension. We hypothesize that values affirmation will improve adherence to a greater degree in African American patients suggesting the intervention is targeting perceived discrimination related to race.  In aim 3, we will formally evaluate the intervention for widespread dissemination using the RE-AIM (reach, effectiveness, adoption, implementation and maintenance) framework. We hypothesize the intervention will have favorable characteristics for widespread dissemination within primary care. The project is innovative, as it will use a novel intervention that has not been widely applied in the healthcare setting. Since values affirmation is not specific to hypertension or African Americans, this study will be the first to provide evidence for a low-resource intervention that has the potential to reduce healthcare disparities across a wide range of health care conditions and populations.