Multi-ethnic Multi-level Strategies and Behavioral Economics to Eliminate Hypertension Disparities in LA County.

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Project Summary/Abstract Eliminating racial/ethnic cardiovascular health disparities in the U.S. cannot be achieved without addressing disparities in evidence-based treatment of hypertension. In Los Angeles County (LAC), there are approximately, 801,000 Latino, 266,000 Asian, and 244,000 African American adults with hypertension, and more than half of these individuals have household income below 200% of the federal poverty level. In the LAC Department of Health Services (DHS), the second largest municipal health system in the US, patient, clinician, healthy system, and community factors contribute to substantial disparities in hypertension prevalence, control, and outcomes by race/ethnicity. Racial/ethnic gaps that contribute to hypertension disparities in LAC DHS relate to differences in healthy eating, physical activity, obesity, antihypertensive pharmacotherapy use, medication adherence, community awareness of hypertension, and community-level physical and social resources. These gaps are widely recognized in LAC DHS as barriers to addressing hypertension-related racial/ethnic health disparities, yet differences in healthy lifestyle practices and treatment persist. We propose to significantly reduce disparities in in LAC DHS by leveraging our team's expertise in multi-ethnic, multi-level evidence-based strategies, community/stakeholder engagement, public-private partnerships, implementation science, and behavioral economics. Our proposal is sensitive to LAC DHS' mission of providing high quality, cost-effective care, which we address with an ancillary focus on reducing the high cost of hypertension-related heart and kidney disease. Using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, we propose a multi-level intervention for hypertension control that will complete EPIS Exploration/Preparation stages in the UG3 phase and the Implementation/Sustainment stages in the UG4 phase. In partnership with all 51 adult primary care clinics in LAC DHS, our aims are: Aim 1 (UG3): Assess multi-level (patient, clinician, health system leadership, and community) barriers to, facilitators of, and preferences for a menu of culturally- tailored evidence-based practices (EBPs) and implementation strategies with established efficacy for hypertension control. Aim 2 (UG3): Select and systematically apply behavioral economics to the design of our patient-, clinician-, and community-directed implementation strategies to maximize acceptability, uptake, and effectiveness. Aim 3 (UG4): Test the effectiveness of our implementation strategies in a stepped-wedge cluster randomized trial design using RE-AIM to guide assessment of uncontrolled hypertension, disparities in comparison to non-minority LAC populations, and evidence-based practices.