An Intervention to Reduce the Effect of Racial/Ethnic Bias on Hypertension Care

描述(申请人提供)：在美国，少数族裔成员易患心血管疾病的患病率更高，心血管疾病的发病率更高，患心血管疾病后的预后更差。造成这些差异的原因是复杂和多方面的，但现在人们普遍认为，偏见是原因之一。在这项申请中提出的研究服务于广泛的长期目标，即建立一种实用和可复制的手段，以减少偏见对临床遭遇的影响。具体地说，该项目将开发和评估一种干预措施，通过自我肯定来减少刻板印象威胁，从而减少偏见的影响。陈规定型威胁是这样一种概念，即少数群体成员担心受到与其所属群体相关的陈规定型观念的评判；这种担心造成的压力损害了工作表现。我们假设，在临床环境中，刻板印象威胁导致的压力导致患者和提供者更不能有效地沟通，这反过来又削弱了访问改善患者自我管理行为的效果。自我肯定是一个过程，在这个过程中，全球的个人价值感得到加强，使个人能够更好地容忍心理威胁。拟议的项目适应于临床环境，这是一种自我肯定的练习，可以改善课堂表现。这项研究的背景是一家独立的门诊诊所，它是安全网医院系统的一部分。在这项拟议的探索性研究中，200名高血压患者(100名非裔美国人和100名拉丁裔)将被随机分为实验和对照两组。实验对象将在预定的初级保健访问之前完成10-15分钟的练习，在其中他们写下一个简短的段落，说明对他们来说重要的价值；控制对象将被要求写下可能对其他人重要的价值。随后的访问将被录音，以便以后对互动的质量进行编码和分析。访问结束后，患者将回答一份问卷，评估与医生的沟通质量、服药依从性、压力水平、对医生的信任、药物自我效能和情绪。在下一次随访后，患者将接受相同问卷的电话调查(不包括情绪和压力评估问题)，并从电子病历中评估血压和用药及就诊依从性。该项目的主要结果衡量标准是少数高血压患者对降压药依从性的变化。主要的次要指标是干预对患者血压的影响。我们将使用压力、信任、效能和情绪的测量来探索干预的机制效应。其他措施将允许评估在常规临床实践中实施干预的可行性。我们预计，从拟议项目中获得的数据将为设计一项更大规模的研究提供参考，其目的是明确证明干预的有效性。公共卫生相关性：与非少数族裔患者相比，高血压对少数族裔患者健康状况不佳的影响更大。该项目的目标是通过改善少数民族患者与其医疗保健提供者的沟通，改善他们对高血压的治疗。

DESCRIPTION (provided by applicant): Members of racial and ethnic minorities in the U.S. have a higher prevalence of conditions that predispose to cardiovascular disease, a higher incidence of cardiovascular disease, and poorer outcomes after developing cardiovascular disease. The causes of these differences are complex and multiple, but it is now widely accepted that bias is one of the causes. The research proposed in this application serves the broad, long-term objective of establishing a practical and replicable means to reduce the impact of bias on clinical encounters. Specifically, the project will develop and evaluate an intervention that reduces the impact of bias by reducing stereotype threat through self-affirmation. Stereotype threat is the concept that members of minority groups are apprehensive of being judged according to the stereotypes associated with the group of which they are members; the stress induced by this apprehension impairs performance. We hypothesize that in clinical settings, the stress induced by stereotype threat renders patients and providers less able to communicate effectively which in turn impairs the effect of the visit to improve patient self-management behavior. Self-affirmation is a process in which global sense of personal worth is strengthened, making individuals better able to tolerate psychological threats. The proposed project adapts for a clinical setting a self-affirmation exercise that improved classroom performance. The setting for the study is a free-standing outpatient clinic that is part of a safety net hospital system. In the proposed exploratory study, 200 patients with hypertension (100 African American and 100 Latino) will be randomized to either experimental or control conditions. Experimental subjects will complete immediately prior to a scheduled primary care visit a 10-15 minute exercise in which they write a brief paragraph about a value important to them; control subjects will be asked to write about a value that might be important to others. The subsequent visit will be audio-taped for later coding and analysis of the quality of the interaction. Following the visit, patients will respond to a questionnaire assessing the quality of communication with their physician, medication adherence, stress level, trust in their physician, medication self-efficacy, and mood. After their next follow-up visit, patients will be surveyed by telephone with the same questionnaire (without the mood and stress evaluation questions), and have blood pressure and medication and visit adherence assessed from the electronic medical record. The primary outcome measure for the project is the change in minority hypertensive patients' adherence with antihypertensive medication. The main secondary measure is the effect of the intervention on patients' blood pressure. We will use the measures of stress, trust, efficacy, and mood to explore the mechanistic effects of the intervention. Additional measures will allow assessment of the feasibility of implementing the intervention in routine clinical practice. We anticipate that the data obtained from the proposed project will inform the design of a larger study whose purpose is definitive demonstration of the intervention's effectiveness. PUBLIC HEALTH RELEVANCE: High blood pressure contributes more to poor health in minority patients than in non-minority patients. The goal of this project is to improve the treatment of high blood pressure for minority patients by improving their communication with their health care providers.