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

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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.

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