Faculty Bibliography

BACKGROUND: Hypertension disproportionately affects African Americans compared to whites, and it is the single most common explanation for the disparity in mortality between African Americans and whites. Adherence with antihypertensive medications can help reduce risk of negative hypertension-related outcomes. Motivational interviewing is a promising patient-centered approach for improving adherence in patients with chronic diseases. In this paper we describe the rationale and design of an ongoing randomized controlled trial testing the effectiveness of motivational interviewing versus usual care in improving medication adherence among 190 African American uncontrolled hypertensive patients, who receive care in a primary care setting. METHODS: The usual care group receives standard medical care, while those in the intervention group receive standard care plus four sessions of motivational interviewing at 3-month intervals for a period of 1 year. This technique consists of brief, patient-driven counseling sessions to facilitate initiation and maintenance of behavior change. The primary outcome is adherence to prescribed antihypertensive medication, assessed with the electronic medication events monitoring system (MEMS) and the Morisky self-report adherence questionnaire. Secondary outcomes are within-patient changes in blood pressure, self-efficacy, and intrinsic motivation between baseline and 12 months. We report the baseline sociodemographic and clinical characteristics of the participants. CONCLUSIONS: Despite the potential utility of motivational interviewing, little is known about its effectiveness in improving medication adherence among hypertensive patients, especially African Americans. In addition to the baseline data this study has generated, this trial should provide data with which we can assess the effectiveness of this approach as a behavioral intervention

OBJECTIVE: The objective was to elicit patients' perceptions regarding the meaning of hypertension and to identify the personal, social, and environmental factors that might influence their perceptions. DESIGN: Qualitative study. SETTING: Adult ambulatory care practice PARTICIPANTS: African American patients with uncontrolled hypertension. INTERVENTION/METHODS: In-depth structured interviews were conducted with a purposive sample of 60 patients. Interviews were audiotaped, transcribed verbatim, and analyzed by using grounded theory. RESULTS: Patient descriptions of hypertension were grouped into three categories: 1) their thoughts on hypertension; 2) the consequences of hypertension; and 3) the impact that having hypertension had on their lifestyle. Factors that might have shaped how patients described hypertension were grouped into three categories: 1) the experiences of their social networks such as family and friends; 2) their personal experiences; and 3) information about hypertension that they might have gathered from the medical literature or during an encounter with a healthcare provider. Patients with family members who had experienced hypertension-related complications such as stroke were more likely to view hypertension as a serious condition. Patients who themselves experienced hypertension-related symptoms and who also had family members with a history of hypertensive disease were more likely to describe a willingness to make lifestyle changes. CONCLUSIONS: In this study, personal experiences, experiences of family and friends, and encounters with the healthcare environment influenced patients' perceptions of hypertension and their willingness to make lifestyle changes. These findings can be used as a framework for helping to tailor effective and culture-specific interventions

BACKGROUND: Ambulatory blood pressure is a better predictor of target organ damage and the risk of adverse cardiovascular events than office measurements. Whether this is due to the greater reliability owing to the larger number of measurements that are usually taken using ambulatory monitoring, or the greater validity of these measurements independent of the number, remains controversial. METHODS: We addressed this issue by comparing physician readings and ambulatory measurements as predictors of left ventricular mass index. The number of readings was controlled by using the average of three physician readings and randomly selecting three awake readings from a 24-h ambulatory recording. RESULTS: In a multiple regression analysis that included both the ambulatory and physician blood pressure measurements, only the ambulatory systolic measurements significantly predicted left ventricular mass index (B=0.37, t=3.11, P=0.002); the coefficient for physician's systolic measurements was essentially zero (B=-0.01, t=-0.26, NS). CONCLUSIONS: These findings suggest that the superiority of ambulatory blood pressure as a predictor of target organ damage, compared with physician measurements, cannot be adequately/fully explained by the impact of the larger number of measurements obtained with ambulatory monitoring

Home blood pressure monitoring (HBPM) improves blood pressure control, but little is known about its effects on medication adherence. The authors conducted a systematic review of the published literature on the effects of HBPM on medication adherence. Of 440 abstracts and citations reviewed, 11 randomized control trials met predefined criteria. Six of the 11 randomized controlled trials reported statistically significant improvement in medication adherence; 84% of these were complex interventions involving the use of HBPM in combination with other adherence-enhancing strategies such as patient counseling by nurses, pharmacists, or a telephone-linked system; patient education; and the use of timed medication reminders. Interventions conducted in primary care settings were not effective compared with those that occurred in hospital-based clinics or nonclinical settings. The data on the effects of HBPM on patients' medication-taking behavior are mixed. Future studies should investigate the independent effects of HBPM in primary care practices where the majority of hypertensive patients receive their care

BACKGROUND: A limitation of blood pressure measurements made in the physician's office is the transient elevation in pressure seen in many patients that does not appear to be linked to target organ damage or prognosis. This has been labeled the 'white-coat effect' (WCE), computed as the difference between blood pressure measurements taken by the physician and the ambulatory level or resting measures. It is unclear, however, which resting measure is most appropriate. The awake ambulatory blood pressure is the most widely used. However, while arguably the most useful measure for prediction of clinical outcomes, it is less appropriate for use as a resting measure, because it is influenced by many factors, including posture and physical activity level. Resting levels taken in the clinic may also be elevated, and will therefore underestimate the WCE. METHODS: We addressed this question by taking resting measures in a non-medical setting on the day before patients were seen at a Hypertension Clinic (day 1), and comparing these with resting measures taken on the following day, in the clinic before the patient saw the physician. RESULTS: As predicted, the day 1 resting levels were lower than those taken in the clinic prior to seeing the physician (P < 0.05 and P < 0.001 for systolic and diastolic pressures, respectively) in both normotensive and hypertensive patients. Using the day 1 resting levels, the estimated WCE for hypertensive patients was 5.3/6.9 mmHg (systolic/diastolic blood pressures), compared with estimates, using the clinic resting levels, of 0.3/0.5 mmHg. The pattern of changes was different in normotensive patients and hypertensive patients, with the physician pressures being slightly lower than day 1 pressures in the former, and substantially higher in the latter. Heart rate changes were similar and modest in both groups. CONCLUSION: The WCE may not just be limited to that narrow interval in which the patient actually sees the physician, but may generalize to the clinic setting, rendering a clinic 'resting' level invalid. While it is strongly positive in most hypertensive patients, it is frequently negative in normotensive patients. Our results suggest that improved methods of measuring blood pressure in the clinic setting are unlikely to resolve the confounding influence of the WCE, and that greater reliance will need to be placed on out-of-office monitoring

A. Bellg, B. Borrelli, et al. (2004) previously developed a framework that consisted of strategies to enhance treatment fidelity of health behavior interventions. The present study used this framework to (a) develop a measure of treatment fidelity and (b) use the measure to evaluate treatment fidelity in articles published in 5 journals over 10 years. Three hundred forty-two articles met inclusion criteria; 22% reported strategies to maintain provider skills, 27% reported checking adherence to protocol, 35% reported using a treatment manual, 54% reported using none of these strategies, and 12% reported using all 3 strategies. The mean proportion adherence to treatment fidelity strategies was .55; 15.5% of articles achieved greater than or equal to .80. This tool may be useful for researchers, grant reviewers, and editors planning and evaluating trials

Treatment fidelity plays an important role in the research team's ability to ensure that a treatment has been implemented as intended and that the treatment has been accurately tested. Developing, implementing, and evaluating a treatment fidelity plan can be challenging. The treatment fidelity workgroup within the Behavior Change Consortium (BCC) developed guidelines to comprehensively evaluate treatment fidelity in behavior change research. The guidelines include evaluation of treatment fidelity with regard to study design, training of interventionists, delivery and receipt of the intervention, and enactment of the intervention in real-life settings. This article describes these guidelines and provides examples from four BCC studies as to how these recommended guidelines for fidelity were considered. Future work needs to focus not only on implementing treatment fidelity plans but also on quantifying the evaluations performed, developing specific criteria for interpretation of the findings, and establishing best practices of treatment fidelity

African-American and Hispanic women receive fewer indicated cancer early detection services than do majority women. Low rates of cancer screening may, in part, explain the disproportionately higher rates of cancer deaths in this population. The aim of this qualitative study was to explore through individual interviews the perceptions of barriers and facilitators of colorectal, cervical and breast cancer screening among 187 low-income, primarily minority women in four New-York-City-based community/migrant health centers. We identified various barriers and facilitators within each of these categories. Clinician recommendation was the most commonly cited encouragement to cancer screening. Other facilitators of cancer screening identified by patients included personal medical history, such as the presence of a symptom. The perception of screening as routine was cited as a facilitator far more commonly for mammography and Pap tests than for either of the colorectal screenings. Less commonly cited facilitators were insurance coverage and information from the media. The most common barriers were a lack of cancer screening knowledge, patients' perception of good health or absence of symptoms attributable to ill health, fear of pain from the cancer test and a lack of a clinician recommendation. Using standard qualitative techniques, patients' responses were analyzed and grouped into a taxonomy of three major categories reflecting: (1) patients' attitudes and beliefs, (2) their social network experience and (3) accessibility of services. This taxonomy may serve as a useful framework for primary care providers to educate and counsel their patients about cancer screening behaviors