Hypertension is a common, chronic condition that contributes substantially to cardiovascular morbidity and mortality and resource use. Despite the proven efficacy of pharmacologic therapy and lifestyle modification for treatment of hypertension and prevention of its complications, most adults with established hypertension are uncontrolled. Limited access to medical care and financial barriers to obtaining medications play am important role; however, even among patients who receive regular care, blood pressure control remains suboptimal. Patient non-adherance to recommended therapies and problems in physician management of patients with hypertension are critical contributors to poor quality of care and negative health outcomes of hypertension. Of particular concern is the disproportionately high prevalence and incidence of hypertension and its complications among African Americans and socioeconomically disadvantaged persons. Ethnic and social class disparities in patient adherence are frequently based on financial, logistical, environmental, and cultural barriers that, while not unique to ethnic minorities and the poor, have a greater impact on these populations. We have designed patient and physician interventions that will address the specific needs of inner city ethnic minorities and persons living in poverty. The proposed study uses a patient-centered, culturally tailored, education and activation intervention with active follow-up delivered by a community health worker in the clinic. It also includes a computerized, self-study communication skills training program delivered via an interactive CD-ROM, with tailored feedback to address physicians' individual communication skills needs. Fifty physicians and 500 of their patients who have uncontrolled hypertension will be recruited into a randomized controlled trial with a 2X2 factorial design. We will compare the relative effectiveness the minimal interventions. The main hypothesis is that patients in the intervention groups will have better adherence to medication and lifestyle recommendations at 3 months and 12 months than patients in the minimal intervention. We will also assess other process and outcome measures (patient and physician ratings of quality of care, physicians' participatory decision-making (PDM) style, and satisfaction; the impact of training on patient-physician communication behaviors; and blood pressure control). This study will add to knowledge about the efficacy of culturally appropriate patient activation interventions and tailored physician communication training skills programs for improving adherence to hypertension therapy among inner city minorities and persons living in poverty.
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