An Intervention to Increase Engagement With Hypertension Care for American Indian Patients
Condition: Hypertension
MeSH terms: Hypertension
Study type: Interventional

Summary: 
      The objective of this study is to reduce the effects of stereotype threat on the adherence of
      American Indian/Alaska Native patients with hypertension.

      The specific aims of this study, which employs a values affirmation intervention, are to:

        1. Compare the effects of the values-affirmation exercise with a control exercise in AI/AN
           patients with hypertension.

        2. Compare the effects of the values-affirmation exercise in AI/AN patients with its
           effects in white patients.
    

Detailed description: 
      American Indians and Alaska Natives (AI/ANs) in the U.S. bear a disproportionate burden of
      cardiovascular disease. They have a higher prevalence of conditions that predispose to
      cardiovascular disease and poorer outcomes after developing cardiovascular disease than white
      Americans. The causes of these differences are complex and multiple, but there are widespread
      concerns that racial bias contributes to the problem. As concluded over a decade ago in the
      2003 Institute of Medicine report, Unequal Treatment, "Racial/ethnic disparities in health
      care occur in the context of broader historic and contemporary social and economic inequality
      and evidence of persistent racial and ethnic discrimination… Bias, stereotyping and prejudice
      on the part of healthcare providers may contribute to racial and ethnic disparities in health
      care." These concerns persist. Minority group members are well aware of negative stereotypes
      targeted at them as a group and of the possibility of bias directed at them as individuals.
      Given the reality of prejudice and their previous experiences with it, it is understandable
      that minority group members would be apprehensive about the possibility of being judged in
      light of the stereotype, both outside and inside the healthcare system. Critically, this
      apprehension may occur in the absence of actual bias. This raises the possibility that
      interventions directed at patients' perception of discrimination may have an independent and
      additive effect beyond the effects of interventions directed at provider bias.

      Investigators propose to evaluate a novel intervention that reduces the detrimental effects
      of negative stereotypes on minority patients by reducing stereotype threat through values-
      affirmation. Stereotype threat is a stressful psychological state that occurs when a person
      fears being judged in light of negative stereotypes. The stress of this situation and the
      pressure to avoid confirming negative stereotypes can result in impaired performance and
      worse outcomes - something of a self-fulfilling prophecy. For example, an American Indian
      patient fearful of confirming the stereotype of being unintelligent may fail to ask for
      clarification of changes in antihypertensive medications and, based on misconceptions,
      persist in taking an old regimen that is ineffective. Values-affirmation is a process in
      which global sense of personal worth is strengthened in the face of a threat, making
      individuals better able to cope with psychological threats.

      The intervention proposed in this application is based on one found to be effective in
      alleviating stereotype threat in other contexts such as education and in alleviating more
      general threats to the self in a health context as well as in a prior study investigators
      performed with African American patients. Investigators will randomly assign AI/AN patients
      with hypertension to complete an affirmation exercise or a control exercise prior to a visit
      with their providers. The affirmation exercise is performed immediately before a clinic
      visit. It asks patients to reflect on values or self-defining skills that they find
      important, and to write a few sentences about why one of them is important. The project is
      innovative in that it is directed against a mechanism, stereotype threat, not generally
      recognized as important in healthcare settings. Since the intervention is brief and easily
      applied across a wide range of health conditions, it directly addresses the need for
      interventions to be generalizable and sustainable.
    

Intervention name(s): Intervention Values Affirmation; Control Values Affirmation
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Participants are asked to circle the two or three values that are MOST important to them. Next, participants are asked to think about times when the values chosen might be important to THEMSELVES and then write a few sentences to describe when and why they might be important.; Participants are asked to circle the two or three items that are LEAST important to them. Next, participants are asked to think about times when the values chosen might be important to SOMEONE ELSE and then write a few sentences to describe when and why they might be important.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Investigator)
Primary purpose: Health Services Research
Keywords: Hypertension; Medication Adherence; Values Affirmation; American Indian/Alaska Native