Blood Pressure Lowering Strategies to Eliminate Hypertension Disparities (BLESSED)

Study Overview
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Brief Summary
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The burden of hypertension and related cardiovascular diseases, stroke, and end-stage kidney disease is disproportionately high in Black populations, especially in the South. The Blood Pressure Lowering Strategies to Eliminate Hypertension Disparities (BLESSED) cluster randomized trial aims to test the effectiveness, implementation, and sustainability of a community health worker (CHW)-led multifaceted intervention compared to enhanced usual care for hypertension control in Black communities. In the BLESSED trial, the investigators plan to recruit 1,176 Black adults with hypertension (approximately 28 per church) from 42 churches in the Greater New Orleans area. The multifaceted intervention will last for 18 months, followed by a post-intervention follow-up visit at 24 months. The BLESSED trial aims to generate evidence regarding the effectiveness, implementation, and sustainability of this CHW-led church-based multifaceted intervention in eliminating hypertension disparities in the United States (US) general population.

Detailed Description
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Louisiana residents, especially African Americans, bear a disproportionately high burden of hypertension and cardiovascular disease (CVD). In the Blood Pressure Lowering Strategies to Eliminate Hypertension Disparities (BLESSED) cluster randomized trial, the investigators will compare the impact of two implementation strategies - a CHW-led multifaceted strategy and a group-based education strategy - for delivering interventions recommended by the 2017 American College of Cardiology (ACC) and the American Heart Association (AHA) hypertension clinical guidelines on implementation and clinical effectiveness outcomes in Black community members over 18 months. The BLESSED study utilizes an effectiveness-implementation hybrid design to: (1). test the effectiveness of a CHW-led church-based multifaceted implementation strategy for reducing estimated CVD risk over 18 months among African Americans at high risk for CVD, and (2). assess the implementation outcomes (acceptability, adaptation, adoption, feasibility, fidelity, penetrance, cost-effectiveness, and sustainability) simultaneously. The Exploration, Preparation, Implementation, Sustainment (EPIS) framework has guided the development and evaluation of the multifaceted implementation strategy, which includes CHW-led health coaching on lifestyle changes and medication adherence; healthcare delivery in community; church-based exercise and weight loss programs; self-monitoring of blood pressure (BP); and provider education and engagement. The CHW-led church-based intervention will provide strong social support and tackle multiple social determinants of CVD disparities. The primary clinical effectiveness outcome is the difference in mean change of systolic blood pressure (SBP) from baseline to 18 months between intervention and control groups. The primary implementation outcome is a fidelity summary score for key implementation strategy components to the CHW-led church-based multifaceted implementation strategy assessed at the participant levels. This study has 90% statistical power to detect group differences in mean SBP change of 5.8 mm Hg over 18 months using a 2-sided significance level of 0.05. The investigators will recruit 1,176 African American participants (28 per church) who are aged ≥18 years with systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mm Hg, and randomly assign 21 churches to intervention and 21 to control; the investigators will implement the multifaceted intervention program; the investigators will follow-up participants and collect data on effectiveness and implementation outcomes at 6, 12, and 18 months; the investigators will evaluate the sustainability of the intervention at 6 months post-intervention; and the investigators will perform intention-to-treat analyses and disseminate and scale-up the proven-effective implementation strategy. The proposed study will generate evidence on the effectiveness, implementation, and sustainability of the multifaceted intervention aimed at eliminating CVD disparities in African American populations in the US.

Official Title
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Blood Pressure Lowering Strategies to Eliminate Hypertension Disparities

Conditions
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Hypertension

Intervention / Treatment
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* Behavioral: Behavioral: Evidence-based interventions recommended by the 2017 ACC/AHA hypertension clinical guideline


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Black or African American men or women aged ≥18 years Community members associated with the participating churches (church members and their families and friends) Systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mm Hg Willing and able to participate in the intervention. Willing and able to sign written informed consent. Exclusion Criteria: Prior hospitalization in the last 3 months for chronic heart failure or heart attack Current diagnosis of cancer requiring chemotherapy or radiation therapy Stage-5 chronic kidney disease requiring chronic dialysis or transplant Pregnant or planning to become pregnant in the next 18 months Planning to move out of the Greater New Orleans area during the next year

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Cluster randomization of 42 churches in New Orleans, Louisiana to 2 arms
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Community health worker-led implementation strategy<br>CHW-led church-based multifaceted implementation strategy: CHWs will conduct individualized health coaching and healthcare navigation, organize church-based health promotion programs (e.g., nutrition education and exercise sessions), and train and assist the study participants in self-monitoring of BP. Nurse practitioners will see study participants at church settings, and community pharmacies will deliver antihypertensive medications to patients' homes. | Behavioral: Behavioral: Evidence-based interventions recommended by the 2017 ACC/AHA hypertension clinical guideline<br>* The recommended evidence-based interventions include therapeutic lifestyle change and medical treatment of hypertension<br>|
| Experimental: Group-based Education Strategy<br>The investigator team will work with church leadership and wellness coordinators to organize group-based education sessions. Health education will be delivered by local primary care providers, dieticians, and health educators. Contact information for primary care providers and information on self-monitoring of BP will also be given at group sessions. | Behavioral: Behavioral: Evidence-based interventions recommended by the 2017 ACC/AHA hypertension clinical guideline<br>* The recommended evidence-based interventions include therapeutic lifestyle change and medical treatment of hypertension<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Difference in mean change of systolic blood pressure | Difference in mean change of systolic blood pressure from baseline to 18 months between intervention and control groups | Measured from baseline to 18 months | 
| Implementation fidelity summary score | The fidelity summary score is composed of the following key implementation strategy components: proportion of assigned health education sessions attended in all participants, proportion of assigned discussion sessions attended in all participants, proportion of recommended minutes of physical activity completed in all participants, proportion of days per week that fruits/vegetables are eaten as recommended in all participants, proportion of recommended home blood pressure (BP) monitoring completed in patients with hypertension, proportion of required provider visits attended in all patients, and proportion of antihypertensive medications taken in patients with hypertension. The score ranged from zero to six with a higher score indicates greater fidelity. | Measured at 6, 12, and 18 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Difference in the proportion of patients with controlled BP between intervention and control groups | Difference in the proportion of patients with controlled BP (<130/80 mm Hg) between intervention and control groups at 18 months | Measured from baseline to 18 months | 
| Difference in mean change of diastolic BP | Difference in mean change of diastolic BP (DBP) from baseline to 18 months between intervention and control groups | Measured from baseline to 18 months | 
| Side effects of medications and adverse events | Change in side effects of medications and adverse events from baseline to 18 months | Measured from baseline to 18 months | 
| Cost-effectiveness | Cost-effectiveness assessed as incremental direct costs per additional percentage of hypertension control | Measured from baseline to 18 months | 
| Acceptability | Percentage of participants, community health worker, providers, and church administrators who reply that the intervention is acceptable (satisfactory). Measured by survey. | Measured from baseline to 18 months | 
| Adoption (Churches) | % of churches adopting the intervention program | Measured from baseline to 18 months | 
| Adoption (Providers) | % of invited providers attending training sessions | Measured from baseline to 18 months | 
| Appropriateness | Percentage of participants, community health workers, providers, and church administrators who reply that the intervention is appropriate (good perceived fit). The outcome will be measured by survey question. | Measured from baseline to 18 months | 
| Feasibility to participant, community health worker, provider and churches | Percentage of participants, community health worker, providers, and church administrators who reply that the intervention is feasible (actual fit, suitability). Measured by survey and study administrative data. | Measured from baseline to 18 months | 
| Exercise Session Fidelity (community health worker-led strategy group) | Percentage of exercise sessions organized. Measured by study administrative data. | Measured at 6, 12, and 18 months | 
| Fidelity of Group Health Education Session | Percentage of group health education sessions conducted out of health educated sessions planned per study protocol. | Measured at 6, 12, and 18 months | 
| Nutrition Education Session Fidelity (community health worker-led strategy group) | Percentage of nutrition education sessions organized. Measured by study administrative data. | Measured at 6, 12, and 18 months | 
| Health Care Appointment Fidelity (community health worker-led strategy group) | Percentage of health care visit appointments made. Measured by study administrative data. | Measured at 6, 12, and 18 months | 
| Percentage of enrolled participants receiving assigned intervention. Measured by study administrative data. Reach (Participants) | Percentage of enrolled participants receiving assigned intervention. Measured by study administrative data. | Measured at baseline, 6, 12, and 18 months | 
| Reach (Participants) | The percentage of eligible/screened/contacted participants enrolled. Measured by study data, administrative data. | Measured at baseline | 
| Penetrance (Participants) | Percentage of enrolled participants receiving assigned intervention. Measured by intervention monitoring data. | Measured at baseline, 6, 12, and 18 months | 
| Penetrance (Providers) | Percentage of trained providers delivering protocol-based care. Measured by intervention monitoring data. | Measured at baseline, 6, 12, and 18 months | 
| Penetrance (educators) | Percentage of trained CHWs or providers and health educators delivering health coaching. Measured by intervention monitoring data. | Measured at baseline, 6, 12, and 18 months | 
| Sustainability (Churches) | Percentage of churches continuing the intervention program and individual components. Measured by 6-month post-intervention survey. | Measured at baseline, 6, 12, and 18 months | 
| Sustainability (Participants) | Percentage of participants maintaining ideal cardiovascular health metrics, healthy lifestyle components, and adherence to medications. Measured by 6-month post-intervention survey and examination. | Measured at 24 months | 
| Sustainability Effectiveness Outcome: Differences in mean change of SBP and DBP | Differences in mean change of SBP and DBP from baseline to 24 months (6 months post-intervention) between intervention and control groups | Measured at baseline and 24 months | 
| Sustainability Effectiveness Outcome: Difference in the proportion of patients with controlled BP | Difference in the proportion of patients with controlled BP (<130/80 mm Hg) between intervention and control groups at 24 months. | Measured at baseline and 24 months | 
| Sustainability of Fidelity | A fidelity summary score for key implementation strategy components at 6 months post-intervention (24 months overall). The fidelity summary score is composed of the following key implementation strategy components: proportion of assigned health education sessions attended in all participants, proportion of assigned discussion sessions attended in all participants, proportion of recommended minutes of physical activity completed in all participants, proportion of days per week that fruits/vegetables are eaten as recommended in all participants, proportion of recommended home BP monitoring completed in patients with hypertension, proportion of required provider visits attended in all patients, and proportion of antihypertensive medications taken in patients with hypertension. Fidelity score ranges from zero to six with a higher score indicates greater fidelity. | Measured at 24 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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church-based, Black, African American, Community-based Intervention, health disparities, cardiovascular disease prevention