"Check It, Change It"

Engaging and empowering a community to Improve Blood Pressure Control

October 30, 2014

KevinThomastb.jpgThe empowering, community-centric concept behind the now famous Yoruba proverb, “It takes a whole village to raise a child,” might ring true for adults, too.

In certain populations, home blood pressure monitoring interventions have held some promise in hypertension control. However, it is uncertain whether this strategy can be generalized. As such, the researchers of the Check It, Change It (CICI) study sought to determine whether a multifaceted, community-based approach could improve hypertension control.

Between December 9, 2010 and November 11, 2011, CICI enrolled 1756 patients with hypertension from eight clinics in Durham County, North Carolina. CICI successfully used a combination of community health coaches, health care providers, and a web-based health portal called Heart360® to empower local residents to affect a positive change in their own health by taking control of their high blood pressure.

Other programs have used similar approaches with multicomponent strategies to manage blood pressure control. But the true novelty in the CICI program, according to the DCRI’s Kevin Thomas, MD (pictured above), was including a diverse group of patients from varying socioeconomic levels, ethnicities, and ages. And its success—within six months, the number of participants with controlled blood pressure (readings of less than 140/90 mmHg) increased by 12%; among participants who had high blood pressure in the range of 140–149/90–99 mmHg, mean systolic blood pressure decreased by 8.8 mmHg; and in those with readings in the higher range of 150/100 or above, mean systolic blood pressure decreased by 23.7 mmHg—is likely tied to the way the researchers involved the community.

“We spent a year engaging the community as active participants in the design of Check It, Change It, and every component of the program was centered on empowering the individual,” said Thomas. Overall, representatives from a wide variety of community groups—such as CAARE, Inc., Community Health Coalition, El Centro Hispano, Lincoln Community Health Center, a coalition of ministers and pastors, nurse practitioners and nurses, community physicians, and an alliance of barber shops and beauty salons—participated in the planning stage. There was also a community advisory board that met quarterly. Additionally, the researchers conducted surveys of patients, key community leaders who were identified by the community advisory board, and community-based health care providers. Additionally, the research team held something it coined “community conversations,” which are round-table-style meetings with community residents to better understand community needs, available resources, and barriers to chronic disease management and to discuss what interventions could bring about change.

Self-motivation and a sense of empowerment was an important factor in the lowering of participants’ blood pressure, according to Thomas. And for those who used it consistently, Heart360® played a key role. Study participants were able to upload blood pressure readings and health data on computer stations and blood pressure monitoring kiosks that were installed in select churches, libraries, barbershops, the health department, community recreation centers, and pharmacies throughout Durham. Furthermore, Heart360® enabled participants to download educational materials and share printed reports with the various individuals involved in their care, including health coaches, physicians, and other health care providers working to help them meet their blood pressure goals.

But using modern web-based technology wasn’t the only key component. Something with a decidedly “old school” feel was also effective. Thomas reports that participants felt appreciative of what the community health coaches provided in terms of support and encouragement as well as education and direction for managing their illness. For those who were amenable, the community coaches conducted home visits for patients with very elevated blood pressures, something today’s physicians typically cannot provide.

For Thomas, one of the most surprising takeaways from the study is “the magnitude of the benefit provided to special populations, including the uninsured, underinsured, and racial and ethnic minorities.” However, while the researchers believe this approach may be transferable to other conditions, one thing to consider in future applications of this approach is the digital divide witnessed among the elderly and impoverished participants of this study.

While some individuals loved the ability to record and manage their health metrics, with one participant submitting 917 blood pressure readings during the course of the program, other individuals simply weren’t able to use a computer or text messaging to enter their blood pressure recordings. Thomas believes a phone line that would allow participants to enter blood pressure measurements and upload to Heart360® would have been useful.

“Multifaceted interventions have the potential to impact chronic disease management to achieve better control across a broad spectrum of patient populations and diseases,” said Thomas. “For future programs, especially those that encompass web-based technology, though, interventions must be adapted to avoid inadvertently alienating populations who stand to benefit.” Furthermore, Thomas sees a need to focus on sustainability among these community-based programs to ensure that benefits can be maintained over a longer period of evaluation. “The core premise and structure of the [CICI] program is transferrable to other chronic conditions such as diabetes, asthma, and hyperlipidemia,” said Thomas. “We need to evaluate this model in those diseases and in different communities.”

Sharon Elliott-Bynum, co-founder and executive director of CAARE, Inc., agrees, which is why CAARE is currently using the community health coach model she, Thomas, Bimal Shah, MD, and the other team members designed for the CICI study. Training of the community coaches was done at CAARE. The research team wanted the community coaches to be able to facilitate reporting and communicate effectively with participants. With such comprehensive training, they were able to create a real continuum-of-care model within CICI, and that has since been easily translated to a current program helping CAARE patients with diabetes.

“High blood pressure is controllable when patients and providers are empowered with the right tools and systems of care,” said Eric Peterson, MD, executive director of the DCRI. “The Check It, Change It program made a difference within the Durham community and could be a model for collaborative care for the rest of the nation!”

Elliott-Bynum believes another one of the strengths of the study is also one of its more unique aspects. Typically, researchers will formulate a project and then go out into the community to inspire involvement and engage local residents. In this study, however, they were able to design something with community buy-in from the beginning. According to Elliot-Bynum, the research team was able to structure something that would be sustainable within the community once the project ended because participants were truly involved. CAARE alone recruited more than 300 people as part of the overall participant group. “These are people who are uninsured and in real need of support, and those same people—three years later—are still engaged,” said Elliot-Bynum, “and to me, that’s the most important thing an academic institution can do, engage the community so that a project like this can be sustainable.”

The research appears online in Circulation: Cardiovascular Quality and Outcomes.

In addition to study principal investigators Thomas, Elliott-Bynum, and Shah, study authors from Duke and DCRI included Kristin Thomas, MPH; Katrina Damon, DM; Nancy Allen LaPointe, PharmD; Sarah Calhoun, MS; Laine Thomas, PhD, Robin Mathews, MD, MHS; Monique Anderson, MD, MHS; Robert Califf, MD, and Eric Peterson, MD, MPH.