Can Storytelling Improve Blood Pressure Control?

Nearly two-thirds of all Americans diagnosed with high blood pressure are treated with medications – but fewer than half are controlled to their goal. And the rate of control is even lower in racial and ethnic minority subgroups.^1,2  Patients who are younger, non-white, as well as those with asymptomatic chronic diseases and taking multiple daily medications have lower medication adherence rates.³

Less than optimal adherence with medications and lifestyle changes are often a barrier to achieving desired blood pressure goals and preventing or mitigating heart disease and stroke.  Strategies that recognize cultural identity and incorporate relevant, individualized messages may have a great chance for success.  The Reasons for Geographic and Racial Differences in Stroke Study found that black patients are often aware of their hypertension status (>60% are aware) and more patients in this population are prescribed medications (when compared to Caucasians).⁴  However, only a third are controlled.⁵  A study by Traylor and colleagues found that improved medication adherence was associated with patient-physician race concordance in black adults with diabetes.  These data suggest that cultural and social/economic influences may be critical variables.⁶  

The purpose of this commentary is to examine the outcomes from a culturally focused patient education strategy where storytelling vignettes were used to improve blood pressure control.  The study was conducted in a high-risk urban black population in Alabama, one of the “Stroke Belt” states of the Southeastern United States.⁷

Houston and colleagues conducted a prospective, randomized, controlled trial comparing a focused, narrative educational intervention to standard care. ⁷  The intervention group included 147 black patients, aged 18-80 years [average age 53.2 years] who received DVDs to view at baseline and then  6 and 9 months after enrollment.  Through the use of real patient stories, the DVDs included information regarding living with hypertension, interacting with physicians, medication adherence, avoiding hidden sodium, and physical activity.  Each DVD was developed by the study investigators using an extensive step-wise approach including focus groups to identify content areas, selection of potential patient actors, structured open-ended interviews to identify appropriate patient stories, and analysis and refinement of story units.  The control group consisted of 152 patients who received only general health maintenance DVDs (“Healthy Habits” topics, not specific to hypertension) and usual physician care.  Participants with controlled and uncontrolled hypertension participated in the study and were randomized in blocks.  The main outcome measure was change in blood pressure from baseline to the 3 and 6-9 month follow-up intervals.

Changes in systolic blood pressure (SBP) in the intervention versus control groups were as follows:

*Represents significance of estimated regression coefficient for change over time in mean blood pressure for the intervention versus control group.

The authors concluded that the customized storytelling intervention reduced blood pressures significantly compared to control patients.  The greatest change was observed in the first 3 months.  It is noteworthy that although differences were significant overall, the reduction in BP was entirely attributable to patients with uncontrolled hypertension. The unadjusted change in the mean SBP in patients with controlled and uncontrolled HTN in the intervention group were:

This research demonstrates that a culturally relevant storytelling intervention does improve blood pressures in patients with uncontrolled hypertension.  The relatively substantial SBP reduction of 6.43 mm Hg (CI 1.41 – 11.45 mmHg; p=0.012)  in the intervention group persisted over the 6-9 study period  Admittedly, the study was relatively short and how this might translate to improvements in clinical outcome over longer time periods is open to speculation. Medication adherence was not directly measured, but it may explain some of the observed improvements in BP control.Approximately 30% of the study population had a high school or less than high school education and nearly 2/3 had an annual household income of less than $12,000.  Only 14.4% of the subjects were older than 65 years of age.  Eighty-two percent of the intervention group and 73% of the control group completed the study.

Previous literature has suggested that medication adherence interventions have greater impact when they are a multi-pronged approach that includes both simple and complex components.⁸   Use of adherence devices / reminders, regimen simplification, plus patient education is arguably the “gold standard” for adherence management.  This study and others suggest that our programs should be framed in a culturally appropriate context so that patients can identify with the delivered messages.  Storytelling by real patients appears to attitudinally and cognitively prepare patients to consider health behavior change. 

Unfortunately, this study also highlights the significant challenge in designing and delivering narrative commentaries.  Extensive preparation was required to produce the intervention DVDs including interviews with 6 focus groups and taping 14 patient interviews totaling more than 80 hours of footage.  High-priority messages were edited into a storyline (1-3 per DVD) and assembled with “Learn More” resources on each DVD. Health care providers could easily be overwhelmed by amount of time and effort require to produce these DVDs.  Moreover, its cost-benefit has not yet been studied. 

Rather than providing substantive “answers,” this research provokes an array of interesting clinical questions.  Should pre-packaged, culturally appropriate adherence interventions replace (or augment) open-ended provider-patient communication?  Should education efforts be targeted to patients with poorly controlled blood pressure (as there appeared to be no benefit in those who had controlled HTN)?  Would live, peer-to-peer education sessions be more effective than traditional one-on-one medication counseling sessions?  Are pharmacists best equipped to improved medication adherence or would culturally appropriate DVDs do a better job? 

For now, providers should continue their efforts to improve adherence with lifestyle changes and medications by using plain language, asking open-ended questions, and checking for understanding with the teach-back technique.   What medication adherence interventions have you found are most successful in your practice?