Community-based intervention for Hypertension among Asian Americans

From Ko Group

Asian Americans report a lower rate of healthcare utilization and awareness of hypertension compared to other racial/ethnic groups. Additionally, a high proportion of Asian Americans, 62%, report having limited English proficiency (LEP).  Previous literature reported that Asian Americans with LEP have trouble receiving specialized and quality healthcare.  Among various racial/ethnic groups, including Asian Americans, older adults have displayed higher rates of hypertension (63%) compared to the 40-59-year-old group (33.2%) and the 18-39-year-old group (7.5%).  These disparities support the rationale to increase awareness and education of hypertension control among older Asian Americans with LEP.

The original evidence-based intervention program, Check it, Change It, created by the American Heart Association (AHA), reported that 70% of participants showed a 10 mmHg decrease in systolic blood pressure after the conclusion of the program. Next, the AHA created Check. Change. Control. (CCC), a community-based intervention program directed towards hypertension management and the prevention of other cardiovascular diseases.  CCC is delivered in a face-to-face group with AHA-trained peer review counselors. The counselors collaborate with participants to create a blood pressure monitoring plan, connect them with healthcare services, and inform them on diet, exercise, and meditation compliance. Previous studies have documented the efficacy of in-person delivery among various racial/ethnic groups. However, limited research exists on the effectiveness and adaptability of phone-based delivery and its components for older Asian Americans. In addition, it’s necessary to understand the counselor’s perspective of the newly, adapted CCC program.  The Ko Group, from the Division of Public Health Sciences, conducted a pilot study to qualitatively evaluate the acceptability of the CCC program from in-person to phone delivery among older Asian Americans with LEP and their counselors. The study is published in Translational Behavioral Medicine: Practice, Policy, Research.

The Ko Group applied the Social Context Framework, the Anderson Behavioral Model of Health Services, and the RE-AIM framework to conduct the pilot study. The Social Context Framework proposes that the Asian communities in the US can guide Asian Americans’ health service utilization, including blood pressure monitoring. The Anderson Behavioral Model suggests that enabling factors such as income and health insurance influence Asian Americans’ health utilization and hypertension management. The RE-AIM framework assessed the counselors’ perceptions and evaluations of the adapted CCC program.

Telehealth, especially in the era of COVID, has been necessary and beneficial for elderly populations and those with barriers to access health services. Telehealth delivers health care services to patients who are distant from providers. Telehealth has exhibited efficiency in the completion of healthcare interventions, the management of diabetes, medication, and heart failure. The services of Telehealth were utilized in the present study. The adapted CCC program included the use of landlines, cellphones, and smartphones from March 2016 and 2017. Participants were screened for the study based on the following eligibility: ethnicity (Chinese, Korean, or Vietnamese), age (65 years or older), residence of Washington state, LEP status, and hypertension risk (experience with high blood pressure or taking medication for hypertension). Letters were mailed to potential participants explaining the details of the study; 13 out of 136 participants who responded were eligible and remained in the study. Four bilingual and multicultural counselors delivered the intervention. Over the course of 4 months, the sessions included general information about hypertension and risk factors (month 1), changing behaviors to reduce hypertension (month 2), importance of medication adherence and effects of uncontrolled blood pressure (month 3), and ways to manage blood pressure (month 4). After the program, a semi-structured interview was conducted with participants over the phone and with counselors in-person. During the interview, the study’s cultural relevance and acceptability were evaluated. 

Graphical Representation of Community-based intervention for Hypertension among Asian Americans
Community-based intervention for Hypertension among Asian Americans

After the participant and counselor interviews were transcribed, two main themes were identified: perception of the CCC program, and acceptability of the counselors and the delivery methods.  One consistent perception was that owning a blood pressure monitoring device was the best way to regularly check their blood pressure. Positive perceptions included receiving a blood pressure device via the program, receiving reminders to check their blood pressure, and being motivated to use the device to regularly measure blood pressure. The participants rated the CCC program as acceptable and gave the counselors high remarks for their reliability, supportive nature, and ability to clearly deliver information.  The counselors reported that participants were committed to the CCC program. As the program advanced, participants increased their interest in blood pressure monitoring and engagement. They also reported how much the free blood pressure device impacted the participants’ decision to participant and stay engaged in the program.

Overall, older Asian Americans reported the importance of the CCC program in managing and lowering blood pressure. Based on the participant interviews, future CCC programs may consider beginning or ending with   educational sessions with an in-person support group meeting to build a relationship between the counselors and participants. Dr. Sou Hyun Jang, the first author of the study, elaborated on future directions for interventions among Asian Americans, “Since we are still in the COVID-19 pandemic and since our study confirmed that the contact-free (phone-based) delivery is acceptable among Asian Americans, I think the researchers need to develop the Internet-based interventions (e.g., using Zoom), confirm its acceptability, and disseminate it among Asian Americans and other racial/ethnic minority groups who might be more vulnerable during the pandemic.”

This research was supported by the National Cancer Institute Cancer Center Support, National Institutes of Health, and National Center for Advancing Translational Sciences of the National Institutes of Health.

Fred Hutch/UW Cancer Consortium member Linda Ko contributed to this work.

Jang SH, Brown EV, Lee EJ, Ko LK. “Blood pressure monitoring should be a habit”: adaptation of the Check. Change. Control. program for Asian American older adults, from group-based in-person to one-on-one telephone delivery. Translational Behavioral Medicine. 2021 Jan 15.