Patients'knowledge concerning their chronic illness has long been considered "necessary but not sufficient" to produce changes in risk-related behaviors. "Necessary" implies that patient knowledge is, therefore, a moderator of the effectiveness of behavioral interventions. However, researchers have tended to ignore patient education as a critical component of behavioral (or, for that matter, pharmacological) interventions. We propose to combine a behavioral intervention that we and others have found to be moderately effective in increasing blood pressure (BP) control in hypertensive patients - using a home BP monitor (HBPM) to obtain feedback regarding their BP control, and providing feedback to the health provider - with a systematic patient education component. We propose an intervention strategy that is meant to be usable as an adjunct to the HBPM and other interventions;one that will increase patients'knowledge, and, we hypothesize, will therefore increase the effectiveness of the "parent" intervention (HBPM, in this case). Our proposal is for a randomized controlled trial (RCT), using a 2X2 factorial design in which we will test the effect of (1) a patient education intervention and (2) HBPM, on ambulatory BP in poorly-controlled hypertensive patients at 3 and 6 months. The education intervention is based on a technique called "Self-Paced Programmed Instruction" (SPPI), a method that has been remarkably effective at increasing knowledge concerning complex topics. Using a computer, a paragraph of content material is presented, followed by probe questions. When patients provide a correct response, they are immediately reinforced by positive feedback;an incorrect response loops the program to re-present the materials, this time with hints;and the subjects then re-attempt the probe questions. The loop continues until a correct answer is recorded. In this manner, every subject achieves mastery over the requisite material. We posit that medication adherence (assessed objectively) will partially mediate the ambulatory BP outcomes;and that Self-Efficacy for the self- management of HTN will mediate medication adherence;we predict that self-efficacy will be enhanced by the mastery of the HTN-related materials, and by the reduction of ambiguity, which will lead to greater confidence in the patient's decision-making processes. We predict that the SPPI - HBPM condition will have the greatest effect on ambulatory BP, compared to the other three groups. PUBLIC HEALTH RELEVANCE: Hypertension remains a hugely costly problem in the United States in terms of morbidity and economic burden. Many patients cannot or will not take medications;the application proposes a non-pharmacological intervention that will help hypertensive patients adhere to their prescribed medication regimens, and to control their blood pressure.

R01HL089402

2009-09-30

2012-07-31