BACKGROUND/RATIONALE:
Hypertension (HTN) is a major risk factor for cardiovascular disease, disability and death. Getting blood pressure (BP) to goal levels reduces this risk. While BP control in VHA compares favorably to that achieved in other medical settings, many veterans have suboptimal control. Based on prior work suggesting that community and peer support can improve chronic disease self-management, we partnered with veterans' service organizations (VSO) to carry out an intervention focused on improving HTN-related health behaviors.

OBJECTIVE(S):
We addressed three objectives. First, we formed a partnership among VHA clinicians, VSO members, and academicians. Second, we used a randomized controlled trial (RCT) to test whether veterans participating in an intervention based on peer-delivered health education would have better self-management practices and BP control than veterans who were exposed to similar content through didactic presentations by healthcare professionals. Finally, we performed a process evaluation to determine key barriers and facilitators to intervention success.

METHODS:
Our project had three components. First, we worked with four key VSO in Wisconsin-the American Legion, Veterans of Foreign Wars, Vietnam Veterans of America, and the National Association of Black Veterans-to refine our proposed approach. The VSO endorsed the final project and designated senior members to serve on an advisory board.

The RCT compared a peer-led (PL) intervention to a series of educational seminars (ES). At all participating posts, volunteer members encouraged the use of self-monitoring equipment. We trained individuals from each PL post to deliver monthly health-focused presentations, encourage health promotion activities, and maintain a post "health corner." At ES posts, study clinicians delivered seminars addressing similar topics. We recruited members with hypertension to participate in a study comparing the interventions. Before we randomized the posts, we measured study participants' BP and weight and surveyed them regarding health-related knowledge, attitudes, and behaviors. We repeated these measures at 6 and 12 months. Our primary endpoint was change in systolic BP. Our analysis accounted for clustering using generalized estimating equations.

We used mixed methods for our process evaluation. These methods included observation of post activities, focus groups, and interviews.

FINDINGS/RESULTS:
We enrolled 404 veterans from 58 posts. Systolic BP improved significantly in both groups; improvement was similar in PL and ES posts. Obese members of PL posts lost 4 pounds, while similar ES post members gained 1 pound (p < 0.01). Diastolic BP, physical activity, healthcare engagement, and social support improved similarly in PL and ES posts. PL posts were more likely than ES posts to self-monitor blood pressure and report improved overall health.

IMPACT:
We have firmly established our relationship with the VSO, engaging over 100 veterans across 58 posts as intervention partners and working with them to devise new programs. We have engaged MOVE! program leadership locally and at the national level to design a program that uses post support to increase MOVE! participation among eligible veterans.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Whittle J, Schapira MM, Fletcher KE, Hayes A, Morzinski J, Laud P, Eastwood D, Ertl K, Patterson L, Mosack KE. A randomized trial of peer-delivered self-management support for hypertension. American journal of hypertension. 2014 Nov 1; 27(11):1416-23. [view]
2. Patterson L, Morzinski J, Ertl K, Wurm C, Hayes A, Whittle J. Engaging community-based veterans' organizations in health promotion programs. Family & Community Health. 2011 Oct 1; 34(4):311-8. [view]
3. Whittle J, Fletcher KE, Morzinski J, Ertl K, Patterson L, Jensen W, Schapira MM. Ethical challenges in a randomized controlled trial of peer education among veterans service organizations. Journal of empirical research on human research ethics : JERHRE. 2010 Dec 1; 5(4):43-51. [view]
4. Rosenwald K, Ertl K, Fletcher KE, Whittle J. Patterns of arthritis medication use in a community sample. Journal of primary care & community health. 2012 Oct 1; 3(4):272-7. [view]
5. Hayes A, Morzinski J, Ertl K, Wurm C, Patterson L, Wilke N, Whittle J. Preliminary description of the feasibility of using peer leaders to encourage hypertension self-management. Wmj : Official Publication of The State Medical Society of Wisconsin. 2010 Apr 1; 109(2):85-90. [view]

Journal Other

1. Whittle JC, Hayes A, Eastwood D, Morzinski J, Ertl K, Wurm C. Effect on health behaviors of a health promotion intervention delivered through veterans service organizations. [Abstract]. Journal of general internal medicine. 2010 Jul 1; 25(Supple 3):S264. [view]

Center Products

1. Morzinski J, Patterson L, Ertl K, Wilke N, Fletcher K, Wurm C, Hayes A, Whittle JC. Peer-Leader Training to Improve the Health of Veterans: The POWER Curriculum. [Website]. 2012 Jun 26. [view]

Conference Presentations

1. Schapira M, Fletcher K, Eastwood D, Hayes A, Patterson L, Ertl K, Whittle JC. Development and validation of the Hypertension Evaluation of Lifestyle and Management (HELM) knowledge scale. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2011 May 5; Phoenix, AZ. [view]
2. Whittle JC, Schapira MM, Fletcher K, Hayes A, Morzinski J, Ertl K, Eastwood D, Patterson L, Laud P. Impact of a peer support intervention delivered in veterans service organizations on blood pressure control. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 1; Washington, DC. [view]
3. Morzinski J, Patterson L, Eldredge C, Ertl K, Lawrence S, Whittle JC. Training community health workers to teach peers about chronic disease self-management: outcomes and implications. Poster session presented at: Society of Teachers of Family Medicine Spring Conference; 2011 Apr 28; New Orleans, LA. [view]

DRA: Aging, Older Veterans' Health and Care, Health Systems, Cardiovascular Disease
DRE: Treatment - Observational, Prevention
Keywords: Care Management, Hypertension, Satisfaction (patient)
MeSH Terms: none