High blood pressure (BP) is the most common chronic condition in Veterans with a prevalence of approximately 37%. It affects more than 1 million Veterans, greatly increasing their risk for CVD. We completed a randomized clinical trial (RCT) demonstrating a strong effect for a telephone-delivered Transtheoretical Model-based stage-matched intervention (SMI) to improve BP control by targeting diet, medication-taking, and exercise in Veterans with uncontrolled BP. BP control improved by 20% and systolic BP decreased by 3.5 mm Hg in the SMI group compared to usual care. We began this project to refine the intervention and build a toolkit for dissemination that is based on the SMI used in the previous RCT.
This project was conducted in three phases. In phase 1, we translated the SMI into a standardized prototype toolkit consisting of: 1) the SMI Counseling Package, 2) the SMI Training Manual, and 3) Sample recordings of counseling sessions. In phase 2, we are conducting formative evaluation of the toolkit with clinicians of different disciplines to make further refinements to the SMI as well as to make modifications to the toolkit based on differences in training needs between disciplines. In phase 3, we will make final adjustments to the toolkit after getting feedback from more clinicians and senior implementation scientists before finalizing the toolkit for dissemination. We plan to conduct a Service Directed Project with the finalized toolkit.
In phase 1, we interviewed 6 RCT counselors and research staff, 7 clinicians (2 doctors, 2 nurses, 1 social worker, 1 dietitian, 1 pharmacist), and 2 informatics experts to create the prototype using heuristic evaluation and usability testing. We evaluated the ease of use, attractiveness and perceived usefulness of the prototype via written evaluations with five-point Likert-scales and open-ended questions, and the "think aloud" procedure. Each participant received a standardized introduction to the SMI and training in "thinking aloud" so study observers could follow and understand participants' thought processes as they navigated the SMI. Participants worked with the SMI for approximately 1 hour, performing standardized counseling with fictitious patients. After incorporating feedback received in phase 1, we developed the initial translated toolkit to be evaluated in phase 2. One group of pharmacists (n=4) and 2 groups of Patient Aligned Care Team (PACT) nurse care managers (n=10) used the toolkit to undergo supervised training in delivering the SMI to patients with uncontrolled BP at the Brooklyn and Manhattan VA campuses. We gathered feedback through practice calls with participants as well as through qualitative interviews with both patients and staff. Further refinements will be made based on the data collected in the current phase. Clinicians' calls are being rated for treatment fidelity using the SMI fidelity checklist and the Counseling Skills Scale to get an understanding of the ability to deliver the SMI between clinicians of different disciplines. In phase 3, we will conduct focus groups with clinicians as well as usability testing with the translated toolkit to develop the final toolkit.
After interviewing RCT counselors/staff, we made the SMI less scripted and more conversational, removed redundant material and material that had no theoretical underpinnings, emphasized short-term goals and changed the manual design. Then, clinicians and informatics experts evaluated the content and design of the SMI. We gathered information about the user interface and functionality of the prototype through observations of participants performing tasks intended to represent encounters with patients while "thinking aloud." Written evaluations revealed further insights regarding the usability/understandability of the prototype. After evaluation of observations/information, appropriate modifications were applied to create a revised prototype. At the end of Phase 1 our initial "translated SMI" consisted of: 1) SMI Counseling Package, 2) SMI Training Manual, and 3) Sample recordings of counseling sessions created for the toolkit. In phase 2, we are conducting formative evaluation of the translated toolkit and making iterative refinements to the toolkit based on feedback from clinicians. Thus far, it seems that the manual aids different disciplines in delivering comprehensive health behavior counseling to hypertensive patients, but the manual may still need to be shortened and made even more conversational. Also, due to changes in location and duties after Superstorm Sandy, and the reduced space available after Sandy, clinicians, specifically RN-Care Managers in Manhattan, have had difficulty with finding space and time to train in delivering the SMI.
We anticipate that the finalized toolkit will effectively help clinicians self-train in delivering the SMI to hypertensive patients. Since this intervention was found to help patients control their blood pressure, training staff to deliver this intervention would likely lead to better blood pressure control among our Veteran patients. This study used the same sophisticated psychological techniques that worked in the trial, but with sufficient testing to assess the feasibility of applying this in routine clinical practice among different health care staff. This inexpensive training toolkit can easily be disseminated so clinicians across the VA's can self-train in delivering the SMI. If this promising theory-driven intervention can be implemented using this discipline-based approach in VA clinical settings where improvements in hypertension control are still needed to provide new tools to target hypertension control, it will be an important contribution.
External Links for this Project
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