Hypertension success stories boost BP control | TheHeart.org

The first randomized controlled trial to examine the effect of a culturally appropriate storytelling intervention on control of blood pressure has shown some success, with those who were uncontrolled at baseline improving systolic BP by 11 mm Hg over the course of the study, published in the January 18, 2011 issue of the Annals of Internal Medicine [1].

Dr Thomas K Houston (University of Massachusetts, Worcester) and colleagues created DVDs of real African American patients from a low-income, inner-city setting telling their own stories of how they battled hypertension [2]. They showed these to half of the people in their study, while the remainder saw a “control” DVD that covered health topics not related to hypertension. The BP reductions seen, particularly in those with uncontrolled hypertension at baseline, are “similar” to those achieved with pharmaceutical interventions and dietary approaches, say Houston et al.

“I do think that storytelling is innately human. It’s a way we make meaning out of the world and understand our lives,” Houston told heartwire. “So it does apply across the board, it has value for everyone, although there is evidence that the benefit is greater for those of lower literacy.”

I do think that storytelling is innately human. It’s a way we make meaning out of the world and understand our lives.

He acknowledges that further work is needed to fine-tune these findings. “But we can envision a future where providers would refer patients to websites or DVDs that would have a pool of stories featuring people like them, which would help them manage themselves. Communicating with patients has value, and we have packaged that into something easily disseminated.”

In an accompanying editorial [3], Drs Kimberley R Myers and Michael J Green (Penn State College of Medicine, Hershey) say Houston et al “have done much to corroborate anecdotal evidence that storytelling can benefit patients with chronic illness.” However, they add that their claims that the intervention is as effective as pharmacologic therapy are “overstated” and that “stories are unlikely to become a routine part of treatment until additional evidence shows that their effect is both sustainable and generalizable.”

Narrative communication: A well-known marketing tool

Houston explained to heartwire that the notion of storytelling—or “narrative communication,” as it is termed by industry—is well-recognized as being a powerful force in marketing. There is also a national community of scientists working with the concept in healthcare, he says, including some “wonderful work” done with storytelling that has been successful in increasing the rates of breast-cancer screening.

Communicating with patients has value and we have packaged that into something easily disseminated.

He and his colleagues decided to test the concept in blood-pressure control, which is poor in particular sectors of society, including among African Americans. Evidence suggests “that storytelling may offer a unique opportunity to promote evidence-based choices in a culturally appropriate context,” Houston notes, helping listeners make meaning of their lives and influencing them if they actively engage in a story. This is based on the idea of “homophily,” he says, whereby people identify themselves with the storyteller and picture themselves taking part in the action, making them susceptible to behavior-change messages and suggested new ways of interacting with family healthcare providers.

“What we did is we went into a community hospital in Birmingham, AL and recruited patients to tell us their stories of success and then packaged them into an interactive DVD that we then redeployed in a randomized trial,” Houston says. “We worked with people who had expertise in documentary film-making, so we edited these productions so they would be stories, with a beginning, middle, an end, and a conclusion.”

Most benefit seen in group with uncontrolled BP at baseline

The researchers then took African American patients from a hypertension clinic in Birmingham, some of whom were controlled on medication at the start of the trial (n=172) and some of whom were uncontrolled (n=123). The controlled patients were included to see whether the intervention would be useful in maintaining BP control, Houston said.

Half of the patients received the intervention, a series of three DVDs that contained patient stories delivered at baseline, three months, and six months. The control group got the attention DVDs.

“We did stratified randomization—two randomized trials in one—which allows us to see the overall effect of the study but also to maintain randomization when comparing the subgroups,” Houston explained. “We did find a significant, positive overall effect for systolic BP in the overall cohort, including everyone together. But the change in the uncontrolled was driving the change; there was very little effect in the controlled group.”

Change over time in mean BP for the intervention vs comparison groups

Subgroup and BP measure Estimated regression coefficient,* baseline to 3 mo p Estimated regression coefficient,* baseline to 69 mo p
All patients
Systolic 6.53 0.014 6.41 0.019
Diastolic 3.05 0.058 2.66 0.109
Controlled hypertension at baseline
Systolic 1.12 0.71 0.44 0.89
Diastolic -0.19 0.92 0.88 0.67
Uncontrolled hypertension at baseline
Systolic 11.21 0.012 11.9 0.007
Diastolic 6.43 0.012 4.22 0.119
*Positive differences indicate greater blood-pressure reduction in the intervention group than in the comparison group

Could Twitter, YouTube, and Facebook be employed to control BP?

Houston et al note some limitations of their study, including the high dropout rate of 25% and the fact that they could not confirm whether patients actually watched the DVDs that were mailed to their homes. “Additional studies are needed to clarify the mechanisms through which storytelling works, address more long-term follow-up, and test similar interventions for different populations and conditions,” they conclude.

Physicians might actually include a prescription for stories along with one for medication, a development we would welcome.

But should this ultimately be proven to be a useful intervention, social networking media such as Twitter, YouTube, and Facebook could be used to make such narratives readily accessible, say Myers and Green in their editorial. “Physicians might actually include a prescription for stories along with one for medication, a development we would welcome,” they state.

Lisa Nainggolan, TheHeart.org http://www.theheart.org/article/1174127.do