Blood Pressure Control Advancing Refugee Health Equity (BPCARE): an RCT of adherence - Project Summary A persistent ~50% of Americans with hypertension are non-adherent to antihypertensive medications. These rates are even lower for refugees, whose numbers are at an all-time high. Uncontrolled blood pressure is the leading cause of cardiovascular disease among refugees, putting them at almost double the risk compared to native and other immigrant populations. Despite advancements in implementation science to include racial and ethnic minority groups, refugees remain one of the most socially vulnerable groups on which evidence on successful medication adherence interventions remains severely limited. The current proposal is a culmination of extensive preliminary research, including (a) in-depth qualitative research with refugees that documented barriers to medication adherence, (b) interviews with providers and key informants who provided specific suggestions for adherence intervention content and delivery strategies, and (c) a pilot randomized clinical trial (RCT) that demonstrated the feasibility, acceptability, and preliminary efficacy of our proposed approach. This extensive research has led to the development of the “Blood Pressure Control Advancing Refugee Health Equity: BPCARE” intervention. BPCARE is a brief, multi-component behavioral intervention delivered to refugees with hypertension who are prescribed antihypertensive medications by highly trained refugee CHWs embedded within a federally qualified health center that seeks to improve antihypertensive medication adherence (primary outcome) and blood pressure control (secondary outcomes) among refugees by increasing hypertension and medication adherence knowledge, improving cardiovascular disease risk perceptions and medication adherence interest and motivation, cultivating medication use self-efficacy and behavioral skills, and reducing structural barriers to medication adherence. We propose testing the efficacy of “BPCARE” in a large federally qualified health center in San Diego, California, a refugee resettlement hub. We will equally randomize 250 refugees with hypertensive to receive either (a) the “BPCARE” intervention, which includes CHW-delivered, theory-informed hypertension and medication adherence education, motivational interviewing, problem-solving and planning, and ongoing medication adherence navigation (n=125), or (b) enhanced usual (information and home BP monitor only; n=125). We will evaluate successful antihypertensive medication adherence (via questionnaire/unannounced pill count), BP control (via connected BP cuffs), and persistence (via questionnaire and connected BP cuffs) over 9 months. We will also examine the degree to which intervention efficacy occurs through specific conceptual mediators (e.g., hypertension knowledge, motivation, self-efficacy, racism) and differs according to hypothesized moderators (e.g., age, gender, acculturation, polypharmacy, comorbidities). This design provides both strong tests of theory and an enhanced ability to guide health promotion strategies to enhance hypertension self-management behaviors to ultimately achieve cardiovascular health equity.
