Abstract
IMPORTANCE: Hypertension treatment advances have resulted in improvements in blood pressure control and self-management. Yet, disparities persist for Black veterans. OBJECTIVE: To examine the impact of a narrative-informed texting intervention with educational content and bidirectional text messaging on blood pressure and hypertension self-management. DESIGN, SETTING, AND PARTICIPANTS: This nonblinded, 2-arm randomized clinical trial recruited participants from March 2021 to July 2022 at 2 Veterans Affairs (VA) medical centers (1 in Chicago, Illinois, and 1 in Philadelphia, Pennsylvania); follow-up was completed in May 2023. Participants were Black veterans with at least 1 medication for hypertension, with oversampling of female veterans. Participants were randomly assigned to the intervention arm or control arm. Data analysis was based on the intention-to-treat principle. INTERVENTION: Those assigned to the intervention group received the Continuing the Conversation intervention, which involved watching 5 videos (5-7 minutes each) of Black veterans sharing stories of their challenges and successes with managing hypertension. Participants selected a favorite storyteller and were enrolled in a 6-month texting protocol wherein they received 3 types of text messages: narrative (quotations from storytellers), educational, and bidirectional. The comparison or control arm received 6 months of bidirectional text messages (BTMs) only. MAIN OUTCOMES AND MEASURES: Change in systolic and diastolic blood pressure from baseline to 6-month follow-up was the primary outcome. Secondary outcomes included change in self-reported hypertension management activities (medication adherence, diet, physical activity). All outcomes were prespecified. Difference-in-differences (DID) regression models assessed whether the intervention arm had a 6-month improvement larger than that in the control arm. Engagement (6-month response rates to BTMs) and motivation of participants were also evaluated. RESULTS: Of the 600 Black veterans enrolled (469 males [78.7%]; mean [SD] age, 64.0 [9.1] years), 516 veterans (86.0%; 262 in intervention arm, 254 in control arm) completed the 6-month follow-up. There was no significant difference between arms in mean change of systolic (DID, -0.8 mm Hg; 95% CI, -3.9 to 2.3 mm Hg; P = .62) or diastolic (DID, 0.4 mm Hg; 95% CI, -1.6 to 2.4 mm Hg; P = .70) blood pressure or in secondary outcomes. Mean systolic (-2.1 mm Hg; 95% CI, -3.7 to -0.6 mm Hg; P = .006) and diastolic (-1.8 mm Hg; 95% CI, -2.8 to -0.8 mm Hg; P = .001) blood pressure measurements decreased significantly for the entire cohort. In the intervention arm, 221 of 239 participants (92.5%) agreed with the statement: "I could identify with the Veteran in the video." Across both arms, the response rate to BTMs was 57.5% (11 427 of 19 875 possible opportunities to respond), and 60.7% (10 564 of 17 407 possible opportunities to respond) among those completing follow-up. Of 516 veterans, 410 (79.5%) described text messages as helpful motivators for improving health. CONCLUSIONS AND RELEVANCE: In this randomized clinical trial of video stories followed by narrative, educational, and BTMs to support hypertension self-management, this intervention did not improve blood pressure compared with receiving BTMs alone. Text messages supported engagement and enhanced motivation for Black veterans. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03970590.