Overcoming Racial and Ethnic Disparities in Blood Pressure Control: A Patient‐Centered Approach to Cross‐Cultural Communication

Abstract

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”—William Osler ¹

Medical providers today care for an increasingly diverse patient population, necessitating increased emphasis on culturally competent care. In its 2002 report entitled Unequal Treatment, the Institute of Medicine reported that racial and ethnic disparities were consistently found across a wide range of health care settings, disease states, and clinical services, even when various potential confounders such as socioeconomic class and access to health insurance were taken into account. ² These disparities are particularly evident in the areas of cardiovascular disease in general and hypertension in particular. In this editorial, we will (1) review the extent of the disparity in blood pressure (BP) prevalence, awareness, treatment, and control among different racial and ethnic groups; (2) discuss some of the potential causes of disparities in the delivery of health care to patients with hypertension; and (3) present a unique, patient‐centered model of communication that can be used in the clinical setting to overcome barriers to BP treatment and control in our increasingly racially and ethnically diverse communities.

Hypertension affects nearly 70 million persons in the United States. The highest prevalence is among black Americans and the lowest is among Hispanic Americans, with white Americans in between. ³ In addition to having a higher prevalence of hypertension, hypertension tends to have earlier onset and greater severity in black Americans and leads to a greater degree of end‐organ damage and premature cardiovascular death than in other populations. ⁴ , ⁵ , ⁶ , ⁷

More patients visit physicians and receive prescriptions for the treatment of hypertension than for any other chronic medical condition. Yet, despite these efforts, national BP control rates remain below the Healthy People 2010 goal of 50%, and still about 1 million Americans die each year from the direct and indirect effects of hypertension. The most recent data from the National Health Awareness Nutrition Education Survey (NHANES) suggest that in 2003–2004, BP awareness treatment and control differed significantly among major racial and ethnic groups in the United States. ⁸ In non‐Hispanic blacks, rates of awareness, treatment, and control were 66.4%, 55%, and 28.9%, respectively. For non‐Hispanic whites, these rates were 66.4%, 53.7%, and 35.4%, respectively. Mexican Americans had the lowest rates: 63.5%, 48.3%, and 26.5%, respectively.

Knowledge of these epidemiologic trends can be helpful in designing interventions for populations that have traditionally been difficult to screen and treat. For example, in a series of clinical trials, barbershops were employed as hypertension detection, referral, and follow‐up centers for black men in the South, leading to significantly improved BP treatment and control rates. ⁹ These types of focused interventions can be successful. Given the profound diversity and heterogeneity found within different cultural, social, racial, and ethnic groups, these strategies are best focused on small segments of a local community, rather than applied broadly to different racial and ethnic groups. For example, an effective strategy for low‐income black Americans living in the urban South may not be as effective for middle‐income black Americans in the suburban Northeast. We also need to realize that these types of interventions may not be effective for all individuals in a given community, some of whom may not share similar core values, beliefs, and behaviors.

For individual patients coming to the practitioner's office, the prevalence (or pretest probability of disease) and natural history of hypertension do not differ substantially enough to call for different BP screening intervals or definitions of hypertension for different racial and ethnic groups. Similarly, once hypertension is diagnosed, guidelines suggest similar BP goals regardless of race and ethnicity. However, while the definition and goals of therapy remain unchanged, the practitioner needs to be aware that minority populations may face specific individual and systemic barriers to achieving adequate BP control. ⁴ Research on how disparities emerge in the structure and process of care is generally lacking. Certainly, in some instances systemic barriers outside of the medical encounter, including issues of access to and affordability of care, play an important role. In addition, within the medical encounter, it is possible that practitioner bias, including implicit or unconscious bias that may be propagated through the media, peers, the educational system, or personal experience, may at times be an issue. ¹⁰ However, perhaps the biggest obstacle to improved BP control among minority populations (and perhaps majority populations as well) is poor provider‐patient communication and lack of cultural competency among providers. Observational studies have reported systematic differences in the quality of clinical interactions based on patient race and ethnicity, particularly in the realm of physician‐patient communication. ¹¹ Improved communication skills can lead to more satisfied patients, enhanced adherence to recommended therapies, better patient follow‐up, and improved clinical outcomes.

Previous efforts in improving cultural competency among providers have focused on various aspects of care. Attempts have been made to overcome language barriers through the use of bilingual or bicultural providers, interpreter services, and linguistically specific literature. Sensitivity to particular aspects of culture has been emphasized. Education and training programs have been designed to teach providers about the specific values, customs, and beliefs attributed to different racial and ethnic groups. However, each of these approaches, while certainly well‐meaning, relies heavily on categorical constructs that tend to lump patients of similar races or ethnicities into groups that are believed to share similar characteristics. This strategy may lead to significant stereotypical oversimplification. For example, while both may describe themselves as young Hispanic Americans, a 35‐year‐old single mother born in Cuba but now residing in Miami may have very little in common with a 35‐year‐old married professional without children living in suburban Chicago whose parents immigrated from Mexico before she was born. Applying the same categorical constructs to both these patients may be ineffective and perhaps even counterproductive.

Rather than apply this rigid approach, we have suggested a more flexible patient‐based approach to cross‐cultural communication that emphasizes determining each individual's unique social context, cultural health beliefs, and behaviors. ¹² , ¹⁴ This model emphasizes 4 domains to effective cross‐cultural communication that, when addressed by providers who treat diverse patient populations, may improve satisfaction, adherence to medical therapy, and heath outcomes. The domains of this model (ESFT) are Explanatory model (E), Social and financial risk for nonadherence (S), Fears and concerns about treatment (F) and Therapeutic contracting (T). ¹² Of particular importance to this strategy is the concept of the explanatory model or conceptualization of disease. ¹³ To improve patient adherence to recommended therapies, it is imperative that practitioners explore the patient's conceptualization of the diagnosis and ensure that the patient understands the practitioner's concept of the condition. In the case of hypertension, we would like our patients to more fully understand that it is a chronic, usually asymptomatic medical condition that increases the risk of cardiovascular events such as stroke and myocardial infarction if not aggressively treated. However, patients may have a very different understanding, for example, the notion that hypertension is episodic and primarily stress‐related. Once the patient's explanatory model has been elicited, the practitioner should explicitly explore social or financial barriers to adherence, including ability to afford or physically obtain medication and particular fears and concerns the patient may have about adverse effects of treatment. Finally, rather than taking a paternalistic approach, the practitioner should negotiate the next steps for treatment and ensure that the patient understands the treatment regimen.

This easy‐to‐use, common‐sense communication intervention can be used at every visit and is applicable to multiple medical conditions and to patients of all racial, ethnic, and social backgrounds. We hope that by improving practitioner‐patient communication, this tool, or other individualized patient‐based models that are developed in the future, can help identify and overcome barriers to patient adherence and improve outcomes for all hypertensive patients.