“Blood pressure monitoring should be a habit”: adaptation of the Check. Change. Control. program for Asian American older adults, from group-based in-person to one-on-one telephone delivery

Abstract

Asian Americans have the lowest rate of awareness about hypertension, including controlled hypertension, among all racial/ethnic groups in the USA. A high proportion of Asian American older adults have limited English proficiency (LEP) and hypertension. This study adapted the Check. Change. Control. (CCC) program, a community-based intervention for hypertension control delivered in a face-to-face group setting, to phone-based delivery and evaluated the acceptability of the program among Asian American older adults with LEP. Thirteen participants received phone-based educational sessions on hypertension control over 4 months. After 4 months of interventions, we interviewed the 13 Asian American older adults and 4 counselors to examine the acceptability of the adapted CCC program. Both Asian American older adults and counselors found the phone-based delivery of the CCC program to be acceptable, and some participants recommended holding an in-person meeting before telephone delivery to review the program content and clarify information. Future study needs to explore the effectiveness of the phone-based delivery of the program on blood pressure management among larger groups of Asian American older adults.

Telephone-based delivery of a hypertension control intervention is acceptable among Asian American older adults with limited English proficiency.

Implications.

Practice: Telephone-based delivery of intervention for hypertension control is acceptable among Asian American older adults with limited English proficiency.

Policy: The future program could diversify the delivery methods to one-on-one Zoom, Facetime, or Skype, especially in the COVID-19 era.

Research: Future studies need to examine the acceptability of the program among larger groups of Asian American older adults.

INTRODUCTION

Telehealth, “the delivery of health care services, where patients and providers are separated by distance [1],” has been found to be effective in various health interventions, such as the management of diabetes [2,3], medication [4], chronic obstructive pulmonary disease (COPD) [5,6], and heart failure [7–9]. Telehealth provides unique benefits to delivering services; it affords an opportunity for people to receive services in familiar environments, such as their homes [10–12], and reaches populations that are immobile or in rural [13–15] and underserved [14,16] areas. Telehealth has been regarded as critical and beneficial for elderly populations with barriers to accessing health services [1].

Asian Americans are one of the fastest-growing racial/ethnic groups in the USA [17]. Compared to other racial/ethnic groups, Asian Americans report a low rate of health care utilization [18]. Furthermore, a high proportion of Asian Americans report having limited English proficiency (LEP; 62%) [19]. Previous studies found that Asian Americans with LEP encounter barriers to receiving high-quality health care [20–22]. In addition to their LEP status, Asian Americans report lower awareness and knowledge about hypertension than other racial/ethnic groups in the USA [23,24]. Older adults in general experience higher rates of hypertension (63.1%) compared to their younger counterparts in the 40–59 year old group (33.2%) and those in the 18–39 year old group (7.5%) [25]. Similarly, older Asian Americans experience higher rates of hypertension compared to their younger counterparts [26]. These disparities highlight the need for tailored strategies to increase awareness and knowledge of hypertension control among Asian American older adults with LEP.

The Check It, Change It (CICI) program is an evidence-based program that was developed by the American Heart Association (AHA) in collaboration with Durham Health Innovations to support blood pressure monitoring [27,28]. A study of the CICI program found that about 70% of participants experienced a 10 mmHg decrease in systolic blood pressure after participating in the program [28]. Building upon the CICI program, in 2013, the AHA launched the Check. Change. Control. (CCC) program, a community-based intervention program focused on blood pressure management and the prevention of other cardiovascular diseases [29]. CCC is delivered in a face-to-face group setting by AHA-trained local peer counselors. The counselors assist older adults in creating a blood pressure monitoring plan, help them self-monitor their blood pressure, and connect them with the appropriate resources (e.g., facilities with free blood pressure monitoring equipment). Additionally, they provide participants with ongoing counseling on diet, exercise, and medication compliance. Previous studies have found the CCC program to be acceptable and effective in improving hypertension management among African Americans [28], Chinese Americans [30], and Hispanics [30]. A multisite evaluation study of the CCC program [29] indicated that participants across all 18 community sites experienced decreased systolic blood pressure, suggesting the program’s effectiveness across diverse populations [29].

While the effectiveness of the in-person delivery of the CCC program has been well documented quantitatively, limited research has used qualitative research methods to examine the acceptability of the program when it is adapted from in-person to phone-based delivery for older Asian American adults and their counselors. Specifically, there is a lack of research examining the acceptability of the CCC program, its components, the delivery mode from the perspectives of older Asian American adults, and understanding the implementation process from counselors’ perspectives. Applying the Social Context Framework, the Andersen Behavioral Model of Health Services, and the RE-AIM framework, we conducted a pilot study to qualitatively evaluate the acceptability of the CCC program on blood pressure monitoring and the adaptation from in-person to phone-based delivery among Asian American older adults and their counselors.

Theoretical considerations

Three theoretical frameworks informed development and analysis in this study: the Social Context Framework [31,32], Andersen’s Behavioral Model of Health Services [33,34], and the RE-AIM framework [35]. The Social Context Framework maintains that a wide range of sociocultural forces (e.g., social structures, processes, organizations, institutions, and individual/personal trajectories in society) are interrelated and shape individuals’ daily experiences, as well as their health behavior [31,32]. Previous studies have identified the impact of different but intertwined sociocultural forces on health behavior among immigrant and minority populations, such as Human Papillomavirus vaccination uptake among East African immigrant women [36] and cancer prevention for working-class multiethnic populations [37]. As a useful tool to understand individuals’ health behavior in their society, the Social Context Framework suggests that Asian culture and the Asian community in the USA could influence Asian Americans’ health service utilization, including blood pressure monitoring.

The Andersen Behavioral Model of Health Services [33,34] provides a health care perspective suggesting that health care utilization could be stipulated by predisposing factors (e.g., demographic and attitudinal-belief factors), enabling factors (e.g., income and health insurance status), and need for care factors (e.g., perceived and diagnosed illness). In general, earlier studies have noted the importance of enabling factors rather than predisposing or need factors to explain Asian Americans’ health care utilization [38,39] and hypertension management [40].

In addition, this research was informed by the RE-AIM framework [35], which guided the assessment of the counselors’ evaluations of the delivery of the adapted CCC program. The RE-AIM framework suggests five different multilevel dimensions to comprehensively evaluate the impact of public health interventions: reach (individual level), efficacy (individual level), adoption (organization level), implementation (organization level), and maintenance (individual and organization level). The RE-AIM framework has been widely used to understand key dimensions that facilitate the adoption, implementation, and sustainability of effective interventions [41].

DATA AND METHODS

Study design

We conducted a pilot study to qualitatively evaluate the acceptability of a 4 month CCC program adapted from group-based, face-to-face delivery to phone-based delivery, including the use of landlines, cellphones, and smartphones between March 2016 and September 2017. After the completion of the CCC program, we conducted a semistructured interview with each participant over the phone, and each counselor was interviewed in person. Interview questions were framed to gather participants’ and counselors’ perspectives regarding the program’s cultural relevance and acceptability. The interviews were conducted in the participants’ preferred language and audio recorded; all counselors were interviewed in English. We have followed the methodology using the consolidated criteria for reporting qualitative research (COREQ) guidelines [42] for conducting qualitative methods.

Participants and recruitment

Two groups of participants were included in this study. The first group of participants in this study consisted of three groups of Asian American older adults (Chinese, Korean, and Vietnamese); all participants lived in Washington State. Using convenience sampling, we collaborated with a large community-based organization that provides social services to a diverse group of Asian American and Pacific Islander (AAPI) seniors to identify potential participants through a helpline database and community outreach. We screened participants for eligibility based on their ethnicity (Chinese, Korean, or Vietnamese), age (65 years old or older), state of residency (Washington state), LEP status (defined as speaking English less well), and their risk for hypertension (those who had experienced high blood pressure or had taken medication for hypertension were selected). We focused on Chinese, Korean, and Vietnamese older adults, as these populations were those most served by the organization’s helpline and within the top five Asian American subgroups in Washington State.

Once potential participants were identified as meeting initial eligibility criteria (ethnicity and age), staff members sent a letter to potential participants explaining the research project and inviting them to participate. A total of 136 invitation letters were sent out (51 in Chinese, 15 in Korean, and 70 in Vietnamese). The invitation letter briefly described the CCC program and its purpose, what participation would entail, and the potential benefits and harm from participating in the research project; recipients were asked to call the research team if they were interested in the project. Of the 136 participants, 14 Asian American older adults responded to the letter, were deemed eligible, and were enrolled. A participant discontinued their participation in the study, resulting in a total of 13 Asian American older adults. Since we reached data saturation with 13 participants, we did not attempt to recruit more participants.

The second group of participants in this study included four bilingual and bicultural (2 Chinese, 1 Korean, and 1 Vietnamese) phone counselors. All were female, foreign born, and had a BA degree. Two were in their 60s and the other two were in their 20s. All counselors had extensive experience providing services to seniors and were from the same culture, so they had an adequate understanding of Asian American older adults. The interviews with phone counselors were in English by the data collectors.

Intervention

Four bilingual and bicultural counselors delivered the intervention. Prior to the counseling sessions, counselors received a day-long training from AHA. In addition to providing a blood pressure monitoring device to track blood pressure, the CCC program offered educational and counseling sessions over 4 months to help participants manage hypertension. Sessions included general information on hypertension and risk factors (Month 1), behavior change to reduce risk factors (Month 2), the importance of medication adherence and consequences of uncontrolled blood pressure (Month 3), and ways to manage blood pressure (Month 4). The counselors delivered the intervention via telephone eight times (biweekly for 4 months) to check the participants’ blood pressure. During the call, counselors asked additional questions about the participant’s health and their other needs. To achieve intervention fidelity, the researcher met with the counselors regularly to review their adherence to intervention delivery protocol.

Data collection

At the end of the intervention, three bilingual and bicultural (Chinese, Korean, and Vietnamese) data collectors conducted semistructured interviews with older Asian American adults in their respective language and with the counselors in English. On average, the interviews took 40–60 min and were conducted on the phone. All interviews were audio recorded, transcribed in the language the interview took place, and translated into English for data analysis. The data collectors were not the counselors who delivered the CCC program to the older Asian American adults. All three bilingual (Chinese, Korean, and Vietnamese) and bicultural data collectors were females, had advanced degrees (masters and higher) in social work and public health, were employed at the partnering organization, had experience working with older adults, and were trained and experienced in collecting qualitative interview data. All data collectors received training from the AHA on the CCC program, hypertension management, and gathering field notes during the interviews. Field notes were minimal, as the data collection took place on the phone, and did not provide further information than the interview data.

Participants’ interview guide

The participants’ semistructured interview guide explored the older Asian American adults’ overall experiences in the program, as well as their thoughts on specific components of the intervention, counseling calls, the counselors themselves, and blood pressure monitoring. The participant interview guide was informed by the Andersen Behavioral Model of Health Services and included predisposing, enabling, and the need for care factors [33,34]. The interview guide was also informed by the Social Context Framework to explore social, cultural, and religious contexts [31,32]. Table 1 presents examples of interview questions. These questions were reviewed by the bilingual and bicultural data collectors for comprehension and cultural appropriateness prior to the interviews.

Table 1.

| Asian American older adults interview questions based on Social Context Framework and Andersen’s Behavioral Model of Health Services

	Domains	Example of questions
Social context	Social context	- Can you tell me how friends and family may influence your decision to check your blood pressure?
	Cultural context	- Can you tell me cultural beliefs in your [Ethnic Group] community that can either help or make it difficult for people to decide to monitor their blood pressure?
	Religious context	- Are there religious beliefs that may influence whether or not people in your [Ethnic Group] community decide to monitor their blood pressure? What are they?
Andersen’s Behavioral Model of Health Services	Health care context	Predisposing - How could a person’s age impact whether or not they check their blood pressure?
		Enabling - How easy or difficult is it to find health professionals in your [Ethnic Group] community who can provide information about blood pressure monitoring?
		Need - How much do you think people in your [Ethnic Group] community are aware of blood pressure monitoring?

Phone counselors’ interview guide

All interviews with phone counselors were in English and were transcribed verbatim. Questions explored the counselors’ overall thoughts and experiences with delivering the group-based, in-person program compared to a telephone-based delivery. The counselor interview guide was informed by the RE-AIM framework to explore the adoption, implementation, and maintenance of the telephone-based CCC program [35]. Examples of counselor interview guide questions are included in Table 2.

Table 2.

| Counselor interview questions informed by the RE-AIM framework to explore adoption, implementation, and maintenance

Dimension	Example of questions
Community awareness Agency awareness	- How much does the [Ethnic Group] community that you serve consider hypertension to be a problem? - How much do the participants consider the Check. Change. Control. program to be a solution to the problem?
Adoption	- How comfortable were you in approaching your supervisor when you needed assistance with the Check. Change. Control. program? - Did you feel that the information you delivered was culturally appropriate to your [Ethnic Group] community? Why or why not?
Implementation	- What are some resources in your organization that made it easy for you to deliver the calls to the clients? - Can you tell me if your organization currently has the resources needed (staff, facilities, and partners) to implement the Check. Change. Control. program?
Maintenance	- What kind of resources do you think your organization would need to maintain the Check. Change. Control. program in the long term? - What kind of partnerships would be helpful to your organization in order to maintain the Check. Change. Control. program?

Data analysis

The data were organized using Atlas.ti, version 7 (Scientific Software Development, Berlin, Germany, 2013). Two coders independently coded the first three transcripts using the inductive (without predetermined codebook) constant comparison approach, in which concepts were identified and codes were derived from the data and met to discuss and create a tentative codebook. Using an iterative process, both coders met biweekly to refine the codebook—adding, removing, and revising codes as needed—to resolve discrepancies and arrive at a consensus and to compare new codes with existing codes. When a new code was found, the coders reread all transcripts to ensure consistent coding of the emerging concepts (compare and contrast). We found a consensus around themes that were identified throughout the coding and analysis process.

RESULTS

The CCC program (Asian American older adults)

This section analyzes themes from interviews with Asian American older adults only. Two major themes were identified: perception of the CCC program and acceptability of the counselors and the delivery methods.

Perception of the CCC program

There was an overall sentiment across the interviews that self-reminders and having one’s own blood pressure monitoring device were necessary to check their blood pressure regularly. A participant summarized the importance of regular self-monitoring and her habit of measuring her blood pressure daily before she dives into the news on her computer:

Blood pressure monitoring should be a habit. It’s easy. I made it my habit. I have a computer in front of my desk. When I open the computer, I measure before I watch the news and then I see the blood pressure.

However, participants also found it difficult to check their blood pressure regularly because self-reminders were more difficult to enact with older age (as a predisposing factor), and they did not have a blood pressure monitoring device at home (as an enabling actor). Participants commonly stated that their culture or religion were unimportant regarding blood pressure monitoring, as it is an individual responsibility:

In this matter, no. You take care of yourself. In religious activities, they seldom pay attention to these matters. This is something that commonly occurs in life, so you pay attention to it, and with religious communities, they really only pay attention to their most important purpose, they don’t pay attention to these things. This is a matter confined to the field of health.

Unlike cultural and religious contexts, social contexts, especially that of the family, was considered important because people are able to remind each other. However, participants pointed out that more information should be disseminated among the Asian American community so that the family members can remind each other with relevant information about blood pressure monitoring:

… families that have the knowledge…can remind each other. If family members have learned new information, they will remind each other. But for families that don’t know, then they don’t really do that.

Consequently, all Asian American older adults perceived the CCC program positively and appreciated it because they felt it was beneficial and relevant to promoting their health. A participant perceived that the CCC program would positively impact their community:

I want to say that continuing this program is good for the Vietnamese community, the Asian American community at large. It’s very good.

Another participant discussed the comparative access of community resources (enabling factor) in their home countries and the USA, revealing a positive perception of the CCC program:

I think this is already very good. In China, they will do this by setting up a table in the parks or public areas to provide a free service for blood pressure monitoring. Sometimes educating people. Though it’s free, the time is short. Now, we can find this kind of program in the Chinese communities [in America]. Many seniors would like much of these programs for blood pressure and blood sugar monitoring.

Discussions about the positive perception of the CCC program centered around increasing resources that enable individuals to engage in blood pressure monitoring, such as receiving reminders to check their blood pressure, receiving a blood pressure device through the program, and being motivated to use the device to regularly “measure” their blood pressure and “see how much it is.” Furthermore, several participants felt that they had gained “confidence” in, and felt more in control over, their health by regularly self-monitoring their blood pressure. Discussions about the positive perception of the CCC program included receiving new information and empathy from their counselors and that the counseling sessions helped identify new health questions for their doctors.

They [the counselor] asked me about my heart rate, high blood pressure, low blood pressure readings. I’ve never thought about my heart rate before but I learned about it. I asked about high and low heart rate and the counselor said they weren’t sure about it either. So I just thought I should go and ask my doctor about it when I visit the hospital.

Acceptability of the counselors and the delivery methods

Many Asian American older adults raised the subject of low community awareness (predisposing factor) about blood pressure. Vietnamese participants stated that awareness in their community is “actually very little.” A Chinese participant shared this sentiment and explained her friends’ experience:

I think so [that the community awareness around hypertension is low]. Many of my friends said they seldom measure [their] blood pressure. If doctors ask them to take medicine, after a while, if they measure their blood pressure [and it] is OK, they don’t take the medicine. They don’t pay much attention to this problem.

They claimed that community awareness helps people monitor their blood pressure more frequently and saw the need for a hypertension control intervention program in the Asian American community. Based on their participation, Asian American older adults felt that the CCC program was acceptable and that the counselors were friendly, reliable, supportive, and good at clearly delivering the needed information:

I think she is trustworthy and punctual. When the appointment is at a certain time, she would call at that time. She never misses an appointment. During counseling sessions, she is very willing to talk to you. If my blood pressure is very good, she will praise me about it. If my blood pressure is not too good, she will ask the causes. She was very good and very friendly.

The phone delivery method was generally well received, but some wanted this to be coupled with in-person meetings. Some participants stated that the phone-delivered program was sufficient, saying “It’s nice and easy to do things via phone,” and “I liked the phone calls because it made me gain interest and keep track of monitoring my blood pressure.” However, others thought that phone delivery was not sufficient and suggested combining the calls with in-person meetings with the counselors, especially for the first session.

Adaptation and implementation of CCC program (counselors)

Community and agency awareness

All counselors agreed that the community awareness around blood pressure monitoring is still low, which raised the need for “opening up the dialogue and introducing new information”:

I think it is important for them to be aware of that. For the people in the community to be aware of that. Not all of them know a lot about their blood pressure or they seem to not really care. They don’t know about the diseases or conditions so they are not aware of their health issues. I think it is important to reach out to the community and let them know.

Some counselors emphasized that increasing community awareness around blood pressure monitoring “is very important for any community, especially when it comes to older age because health disease and chronic diseases develop over time.”:

Well, I know when you’re young, you may not be inclined to check it as often because you believe heart disease is for older people and I’m still young. In older people, I don’t think they are aware that blood pressure has such an important role in their overall health. This is because heart disease is the number one killer, but it can help educate them. They are just unaware of what risks they have and how they can fix them. Open up the dialogue and you just introduce new information to them. But I think age shouldn’t matter when it comes to health and what an individual can and cannot do about it.

Regarding the promotion of blood pressure monitoring among Asian American older adults, counselors perceived that the adapted CCC program is needed and helpful:

It is very helpful because when we talk about blood pressure, I think a lot of the participants only get to check it when they go to the doctor. If they become aware, it becomes a habit to check it regularly. If they can get their own blood pressure machine, I think it would help them be more aware of the habits that can lower blood pressure. Maybe it’s stress, eating, diet, and exercise. It gives them a tangible measurement of how they are doing with their blood pressure.

Adaptation, implementation, and maintenance

Overall, the counselors reported that the participants were engaged in the CCC program and, as the program progressed, they saw increased interest in blood pressure monitoring, a powerful enabling resource. Furthermore, counselors commonly mentioned that the free blood pressure monitoring device was a big incentive for Asian American older adults to join the CCC program and was essential in keeping them engaged in the program.

Most of them took the offer [to participate in the program] because of the incentive for the blood pressure monitor. However, [considering] the whole process when compared from the beginning to the end of the program, many developed more interest [in the program]. They even checked it [blood pressure] more than required.

Overall, the comfort level with intervention delivery was high among counselors because they had a detailed script, they were able to modify it when needed, and they practiced the script. Their supervisor also tried to help them throughout the implementation process. In addition, having a list of participants who had participated in other health promotion programs was a helpful resource that made it easy for counselors to deliver calls to Asian American older adults:

A big resource that was helpful was a list of participants that are currently in the program. Because we do have these programs, the participants and the demographics of each program, it was easy to reach out to them. They were already familiar with NAPCA and this was just an extra service we were able to offer.

However, counselors reported that they would need more resources to make it more effective.

Currently, I believe we are partners with the American Heart Association for this program, but I would like to see written resources, like educational material. As for staff, health consultants would be a good resource, like dieticians, nutritionists, and nurses, just to give us some professional advice for when participants ask difficult questions related to their health.

Counselors said greater staff capacity, more trainings, more workshops, and better phone system facilities would help sustain the program. Additionally, they felt that new partnerships, such as those with the AHA and other partnering agencies through the Senior Community Service Employment Program, would facilitate sustainability.

American Heart Association. We need to have that partnership. And then maybe, if we can expand more of our partnerships with other organizations that focus on health care. Maybe we can find a specific AAPI serving organization, or maybe non-AAPI would be okay too. As long as they have the training, materials, and knowledge about this program in the community.

Since counselors felt that “health is a sensitive topic for many people,” and “situations are different for every person and it depends on how we design it,” many preferred one-on-one phone delivery. Moreover, some perceived that phone delivery could be appropriate, providing older adults with greater flexibility:

I think it might not be as convenient with our seniors because they need to arrange the time to go to the office and may have problems with transportation. That’s why I think that using video conferencing allows our seniors to be more flexible and doesn’t restrict them from access or receiving the counseling.

However, similar to the participants, the counselors suggested combining in-person visits with phone calls. They emphasized the importance of having an in-person meeting with a participant before they joined the program to facilitate better communication over the phone later:

In the beginning, we wanted to meet participants in-person before we started the program. I believe we should implement that in the future because I think the number one reason why participants were hesitant in participating was because of the phone call interactions. It could be more personal if we had met them first.

DISCUSSION

We conducted a pilot study to evaluate the acceptability of a 4 month CCC program adapted from group-based, in-person delivery to phone-based delivery. Our findings revealed that the adapted CCC program, with a blood pressure monitoring device and coethnic counselors who provided one-on-one phone reminders, educational sessions, and counseling sessions, was generally acceptable among Asian American older adults and counselors, as they perceived that it was helpful. Several counselors mentioned that phone calls should be combined with in-person visits, and Asian American older adult participants also pointed out the need for the first session to be in person. This enabled us to understand what is needed to further promote blood pressure monitoring among Asian American older adults and how to better implement and maintain the CCC program between Asian American older adults and phone counselors.

Similar to the findings of previous studies [23,24], in our study, Asian American older adults mentioned that low awareness (predisposing factors) inhibits individuals’ ability to monitor their blood pressure. Participants noted the importance of the counseling calls in raising their awareness to the importance of blood pressure monitoring, as well as their overall health. This is significant as home-based blood pressure measurement has been noted in the literature to be more precise and effective than both blood pressure measurement in physicians’ offices [43,44] and ambulatory blood pressure monitoring [45]. Beyond the program’s impact at the individual level, the future CCC program could be expanded by providing free blood pressure devices to Asian community centers, including senior centers so that more Asian American older adults can monitor their blood pressure routinely in their ethnic community in the USA. As a Chinese participant pointed out the helpfulness of a free device at parks in China, a shared device at the ethnic community center would benefit a larger number of Asian Americans regarding blood pressure monitoring. In addition to enabling factors at both individual and community levels, Asian American older adults indicated predisposing factors. Overall, they perceived a high level of awareness around blood pressure monitoring at the individual level due to their old age and a low level of collective awareness in the community as a whole. Given participants’ perception of the lack of community awareness around blood pressure monitoring, a future CCC program could be further adapted to help Asian American older adults actively share blood pressure control information and monitoring devices with their family and friends in the ethnic community.

Overall, counselors perceived the need to raise awareness around blood pressure monitoring in the Asian American community, especially among Asian American older adults, for whom the adapted CCC program could be particularly helpful. They also perceived that Asian American older adults were receptive to the phone-based CCC program. During the interviews, the counselors indicated that greater staff capacity and partnerships with other agencies would facilitate the long-term sustainability of the CCC program. Although both participants and counselors revealed positive perceptions of the phone-based CCC program, they suggested slight modifications. Rather than fully relying on one-on-one phone-based delivery, they suggested combining the telephone delivery with in-person meetings or having an in-person meeting to launch the program before telephone delivery; they argued that this would make the program more acceptable and usable among Asian American older adults. The future CCC program could incorporate an in-person support group meeting at the beginning or end of the educational sessions to establish a rapport between the counselors and the participants.

This study has several limitations. First, it only included three major Asian ethnic groups (Chinese, Korean, and Vietnamese). Second, it had a small number of counselors (n = 4), who were also from major Asian countries. Therefore, the transferability of the findings may be limited. While the results are not transferable across diverse Asian American older adults, they could be applied to older adults with similar demographic and health needs. Furthermore, future studies must conduct a larger trial with a larger sample of Asian American older adults. Last, the findings could have been strengthened by conducting member checking (e.g., getting feedback from the participants) [46].

Despite the limitations, it is noteworthy that to the best of our knowledge, this is the first study that examined the acceptability and implementation of the CCC program, focusing on Asian American older adults across different ethnic groups (Chinese, Korean, and Vietnamese), and that assessed the perspectives of both Asian American older adults and counselors. Future studies should examine the acceptability of the CCC with a larger trial with AAPIs before moving to any other ethnic groups.

Implications for practice

The findings of this study contribute to a better understanding of the acceptability of telehealth among older Asian Americans with LEP status and will assist in understanding the extent to which telehealth can be leveraged to reach Asian American older adults with LEP. Although older adults generally preferred receiving CCC information via phone and counselors enjoyed delivering it, they also wanted some in-person interaction at the start of the intervention; thus, they did not prefer the exclusive use of telehealth. Older adults had access to culturally and linguistically concordant counselors, which may have played a role in increasing the acceptability of the intervention. In that regard, the implication for practice is that older Asian Americans would favor a hybrid model that still gives them an opportunity to engage with the counselors in-person. While telehealth contributed to making participation easier for older participants, having access to culturally and linguistically concordant counselors may have increased their acceptance of the program.

Delivering health services via telehealth has become more relevant during the coronavirus disease 2019 (hereafter COVID-19) pandemic, which has affected people’s daily lives, as well as their health and health service utilization. In the COVID-19 era, people are becoming more familiar and comfortable with connecting with others virtually [47]. To avoid in-person contact, which could cause the virus to spread from person to person, telehealth has been leveraged as one of the important ways to deliver interventions and health care in the “untact” age [47–49]. Considering that telehealth is more valuable for vulnerable and elderly populations [1], the phone-based intervention delivery of the CCC program may be even more relevant for Asian American older adults with LEP in the era of COVID-19. As individuals may experience lower psychological resistance to receiving virtual health interventions in the post-COVID-19 era, future studies could diversify the delivery methods of the CCC program beyond phone delivery; one-on-one Zoom, Facetime, or Skype delivery might be more acceptable, or a hybrid of in-person and virtual methods could be used.

CONCLUSION

Asian Americans have the lowest rate of awareness around hypertension, including controlled hypertension, among all racial/ethnic groups in the USA. The promotion of hypertension awareness and regular blood pressure monitoring must include tailored approaches to reach older adult populations. Our study shows that an adaptation of the CCC program from an in-person, group-based setting to phone-based delivery is acceptable and well received by Asian American older adults and telephone counselors. Future research should explore the effectiveness of a phone-based delivery of a blood pressure management program among larger groups of Asian American older adults.

Compliance with Ethical Standards

Conflicts of Interest: The authors declare that they have no conflicts of interest.

Author Contributions: L.K.K. and E.J.L. contributed to the conceptualization and design of the study. L.K.K. and E.J.L. contributed to the implementation of the study and data collection. S.H.J. and L.K.K. contributed to the data analysis. S.H.J. and L.K.K. contributed to the interpretation of the data. S.H.J., L.K.K., E.J.L., and E.V.R.B. contributed to the manuscript development. All authors contributed to the critical revision of the manuscript for important intellectual content.

Ethical Approval: This study was approved by the Institutional Review Board of the Fred Hutchinson Cancer Research Center.

Informed Consent: Informed consent (verbal) was obtained from all individual participants included in the study because the study presented no more than minimal risk of harm to subjects.

Consent for publication

Not applicable. No details, images, or videos relating to individual participants are included in the manuscript.

Data Availability

Data files and materials pertaining to this publication are available upon request at Lko@fredhutch.org.