Design and Rationale of the Cardiometabolic Health Program Linked with Community Health Workers and Mobile Health Telemonitoring to Reduce Health DisparitieS (LINKED-HEARTS) Program.

BACKGROUND: Hypertension and diabetes are major risk factors for cardiovascular diseases, stroke, and chronic kidney disease (CKD). Disparities in hypertension control persist among Black and Hispanic adults and persons living in poverty in the United States. The "LINKED-HEARTS Program" (a Cardiometabolic Health Program LINKED with Community Health WorkErs and Mobile HeAlth TelemonitoRing To reduce Health DisparitieS"), is a multi-level intervention that includes home blood pressure (BP) monitoring (HBPM), blood glucose telemonitoring, and team-based care. This study aims to examine the effect of the LINKED-HEARTS Program intervention in improving BP control compared to enhanced usual care (EUC) and to evaluate the reach, adoption, sustainability, and cost-effectiveness of the program. METHODS: Using a hybrid type I effectiveness-implementation design, 428 adults with uncontrolled hypertension (systolic BP ≥ 140 mm Hg) and diabetes or CKD will be recruited from 18 primary care practices, including community health centers, in Maryland. Using a cluster-randomized trial design, practices are randomly assigned to the LINKED-HEARTS intervention arm or EUC arm. Participants in the LINKED-HEARTS intervention arm receive training on HBPM, BP and glucose telemonitoring, and community health worker and pharmacist telehealth visits on lifestyle modification and medication management over 12 months. The primary outcome is the proportion of participants with controlled BP (<140/90 mm Hg) at 12 months. CONCLUSIONS: The study tests a multi-level intervention to control multiple chronic diseases. Findings from the study may be leveraged to reduce disparities in the management and control of chronic diseases and make primary care more responsive to the needs of underserved populations.

The impact of the Prime Time Sister Circles® (PTSC) on blood pressure of low-income mid-life African American women in the United States.

There is a pressing need to develop and evaluate culturally tailored, community-based interventions that address hypertension management among low-income African American women. We employed a randomized controlled trial to test the effectiveness of the Prime Time Sister Circles® Program in reducing blood pressure and body mass index among low-income African American women ages with hypertension. Study participants (N = 339) were African American women aged 40-75 years who were diagnosed with hypertension and received their primary care at government funded health centers in Washington, D.C. Compared to the usual care group, Prime Time Sister Circles® participation was associated with a reduction in systolic BP by - 2.45 (CI - 6.13, 1.23) mmHg, a reduction in diastolic BP by - 3.66 mmHg (CI - 6.32, - 0.99), and a change in BMI by - 0.26 (CI - 2.00, 1.48) from baseline to 15 months. The results suggest that culturally tailored community-based interventions can improve hypertension management in low-income women.

Voices, Images, And Experiences Of Community Health Workers: Advancing Antiracist Policy And Practice.

Community health workers (CHWs) are front-line public health personnel who share common attributes with or have a nuanced understanding of the communities they serve. Their membership in marginalized communities gives them expertise in delivering contextualized interventions that mitigate their clients' social risk factors, but it also places them at greater risk for exposure to various harms. We employed the photovoice method to illuminate how the lived experiences of CHWs working, residing, or both in Baltimore City, Maryland, dovetail with facets of their jobs. In partnership with our sixteen predominantly racial and ethnic minoritized study participants, we surfaced the ways in which CHWs negotiated and subsequently leveraged experiences with social risk factors rooted in structural racism to shape their approach to intervention delivery for structurally vulnerable communities. We also uncovered several occupational hazards that participants faced as a function of their identities. Our findings underscore the need to embed antiracist principles in the fabric of policies and practices that directly affect the CHW workforce.

Palliative Care Curriculum and Training Plan for community health workers.

African American patients are less likely than White patients to access palliative care. Community health workers (CHWs) are non-clinical public health workers who may address this gap. We developed a Palliative Care Curriculum and Training Plan for CHWs as part of an ongoing randomised controlled trial evaluating the effectiveness of a CHW palliative care intervention for African American patients with advanced cancer. This study aimed to determine whether the Palliative Care Curriculum and Training Plan leads to gains in knowledge, perceived competence on CHW study-based tasks, and satisfaction among CHWs. The curriculum was delivered over 3 months using synchronous, asynchronous and experiential training components. CHWs were assessed through survey questionnaires and semistructured interviews. We trained a total of three CHWs, one from each of our enrolment sites: Johns Hopkins Hospital, TidalHealth Peninsula Regional and University of Alabama at Birmingham Hospital. CHWs demonstrated an increase in knowledge, with a mean pre-training test score of 85% (SD 10.49) and post-training test score of 96% (SD 4.17). The training led to increases in perceived competence among CHWs. Areas for future training were identified. This curriculum serves as a template for CHW training focused on palliative care, oncology and health disparities.

Evaluating the Impact of the Prime Time Sister Circles® Intervention on Reducing Depressive Symptoms Among African American Women with Uncontrolled Hypertension.

BACKGROUND: The Prime Time Sister Circles®, a randomized controlled trial (PTSC-RCT), assessed the impact of a community-based peer support program on hypertension management among African American women 40-75 years of age. While the PTSC-RCT was designed to evaluate changes in blood pressure control, subsequent sub-analyses revealed a high proportion of self-reported depressive symptoms in our sample. Accordingly, we conducted an ancillary investigation of the PTSC intervention on depression to ascertain its impact on reduced depressive symptoms in the study population. METHOD: Depressive symptoms were measured using an adapted version of the Center for Epidemiologic Studies Depression Scale Revised (CES-D-10). We used unadjusted and adjusted fixed effect models. Data for this study came from the PTSC-RCT. We collected data between 2017 and 2018 in Washington, DC. We used a balanced analytical sample of 172 African American, English-speaking women between 40 to 75 years old with uncontrolled hypertension. INTERVENTION: The intervention group participated in a 2-h, peer-based support group once a week for 13 weeks. A trained PTSC facilitator facilitated sessions with experts who delivered content on various topics, including psychosocial wellness (e.g., stress, depressive symptoms, anxiety management, and self-esteem), physical health (e.g., hypertension, inflammation, and heart disease), physical activity, and healthy nutrition. RESULTS: Results from the fixed-effects models indicated that participants in the PTSC program exhibited a greater reduction in CES-D-10 score at three months (Coeff: -1.99, 95% CI: -3.49, -0.49) and at 15 months (Coeff: -2.38, 95% CI: -3.94, -0.83), as compared to those in the control group. CONCLUSIONS: Evidence suggests that the Prime Time Sister Circles® intervention reduced depressive symptoms among African American women with low socioeconomic status and hypertension. TRIAL REGISTRATION: NCT04371614.

Assessing Factors Influencing Commitment to a Disparities Reduction Intervention: Social Justice Attitudes and Organizational Mission.

ABSTRACT: This mixed-methods study aims to understand what the perceptions of leaders and healthcare professionals are regarding causes of disparities, cultural competence, and motivation before launching a disparity reduction project in hypertension care, contrasting perceptions in Federally Qualified Health Centers (FQHCs), and in a non-FQHC system. We interviewed leaders of six participating primary care systems and surveyed providers and staff. FQHC respondents reported more positive cultural competence attitudes and behavior, higher motivation to implement the project, and less concern about barriers to caring for disadvantaged patients than those in the non-FQHC practices; however, egalitarian beliefs were similar among all. Qualitative analysis suggested that the organizational missions of the FQHCs reflect their critical role in serving vulnerable populations. All system leaders were aware of the challenges of provider care to underserved groups, but comprehensive initiatives to address social determinants of health and improve cultural competence were still needed in both system types. The study provides insights into the perceptions and motivations of primary care organizational leaders and providers who are interested in improving chronic care. It also offers an example for care disparity programs to understand commitment and values of the participants for tailoring interventions and setting baseline for progress.

Design and Rationale of the Home Blood Pressure Telemonitoring Linked with Community Health Workers to Improve Blood Pressure (LINKED-BP) Program.

BACKGROUND: Disparities in hypertension outcomes persist among Black and Hispanic adults and persons living in poverty in the United States. The "LINKED-BP Program" is a multi-level intervention linking home blood pressure (BP) monitoring with a mobile health application, support from community health workers (CHWs), and BP measurement training at primary care practices to improve BP. This study is part of the American Heart Association RESTORE (AddREssing Social Determinants TO pRevent hypErtension) Network. This study aims to examine the effect of the LINKED-BP Program on BP reduction and to evaluate the reach, adoption, sustainability, and cost-effectiveness of the intervention. METHODS: Using a hybrid type I effectiveness-implementation design, 600 adults who have elevated BP or untreated stage 1 hypertension without diabetes, chronic kidney disease, history of cardiovascular disease (stroke or coronary heart disease) and age < 65 years will be recruited from 20 primary care practices including community health centers in the Maryland area. The practices are randomly assigned to the intervention or the enhanced usual care arms. Patients in the LINKED-BP Program receive training on home BP monitoring, BP telemonitoring through the Sphygmo app, and CHW telehealth visits for education and counseling on lifestyle modification over 12 months. The primary clinical outcome is change from baseline in systolic BP at 6 and 12 months. DISCUSSIONS: The LINKED-BP Program tests a sustainable, scalable approach to prevent hypertension and advance health equity. The findings will inform implementation strategies that address social determinants of health and barriers to hypertension prevention in underserved populations. CLINICALTRIALS.GOV IDENTIFIER: NCT05180045.

AddREssing Social Determinants TO pRevent hypErtension (The RESTORE Network): Overview of the Health Equity Research Network to Prevent Hypertension.

BACKGROUND: The American Heart Association funded a Health Equity Research Network on the prevention of hypertension, the RESTORE Network, as part of its commitment to achieving health equity in all communities. This article provides an overview of the RESTORE Network. METHODS: The RESTORE Network includes five independent, randomized trials testing approaches to implement non-pharmacological interventions that have been proven to lower blood pressure (BP). The trials are community-based, taking place in churches in rural Alabama, mobile health units in Michigan, barbershops in New York, community health centers in Maryland, and food deserts in Massachusetts. Each trial employs a hybrid effectiveness-implementation research design to test scalable and sustainable strategies that mitigate social determinants of health (SDOH) that contribute to hypertension in Black communities. The primary outcome in each trial is change in systolic BP. The RESTORE Network Coordinating Center has five cores: BP measurement, statistics, intervention, community engagement, and training that support the trials. Standardized protocols, data elements and analysis plans were adopted in each trial to facilitate cross-trial comparisons of the implementation strategies, and application of a standard costing instrument for health economic evaluations, scale up, and policy analysis. Herein, we discuss future RESTORE Network research plans and policy outreach activities designed to advance health equity by preventing hypertension. CONCLUSIONS: The RESTORE Network was designed to promote health equity in the US by testing effective and sustainable implementation strategies focused on addressing SDOH to prevent hypertension among Black adults.

Frontline healthcare workers experiences and challenges with in-person and remote work during the COVID-19 pandemic: A qualitative study.

Introduction: The COVID-19 pandemic created new and exacerbated existing stressors for frontline healthcare workers. Despite being disproportionately affected by COVID-19, little is known about the experiences of frontline healthcare workers serving marginalized populations in community settings. Design: We used qualitative descriptive methods to understand the experiences of 12 frontline healthcare workers (HCWs) supporting primarily underserved populations in outpatient settings during COVID-19. Interviews were conducted from March to April 2021. Methods: Interviews were held virtually via Zoom using a semi-structured interview guide. Interviews were audio-recorded, transcribed verbatim, and uploaded into NVivo 12 qualitative data analysis software. The transcripts were dually coded by members of the research team and a thematic analysis was conducted. Results: Four major themes from the interviews were identified: stressors and burnout, coping strategies, organizational support, and recommendations. HCWs described how the early adjustment period to the pandemic created new challenges as they attempted to navigate changes in the workplace and altered responsibilities at home. HCWs felt largely unsupported by their organizations as they attempted to cope with stressors. Organizational support programs and resources often did not meet frontline workers' needs, and sentiments of unappreciation from leadership contributed to feelings of burnout and frustration as pandemic-related challenges persisted and evolved. Conclusion: Despite encountering numerous stressors at work and home, resulting from pandemic-related disruptions, frontline HCWs continued to provide care for their clients while navigating emerging challenges. Health organizations should include HCWs in decision-making processes when implementing support systems for workers during times of crisis.

Development and Implementation of a Combined Nurse Care Manager and Community Health Worker Training Curriculum to Address Hypertension Disparities.

The use of nurse care managers (CMs) and community health workers (CHWs) has demonstrated effectiveness in supporting improved blood pressure management among racially, ethnically, and socioeconomically minoritized populations. We partnered with a community advisory board (CAB) to develop a CM and CHW training curriculum and team-based collaborative care intervention to address uncontrolled hypertension. The objective of this study was to train CMs and CHWs to implement patient-centered techniques and address social determinants of health related to hypertension control. In partnership with a CAB, we developed and implemented a training curriculum for the CM/CHW collaborative care team. The training improved CM and CHW confidence in their ability to address medical and nonmedical issues that contribute to uncontrolled hypertension in their patients; however, preexisting norms and beliefs among CMs and CHWs created challenges with teamwork. The training curriculum was feasible and well-received. Additionally, the CMs' and CHWs' reactions provided insights to improve future collaborative care training and teamwork.

Effect of substance use on premature mortality among severely hypertensive African Americans.

Low-income African Americans residing in impoverished neighborhoods confront myriad barriers to adhering to antihypertensive regimens. Substance use may thwart medication adherence and lifestyle modification efforts, which has implications for excess cardiovascular disease mortality. The Inner-City Hypertension and Body Organ Damage (ICHABOD) Study was a longitudinal cohort study that evaluated causes of mortality among African Americans who lived in urban areas, had severe, poorly controlled hypertension, and were admitted to a local hospital between 1999-2001 and 2002-2004. The authors employed Cox proportional hazards models to assess mortality associated with illicit substance use, including use of heroin and cocaine, as well as by use of tobacco and alcohol. Among192 participants with poorly controlled hypertension, 30% were active illicit substance users (specifically, 22.7% heroin users, 19.8% were cocaine users, and 30.7% were both cocaine and heroin users). The mean age among substance non-users was 52.3 years versus 48.7 years among those reporting current use. Mortality over 7.6 years of follow-up was 52.5% among substance users and 33.8% among nonusers (p-value, 0.01). After adjusting for potential confounders, the hazard ratio (HR) for cocaine use was 2.52 (95% confidence interval (CI) 1.38-4.59), while the HR for heroin use was 2.47 (95% CI 1.42-4.28) and the HR for both was 2.75 (95% CI 1.60-4.73). Substance use was associated with increased mortality among urban black Americans with poorly controlled hypertension. These data suggest the need for targeted interventions to support African Americans who have poorly controlled hypertension and use illicit substances, as a means of reducing excess mortality.

Honoring Dr. Shalon Irving, A Champion for Health Equity.

Shalon Irving's 2017 death brought national attention to maternal mortality among Black women in the US. This essay remembers her life and legacy.

Patient Navigator and Community Health Worker Attitudes Toward End-of-Life Care.

Background: There are racial/ethnic disparities in hospice use and end-of-life (EOL) care outcomes in the United States. Although the use of community health workers (CHWs) and patient navigators (PNs) has been suggested as a means of reducing them, CHW/PNs' attitudes toward a palliative care philosophy remain unknown. The purpose of this study was to examine how personal attributes affect a CHW/PN's attitude toward EOL care. Methods: CHWs/PNs were recruited from two state-wide organizations and invited to complete an online survey. We collected information on demographics, attitudes toward the palliative care philosophy, and comfort with caring for patients at the EOL. Results: Of the 70 CHWs/PNs who responded to the survey, 82.5% identified as female, 56.4% identified as black, and 56.2% had a four-year college degree or higher. The mean score on a validated scale to assess attitudes toward EOL care was 33.5 (SD = 4.9; possible range, 8-40). Eighty percent strongly agreed or agreed with being open to discussing death with a dying patient. Higher self-efficacy scores were associated with more favorable attitudes toward hospice (r = 0.306, p = 0.016). Conclusions: CHWs/PNs have an overall favorable attitude toward the palliative care philosophy and may be inclined to providing EOL care.

Study protocol of a randomized controlled trial evaluating the Prime Time Sister Circles (PTSC) program's impact on hypertension among midlife African American women.

BACKGROUND: The Prime-Time Sister Circles® (PTSC) program is a multifaceted, community-based peer support intervention targeting African American women who are 40 to 75 years of age. It aims to reduce hypertension disparities observed among African American women by promoting adherence to antihypertensive therapies, including lifestyle modification and therapeutic regimens. METHODS: The PTSC randomized controlled trial will evaluate the effectiveness of the PTSC Program on improved blood pressure control, healthcare utilization attributed to cardiovascular events, and healthcare costs. The study began in 2016 and will end in 2022. African American women who are 40-75 years old, have been diagnosed with hypertension, reside in Washington, D.C. or Baltimore, Maryland, and receive their care from Unity Health Care, a federally qualified health center in Washington, D.C., or Baltimore Medical System, a federally qualified health center in Baltimore, Maryland, are eligible to participate. Those randomized to the intervention group participate in the PTSC Program, which spans 13 weeks and comprises facilitator-led discussions, didactic training about hypertension management, and peer-based problem-solving concerning CVD risk factors and their amelioration. Blood pressure, weight, body mass index, waist circumference, self-reported adherence, physical activity, dietary practices, stress, and healthcare utilization data are collected at baseline, 13 weeks (end of the intervention), 9 months (months post-intervention), and 15 months (one year after the intervention). Healthcare costs will be computed at the end of the study. The study's design is reported in the present manuscript, wherein we employed the SPIRIT checklist to guide its construction. DISCUSSION: Disparities in hypertension prevalence and management observed among mid-life African American women exist as a result of a confluence of structural determinants of health. Consequently, there is a need to develop, implement, and evaluate culturally appropriate and relevant interventions that are tailored to their lived experiences. The PTSC Trial aims to assess the impact of the program on participants' cardiovascular, psychosocial, and cost outcomes. Its results have implications for advancing the science of designing and implementing culturally relevant interventions for African American women. TRIAL REGISTRATION: Unique identifier: NCT04371614 . Retrospectively registered on April 30, 2020.

Evaluating Depressive Symptoms Among Low-Socioeconomic-Status African American Women Aged 40 to 75 Years With Uncontrolled Hypertension: A Secondary Analysis of a Randomized Clinical Trial.

Importance: Depression is one of the leading causes of disability in the United States. African American women of low socioeconomic status with uncontrolled hypertension are at risk of having severe depressive symptoms, yet there is limited research about the mental health of this vulnerable population. Data from the Prime Time Sister Circles randomized clinical trial (PTSC-RCT) study can shed light on the prevalence of depressive symptoms among low-socioeconomic-status older African American women with hypertension. Objective: To determine the prevalence of depressive symptoms among low-socioeconomic-status African American women aged 40 to 75 years with uncontrolled hypertension who receive their care from a federally qualified health center (FQHC) and to identify risk factors associated with depressive symptoms. Design, Setting, and Participants: Cross-sectional analysis of data from the PTSC-RCT of depressive symptomology, measured using an adapted version of the 10-item Center for Epidemiological Studies Depression Scale Revised (CES-D-10). Descriptive statistics were used to characterize the study population. We used logistic regression models to investigate the factors associated with participants with or without symptoms of depression. We used baseline data from the PTSC-RCT study, including 316 African American English-speaking women between ages 40 and 75 years with hypertension (systolic blood pressure ≥140 mm Hg or diastolic ≥90 mm Hg), who received their primary care at a FQHC in Washington, DC, in 2017 and 2018 and were flagged by the FQHC as uncontrolled. Main Outcomes and Measures: We used the CES-D-10 from the Center for Epidemiologic Studies Depression Scale to measure presence of depressive symptoms. Results: A total of 57.0% of the women in the study (180 of 316) scored greater than or equal to 10 on the CES-D-10. Depressive symptoms had a negative association with a postsecondary education (adjusted odds ratio [aOR], 0.492; 95% CI, 0.249-0.968) and a positive association with the number of chronic conditions (aOR, 1.235; 95% CI, 1.046-1.460) and smoking (aOR, 1.731; 95% CI, 1.039-2.881). Conclusions and Relevance: In this study of low-income African American women with uncontrolled hypertension, more than half had symptoms of depression that was associated with less than high-school education, chronic conditions, and smoking. Low-income African American women with uncontrolled hypertension should be screened and adequately treated for depressive symptoms. Trial Registration: ClinicalTrials.gov Identifier: NCT04371614.

Social Determinants of Health as Potential Influencers of a Collaborative Care Intervention for Patients with Hypertension.

Objectives: The use of collaborative care teams, comprising nurse care managers and community health workers, has emerged as a promising strategy to tackle hypertension disparities by addressing patients' social determinants of health. We sought to identify which social determinants of health are associated with a patient's likelihood of engaging with collaborative care team members and with the nurse care manager's likelihood of enlisting community health workers (CHW) to provide additional support to patients. Methods: We conducted a within-group longitudinal analysis of patients assigned to receive a collaborative care intervention in a pragmatic, cluster randomized trial that aims to reduce disparities in hypertension control (N=888). Generalized estimating equations were used to identify which social determinants of health, reported on the study's baseline survey, were associated with the odds of patients engaging with the collaborative care intervention, and of nurses deploying community health workers. Results: Patients who were unable to work and those with higher health literacy were less likely to engage with the collaborative care team than those who were employed full time or had lower health literacy, respectively. Patients had a greater likelihood of being referred to a community health worker by their care manager if they reported higher health literacy, perceived stress, or food insecurity, while those reporting higher numeracy had lower odds of receiving a CHW referral. Implications/Conclusions: A patient's social determinants of health influence the extent of engagement in a collaborative care intervention and nurse care manager appraisals of the need for supplementary support provided by community health workers.

Association of Perceived Stress and Discrimination on Medication Adherence among Diverse Patients with Uncontrolled Hypertension.

Background: Uncontrolled hypertension is a significant risk factor for cardiovascular morbidity and mortality. In the United States, many patients remain uncontrolled, in part, due to poor medication adherence. Efforts to improve hypertension control include not only attending to medical management of the disease but also the social determinants of health, which impact medication adherence, and ultimately blood pressure control. Purpose: To determine which social determinants - health care access or community and social stressors - explain medication adherence. Methods: In this cross-sectional analysis, we used baseline data (N=1820, collected August 2017 to October 2019) from a pragmatic trial, which compares the effectiveness of a multi-level intervention including collaborative care and a stepped approach with enhanced standard of care for improving blood pressure. We used logistic regression analyses to examine the association between patient experiences of care and community and social stressors with medication adherence. Results: The participants represented a diverse sample: mean age of 60 years; 59% female; 57.3% Black, 9.6% Hispanic, and 33.2% White. All participants had a blood pressure reading ≥140/90 mm Hg (mean blood pressure - 152/85 mm Hg). Half of the participants reported some level of non-adherence to medication. Regression analysis showed that, compared with Whites, Blacks (AOR .47; 95% CIs: .37-.60, P<.001) and Hispanics (AOR .48; 95% CIs: .32- .73, P<.001) were less likely to report medication adherence. Also part-time workers (AOR .57; 95% CIs: .38-.86, P<.05), and those who reported greater perceived stress (AOR .94; 95% CIs: .91 - .98, P<.001) and everyday discrimination (AOR .73; 95% CIs: .59 - .89; P<.001) had lower odds of medication adherence. Among Blacks, greater perceived stress (AOR .93; 95% CIs: .88-.98, P<.001) and everyday discrimination (AOR .63; 95% CIs: .49 - .82, P<.005) were negatively associated with medication adherence. Among Hispanics, greater report of everyday discrimination (AOR .36; 95% CIs: .14 - .89, P<.005) was associated with lower odds of medication adherence. Among Whites, the negative effect of perceived stress on medication adherence was attenuated by emotional support. Conclusions: Using the social determinants of health framework, we identified associations between stress, everyday discrimination and medication adherence among non-Hispanic Blacks and Hispanics that were independent of health status and other social determinants. Programs to enhance self-management for African American and Hispanic patients with uncontrolled blood pressure should include a specific focus on addressing social stressors.

Decomposing Race and Ethnic Differences in CVD Risk Factors for Mid-life Women.

OBJECTIVE: This study decomposes race and ethnic differences in hypertension, waist circumference, obesity and allostatic load between black non-Hispanic (BNH), Mexican American (MA), and white non-Hispanic (WNH) women. DATA: This study uses 10,109 observations from The National Health and Nutrition Examination Survey from years 1999-2014 for BNH, MA women, and WNH between 40 and 75 years old. METHODOLOGY: We used the Oaxaca-Blinder decomposition to explore how demographic, socioeconomic, healthcare access, and health behavior factors are associated with race and ethnic differences in blood pressure, waist circumference, body mass index (BMI), and allostatic load score (ALS). RESULTS: We found that demographic factors, socioeconomic status, healthcare access, and health behaviors explained from 0 to 50% of the difference in CVD risk factors between BNH and WNH. However, these factors explain from 39 to 100% of the difference in CVD risk factors between MA and WNH. Differences in demographic, socioeconomic, access to care, and health behavior factor variables explained very little of the differences in CVD risk factors between NHB and MA women. CONCLUSION: The impact of the determinants on CVD risk factors varies by race and ethnicity. Efforts to address differences in CVD risk factors should promote health equity programs and acknowledge that even race and ethnic groups that have similar demographic, SES, access to care, and health behavior factors can have different outcomes.

The RICH LIFE Project: A cluster randomized pragmatic trial comparing the effectiveness of health system only vs. health system Plus a collaborative/stepped care intervention to reduce hypertension disparities.

Disparities in the control of hypertension and other cardiovascular disease risk factors are well-documented in the United States, even among patients seen regularly in the healthcare system. Few existing approaches explicitly address disparities in hypertension care and control. This paper describes the RICH LIFE Project (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) design. METHODS: RICH LIFE is a two-arm, cluster-randomized trial, comparing the effectiveness of enhanced standard of care, "Standard of Care Plus" (SCP), to a multi-level intervention, "Collaborative Care/Stepped Care" (CC/SC), for improving blood pressure (BP) control and patient activation and reducing disparities in BP control among 1890 adults with uncontrolled hypertension and at least one other cardiovascular disease risk factor treated at 30 primary care practices in Maryland and Pennsylvania. Fifteen practices randomized to the SCP arm receive standardized BP measurement training; race/ethnicity-specific audit and feedback of BP control rates; and quarterly webinars in management practices, quality improvement and disparities reduction. Fifteen practices in the CC/SC arm receive the SCP interventions plus implementation of the collaborative care model with stepped-care components (community health worker referrals and virtual specialist-panel consults). The primary clinical outcome is BP control (<140/90 mm Hg) at 12 months. The primary patient-reported outcome is change from baseline in self-reported patient activation at 12 months. DISCUSSION: This study will provide knowledge about the feasibility of leveraging existing resources in routine primary care and potential benefits of adding supportive community-facing roles to improve hypertension care and reduce disparities. TRIAL REGISTRATION: Clinicaltrials.govNCT02674464.