Text Messaging to Improve Hypertension Medication Adherence in African Americans From Primary Care and Emergency Department Settings: Results From Two Randomized Feasibility Studies.
BACKGROUND
Hypertension (HTN) is an important problem in the United States, with an estimated 78 million Americans aged 20 years and older suffering from this condition. Health disparities related to HTN are common in the United States, with African Americans suffering from greater prevalence of the condition than whites, as well as greater severity, earlier onset, and more complications. Medication adherence is an important component of HTN management, but adherence is often poor, and simply forgetting to take medications is often cited as a reason. Mobile health (mHealth) strategies have the potential to be a low-cost and effective method for improving medication adherence that also has broad reach.


OBJECTIVE
Our goal was to determine the feasibility, acceptability, and preliminary clinical effectiveness of BPMED, an intervention designed to improve medication adherence among African Americans with uncontrolled HTN, through fully automated text messaging support.


METHODS
We conducted two parallel, unblinded randomized controlled pilot trials with African-American patients who had uncontrolled HTN, recruited from primary care and emergency department (ED) settings. In each trial, participants were randomized to receive either usual care or the BPMED intervention for one month. Data were collected in-person at baseline and one-month follow-up, assessing the effect on medication adherence, systolic and diastolic blood pressure (SBP and DBP), medication adherence self-efficacy, and participant satisfaction. Data for both randomized controlled pilot trials were analyzed separately and combined.


RESULTS
A total of 58 primary care and 65 ED participants were recruited with retention rates of 91% (53/58) and 88% (57/65), respectively. BPMED participants consistently showed numerically greater, yet nonsignificant, improvements in measures of medication adherence (mean change 0.9, SD 2.0 vs mean change 0.5, SD 1.5, P=.26), SBP (mean change -12.6, SD 24.0 vs mean change -11.3, SD 25.5 mm Hg, P=.78), and DBP (mean change -4.9, SD 13.1 mm Hg vs mean change -3.3, SD 14.3 mm Hg, P=.54). Control and BPMED participants had slight improvements to medication adherence self-efficacy (mean change 0.8, SD 9.8 vs mean change 0.7, SD 7.0) with no significant differences found between groups (P=.92). On linear regression analysis, baseline SBP was the only predictor of SBP change; participants with higher SBP at enrollment exhibited significantly greater improvements at one-month follow-up (β=-0.63, P<.001). In total, 94% (51/54) of BPMED participants agreed/strongly agreed that they were satisfied with the program, regardless of pilot setting.


CONCLUSIONS
Use of text message reminders to improve medication adherence is a feasible and acceptable approach among African Americans with uncontrolled HTN. Although differences in actual medication adherence and blood pressure between BPMED and usual care controls were not significant, patterns of improvement in the BPMED condition suggest that text message medication reminders may have an effect and fully powered investigations with longer-term follow-up are warranted.


BACKGROUND
Clinicaltrials.gov NCT01465217; https://clinicaltrials.gov/ct2/show/NCT01465217 (Archived by WebCite at http://www.webcitation.org/6V0tto0lZ).
Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States.
Lorraine
http://orcid.org/0000-0001-5855-9972
L
Buis
College of Nursing, Wayne State University, Detroit, MI, United States.
Lindsey
http://orcid.org/0000-0001-6438-5913
L
Hirzel
Department of Emergency Medicine, School of Medicine, Wayne State University, Detroit, MI, United States.
Rachelle M
http://orcid.org/0000-0002-8264-2976
RM
Dawood
Department of Emergency Medicine, School of Medicine, Wayne State University, Detroit, MI, United States.
Katee L
http://orcid.org/0000-0001-7670-5929
KL
Dawood
Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States.
Lauren P
http://orcid.org/0000-0002-9915-2308
LP
Nichols
College of Nursing, Wayne State University, Detroit, MI, United States.
Nancy T
http://orcid.org/0000-0003-4021-4735
NT
Artinian
College of Engineering, Wayne State University, Detroit, MI, United States.
Loren
http://orcid.org/0000-0002-7167-7436
L
Schwiebert
College of Nursing, Wayne State University, Detroit, MI, United States.
Hossein N
http://orcid.org/0000-0001-9927-8894
HN
Yarandi
Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States.
Dana N
http://orcid.org/0000-0001-5719-7818
DN
Roberson
Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States.
Melissa A
http://orcid.org/0000-0001-6032-534X
MA
Plegue
Department of Emergency Medicine, School of Medicine, Wayne State University, Detroit, MI, United States.
LynnMarie C
http://orcid.org/0000-0002-6030-4976
LC
Mango
Department of Emergency Medicine, School of Medicine, Wayne State University, Detroit, MI, United States.
Phillip D
http://orcid.org/0000-0001-7306-5620
PD
Levy
African Americans; blood pressure; cell phone; hypertension; medication adherence; telemedicine; text messaging