Helping Hypertension Patients to Interpret Blood Pressure Readings and Motivate Blood Pressure Control
Helping Hypertension Patients to Interpret Blood Pressure Readings and Motivate Blood Pressure Control
Hypertension is a major risk factor for cardiovascular disease, and a leading cause of death
 worldwide. Only about 50% of hypertension patients have good blood pressure control. Patients
 with low health literacy have worse blood pressure control, perhaps because they find it
 harder to interpret whether blood pressure readings are high or low, reflect good or bad
 blood pressure control, and indicate a need for behavior change or medication use.

 The American Heart Association has called for broad efforts to help empower hypertension
 patients from different backgrounds to control their blood pressure. Therefore, the
 investigators will evaluate different ways for helping hypertension patients to interpret
 their blood pressure readings and motivate blood pressure control, in a sample of
 hypertension patients varying in health literacy, age, and socio-economic status. Their
 strategy is based on insights from behavioral science studies, which suggest that people find
 it easier to interpret numbers when they can see the range of possible numbers.

 Aim 1: Based on existing communications, the investigators will create 3 blood pressure
 communications:

 (A) a basic table showing only the normal blood pressure range, which is often used in
 clinical practice and online communications about blood pressure, but may make it hard to
 interpret numbers outside of the normal range, potentially undermining behavior change
 intentions; (B) an enhanced table showing how combinations of diastolic and systolic blood
 pressure reflect normal, elevated and hypertension ranges, from the American Heart
 Association; (C) an enhanced graph to be adapted from Blood Pressure UK to show the same
 color-coded ranges as the enhanced table, with diastolic blood pressure on the x-axis and
 systolic blood pressure on the y-axis.

 Aim 2: : In a sample of 650 diagnosed hypertension patients recruited through the Pitt+Me
 Patient Registry at the University of Pittsburgh Medical Center (UPMC), the investigators
 will evaluate whether being presented with the enhanced table or graph (vs. basic table)
 affects patients' self-reported blood pressure measurement (as averaged across two
 measurements taken at the time of the survey at least 1 minute apart, as per directions of
 the American Heart Association), and improves interpretations of these two blood pressure
 readings and of hypothetical blood pressure readings, as well as behavior change intentions.

 Aim 3: The investigators will examine whether Aim 2 findings vary by health literacy, age,
 and SES.
BACKGROUND Hypertension is a major modifiable risk factor for cardiovascular disease, and a
 leading cause of death worldwide. Lifetime risk of hypertension is 70-90%, but it is higher
 among adults who are older and of low socio-economic status (SES). Older age and lower SES
 are also associated with low health literacy, which undermines understanding of health
 information. Yet, low health literacy in hypertension patients is an independent predictor of
 poor blood pressure control, with only about 50% of hypertension patients having controlled
 blood pressure. Possibly, patients with lower health literacy find it harder to interpret
 whether blood pressure readings are high or low, reflect good or bad blood pressure control,
 and indicate a need for behavior change or medication use. Even college-educated hypertension
 patients who have bought home blood pressure monitors may struggle to interpret blood
 pressure readings that are outside the normal range, undermining their intentions to improve
 their blood pressure control.

 BEHAVIORAL SCIENCE INSIGHT Lab studies in behavioral science have found that individuals'
 ability to interpret numbers (likely including blood pressure readings) is improved by
 showing the range or distribution - also called 'reference information'. In preliminary work,
 the PI showed that many people struggle to interpret credit card APRs, because they do not
 know what numbers are good or bad. In line with the behavioral science insight, the PI found
 that providing graphs with ranges of existing APRs helped recipients to see which credit
 cards posed a bad deal, and reduced their intentions to get such credit cards. It has been
 posited that providing reference information (e.g. normal and abnormal blood pressure ranges)
 should also help hypertension patients to interpret blood pressure readings, and help them to
 control their blood pressure.

 If reference information is used when communicating blood pressure readings in clinics and
 online health records, it often involves a basic table that only shows the normal range
 (e.g., <120 for systolic and <80 for diastolic blood pressure). In one behavioral science
 study, 106 university staff performed similarly when using this basic table or when using a
 color-coded horizontal bar graph (showing the normal range in white and values outside the
 normal range in black). However, neither format followed the American Heart Association's
 communication, which shows more reference information for interpreting blood pressure
 readings outside of the normal range. Hypertension patients may need to see such enhanced
 reference information, because they are more likely to encounter blood pressure readings
 outside of the normal range. Moreover, those readings can be harder to interpret - perhaps
 especially for hypertension patients with low health literacy. The investigators propose to
 evaluate 2 formats for providing the more enhanced reference information from the American
 Heart Association, in either a table (as used by the American Heart Association), or a graph
 (as used by Blood Pressure UK, to be adapted to show the information from the American Heart
 Association). The behavioral science literature suggests that tables facilitate reading
 specific numbers, but that graphs help more with interpreting numbers as high or low, and
 good or bad - though that could depend on recipients' health literacy.

 SPECIFIC AIMS The American Heart Association has called for broad-based efforts to improve
 the proportion of hypertension patients with controlled blood pressure, by "further engaging
 individuals in the hypertension control process" with "adequate representation of [specific]
 populations" including those with lower health literacy, older age, and lower SES. Therefore,
 the investigators propose to conduct an NIH Stage I primary data collection project, to
 evaluate the efficacy of interventions to facilitate blood pressure readings and motivate
 blood pressure control, in a sample of hypertension patients varying in health literacy, age,
 and SES.

 Aim 1: Based on existing communications, the investigators' communication expertise (see
 below), and pilot tests with up to 10 hypertension patients, the investigators will generate
 3 blood pressure communications:

 (A) a basic table showing only the normal range, which is often used but may make it hard to
 interpret numbers outside of the normal range, potentially undermining behavior change
 intentions; (B) an enhanced table with more reference information, showing how combinations
 of diastolic and systolic blood pressure reflect normal, elevated and hypertension ranges,
 from the American Heart Association; (C) an enhanced graph to be adapted from Blood Pressure
 UK to show the same color-coded ranges as the enhanced table, with diastolic blood pressure
 on the x-axis and systolic blood pressure on the y-axis.

 Aim 2:: In a sample of 650 diagnosed hypertension patients recruited through the Pitt+Me
 Patient Registry at the University of Pittsburgh Medical Center (UPMC), the investigators
 will evaluate whether being presented with the enhanced table or graph (vs. basic table)
 affects patients' self-reported blood pressure measurement (as averaged across two
 measurements taken at the time of the survey at least 1 minute apart, as per directions of
 the American Heart Association), and improves interpretations of these two blood pressure
 readings and of hypothetical blood pressure readings, as well as behavior change intentions.

 Aim 3: The investigators will examine whether Aim 2 findings vary by health literacy, age,
 and SES.
Inclusion Criteria:

 -  Diagnosed with hypertension

 -  Proficient in English

 Exclusion Criteria:

 -