U SING T ELEPHONE M ESSAGING FOR C ULTURALLY A PPROPRIATE H EALTH P ROMOTION

A Case Study in Hypertension Control

Public Health Challenge: Health Disparities and the Underserved

Health disparities are growing in the United States, where certain populations tend to bear the burden of disease and poor health. Chronic diseases such as hypertension and diabetes, in particular, disproportionately affect racial and ethnic minorities including African Americans, Asian Americans, and Hispanics. For example, the prevalence of hypertension among African Americans is over 40% compared to 28% for non-Hispanic whites. 1 Despite the high risk of poor health, many underserved groups are also those with the least access health interventions, including programs for health education and promotion that are tailored to their specific cultural and linguistic characteristics.
A Health Promotion Solution: Interactive Voice Response
Using Telephone Messaging for Culturally Appropriate Health Promotion | 2/17/2012

Health education and community-based programs can prevent disease, enhance quality of life, and improve overall health.2 Furthermore, evidence has shown that patient navigators or community health workers (CHWs) can successfully provide linguistically appropriate and culturally tailored health information as well as facilitate access to critical health services for underserved communities.3 Recently, LanguageMate partnered with Project AsPIRE to evaluate the effectiveness of Interactive Voice Response (IVR) technology, a cutting-edge mechanism to impart culturally, linguistically, and literacy-level appropriate health information. IVR telephone support allows healthcare providers to send educational telephone messages to groups of patients in order to improve health outcomes. It has been successfully used in health education campaigns to promote disease self-management and provide discharge instructions, appointment reminders, and general health information.4,5 In particular, IVR has been found to be effective in reducing A1C levels and promoting diabetes and cardiovascular disease self management.6, 7 However, though numerous studies have shown that IVR contributes to positive health outcomes, the overwhelming majority involved only English-speaking patient populations.

Centers for Disease Control and Prevention (2011). Health disparities and inequalities reportUnited States, 2011. Morbidity and Mortality Weekly Report, v.60. 2 US Department of Health and Human Services (2011). Educational and community-based programs. Retrieved from http://healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicId=11. 3 Dohan, D. & Shrag, D. (2005) Using patient navigators to improve care of underserved patients. Cancer 104(4), 848855. 4 Tanke, E.D., & Leirer, V.O. (1994). Automated telephone reminders in tuberculosis care. Med Care, 32, 380-9. 5 Watson, G., Linkins, R.W., Dini, E.F., & Patriarca, P.A. (1994). A randomized controlled trial of the effectiveness of computer-generated telephone messages in increasing immunization visits among preschool children. Arch Pediatric Adolescent Med, 148, 908-14. 6 Piette, J.D., McPhee, S.J., Weinberger, M., Mah, C.A., & Kraemer, F.B. (1999). Use of automated telephone disease management calls in an ethnically diverse sample of low-income patients with diabetes. Diabetes Care, 22 , 1302-1309. 7 Piette, et al. (20087). Improving heart failure self-management support by actively engaging out-of-home caregivers: results of a feasibility study Congestive Heart Failure, 14(1), 12-8.
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Research Study: Evaluating Telephone Messaging for Heart Health

Project AsPIRE, facilitated by the New York University Center for the Study of Asian American Health, was developed to implement and assess the efficacy of a CHW intervention to improve hypertension management and access to care among Filipino Americans living in New York and New Jersey. As a key component of cardiovascular health, hypertension, or high blood pressure, leads to an array of serious health complications, including heart attack and stroke. Compared to other Asian Americans, whites, and African Americans, Filipino Americans have higher rates of hypertension, as well as a higher proportion of deaths due to heart disease.8,9 Furthermore, studies have demonstrated that control and self-management of hypertension through medication and lifestyle is poor among Filipinos. In spite of these disparities, few interventions exist that meet the particular needs of this population. Through the AsPIRE project, participants attend regular workshops with patient navigators or CHWs where they receive key health information and tips in their native language for controlling hypertension through medication, exercise, and healthy eating. In order to evaluate IVR technology as a tool for health promotion and education for underserved groups, LanguageMate worked with Project AsPIRE to create a series of culturally tailored, linguistically appropriate telephone messages to promote healthy behaviors and improve knowledge surrounding hypertension. The messages were specifically designed to reinforce workshop content, including information on how to eat healthy, ways to exercise and the importance of getting blood pressure checked. Messages were recorded in Tagalog, the native language of the Filipino participants, and included culturally relevant information, such as specific foods common in the Filipino diet, and facts about hypertension among Filipinos. Following the four month study, in which participants received 9 health promotion phone calls, we compared a range of outcomes in participants who received messages to those who received one-on-one sessions with CHWs in order to evaluate the effectiveness of IVR as a tool for health promotion.
Study Results: Telephone Messages Improve Health

Our data analysis found a significant improvement in hypertension-related knowledge, behaviors, and clinical indicators among those that received telephone messages.
Figure 1. Participants Receiveing Full Score on Cardiovascular Disease Knowledge

A central goal of Project AsPIRE was to increase knowledge of hypertension among Filipino Americans in order to promote healthy behaviors and improve cardiovascular disease (CVD)-related clinical outcomes. For our research study, we measured the extent of participants understanding of key aspects of cardiovascular disease, such as main signs and symptoms, ways to control the disease, and serious complications. In our analysis, we
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Ryan et al. (2000). Coronary heart disease in Filipino and Filipino-American patients: prevalence of risk factors and outcomes of treatment. Journal of Invasive Cardiology, 12(3). 9 US Department of Health and Human Services. (2003). Cardiovascular risk in the Filipino Community. Retrieved from www.nhlbi.nih.gov/health/prof/heart/other/filipino.pdf

Using Telephone Messaging for Culturally Appropriate Health Promotion | 2/17/2012

found that people who received phone messages had a better understanding of CVD than those who received only one-on-one sessions with CHWs, demonstrating the usefulness of telephone messages as a knowledge-promotion tool (Figure 1). Those receiving messages also reported higher rates of healthy eating behaviors, such as reading nutrition labels to find low-sodium, low fat foods, as well as better exercise habits.
Figure 2. % of Participants who had "Normal" Blood pressure Relaying health information through phone messages resulted in clear 60.0% 54.5% improvements in eating behaviors, 50.0% increased exercise activity, and 42.1% increased health knowledge among 40.0% recipients; furthermore, we found a 30.0% Baseline significant improvement in blood 21.1% 4 Month pressure, a key clinical indicator linked 20.0% to CVD and hypertension. Among 9.1% those receiving messages, there was an 10.0% increase of 45.4 percentage points in 0.0% the number of people with normal LanguageMate CHW blood pressure, a much greater change than in those individuals receiving only one-on-one contact with CHWs (Figure 2).

Using Telephone Messaging for Culturally Appropriate Health Promotion | 2/17/2012

The overall purpose of the AsPIRE project was to reduce the severity and incidence of hypertension among Filipino Americans. Our analysis of the LanguageMate component of the study found significant improvements in hypertension and CVD-related knowledge, behavior, and clinical indicators among participants, demonstrating that telephone messages can be a valuable and effective tool for improving health of underserved populations. In particular, we found that educational messaging facilitated by community organizations can help meet the growing need for culturally appropriate health interventions to reduce health disparities. Based on our success with Project AsPIRE, LanguageMate developed a web-based IVR system, called Messenger, in which health professionals can send culturally appropriate health messages to patients via the telephone. The Messenger System is currently in the beta testing phase and we are actively seeking interested beta customers. For more information about the Messenger System, visit www.languagemate.com.