Multi-ethnic Multi-level Strategies and Behavioral Economics to Eliminate Hypertension Disparities in LA County.

Project Summary/Abstract
Eliminating racial/ethnic cardiovascular health disparities in the U.S. cannot be achieved without addressing
disparities in evidence-based treatment of hypertension. In Los Angeles County (LAC), there are
approximately, 801,000 Latino, 266,000 Asian, and 244,000 African American adults with hypertension, and
more than half of these individuals have household income below 200% of the federal poverty level. In the LAC
Department of Health Services (DHS), the second largest municipal health system in the US, patient, clinician,
healthy system, and community factors contribute to substantial disparities in hypertension prevalence, control,
and outcomes by race/ethnicity. Racial/ethnic gaps that contribute to hypertension disparities in LAC DHS
relate to differences in healthy eating, physical activity, obesity, antihypertensive pharmacotherapy use,
medication adherence, community awareness of hypertension, and community-level physical and social
resources. These gaps are widely recognized in LAC DHS as barriers to addressing hypertension-related
racial/ethnic health disparities, yet differences in healthy lifestyle practices and treatment persist. We propose
to significantly reduce disparities in in LAC DHS by leveraging our team's expertise in multi-ethnic, multi-level
evidence-based strategies, community/stakeholder engagement, public-private partnerships, implementation
science, and behavioral economics. Our proposal is sensitive to LAC DHS' mission of providing high quality,
cost-effective care, which we address with an ancillary focus on reducing the high cost of hypertension-related
heart and kidney disease. Using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework,
we propose a multi-level intervention for hypertension control that will complete EPIS Exploration/Preparation
stages in the UG3 phase and the Implementation/Sustainment stages in the UG4 phase. In partnership with all
51 adult primary care clinics in LAC DHS, our aims are: Aim 1 (UG3): Assess multi-level (patient, clinician,
health system leadership, and community) barriers to, facilitators of, and preferences for a menu of culturally-
tailored evidence-based practices (EBPs) and implementation strategies with established efficacy for
hypertension control. Aim 2 (UG3): Select and systematically apply behavioral economics to the design of our
patient-, clinician-, and community-directed implementation strategies to maximize acceptability, uptake, and
effectiveness. Aim 3 (UG4): Test the effectiveness of our implementation strategies in a stepped-wedge
cluster randomized trial design using RE-AIM to guide assessment of uncontrolled hypertension, disparities in
comparison to non-minority LAC populations, and evidence-based practices.

Grant Number: 5UH3HL154302-06
NIH Institute/Center: NIH
Principal Investigator: ARLEEN BROWN