A Conversation with Felicia Hill-Briggs, PhD, ABPP, Assistant Professor of Medicine, the Welch Center for Pre­vention, Epidemiology, and Clinical Research, Johns Hopkins University
American Journal of Medicine
Increasingly, older adults are using aspirin to prevent heart disease. According to a study published in the November issue of the , aspirin use among 2163 older adults without heart disease nearly doubled (from 17% to 32%). But a subgroup analysis showed that African Americans in the study were less likely to use aspirin (13%) than whites (20%)—despite their known high risk of heart disease. African Americans suffer the highest mortality rates among the total population and African American women in particular are at high risk for chronic heart disease or stroke. Although many are aware of what they can do to ward off heart disease, multiple barriers often prevent them from adopting healthier lifestyles. By better understanding these barriers, and offering some problem-solving strategies, primary care physicians can help their patients to make the changes needed to reduce their risks.
In this interview, Professor Felicia Hill-Briggs offers insights into the important role primary care physicians can play in promoting prevention among African Americans. Professor Hill-Briggs’s primary field of research involves social problem solving in African Americans with type 2 diabetes. She serves on the editorial board for the journal , and was recently inducted into the National Academies of Practice as a Distinguished Practi­tioner of Psychology.
Although the focus of this discussion is on patient-related factors that influence health behaviors/lifestyle modification among urban African-American patients, it would be remiss to not note that numerous other factors are also at play. Health care system level factors, such as access to and quality of care, profoundly contribute to disparities in care. In addition, provider-level factors also influence patient receipt of preventive care. This interview addresses only 1 aspect of a very complex issue.
Q. We frequently hear that healthy behaviors and disease control in African Americans with type 2 diabetes can be impeded by socioeconomic, environmental, and familial barriers. These are very broad terms that don’t easily translate into real life. Can you explain specific types of barriers that may be interfering with these choices?
Familial barriers in this population primarily evolve around caretaking responsibilities. African American women who are middle to older aged are often taking care of their grandchildren primarily, but also adult sons and daughters who may be living in the home or still dependent on them for some care. Typically, these women are responsible for preparing meals and feeding the family. Being able to prioritize their own needs becomes a problem. Financial resources are needed to buy food for the family, and healthy foods for themselves. They are more likely to purchase and prepare foods palatable to the whole family, as opposed to investing the additional money, time, and energy needed to cook a separate meal for themselves. Even if they live alone, often grandchildren or adult children are still coming to the home to eat. That can be a familial barrier to healthier eating.
Socioeconomic and environmental barriers revolve around a number of factors, including the higher costs of healthy foods. The comment you hear most frequently is, “well, it costs more.” Everything that is taken out of a food results in higher pricing for the product; sodium- and sugar-free foods cost more. Neighborhood issues also come into play. Within urban or rural neighborhoods, you sometimes don’t have the types of stores that facilitate healthy behavior. Instead of supermarket chains, there may only be small neighborhood grocery stores that don’t sell fresh fruit and vegetables. Canned products are sold, and storeowners are buying supplies based on what is going to be purchased. Limited shelf-space is a disincentive for purchasing salt- and fat-free products, and fresh produce has a limited shelf life.
In terms of getting adequate exercise, fear of crime decreases the likelihood that people will be active out in the neighborhood. If we are promoting walking or jogging it’s less likely to happen on an inner city street. There are no malls, and less access to schools with tracks to use. So the whole neighborhood environment can impede the ability to engage in recommended health behaviors considered to be easily accessible to most people.
Q. What types of barriers are there to a fairly direct intervention, such as taking an aspirin daily?
The primary issue is lack of knowledge. If you were to take a cross section of African American women and ask them what the recommendations are for aspirin taking in disease prevention, I would bet that this is something they don’t know about. Access to health information is more limited in this population, and that’s related to problems with access to health care in general. They need to hear this information from the primary care physician or they may not hear it at all. Typically, this population is not exposed to a health promoting, continuity-of-care environment and may be less likely to access other avenues such as the Internet to explore options for preserving health.
Another important question is whether these patients are able to re­ceive information they are given. In our research, study participants generally have a 10th- to 11th- grade education, but the literacy level is about 6th grade. A quarter of our study participants have about a 3rd-grade reading level. A doctor can sit and say they should be taking aspirin because of x, y, and z, but most health professionals speak well above a 3rd-grade reading level. And there are virtually no health education materials targeted at this literacy level. The goal is usually to write to an 8th-grade reading level, but in doing so you are missing whole segments of the population. In our studies we have to design materials that hit a 3rd-grade reading level.
How do we develop appropriate education materials that are literacy and age appropriate and culturally relevant? One place we have failed in terms of health promotion research is that we have not utilized educational experts who know how to accomplish this. When we ask how to target health education materials and brochures that aren’t condescending but would hit a 3rd-grade reading level, the educational field can offer useful guidelines. We need to draw upon those insights to develop appropriate materials for adults.
Generally, I would advise primary care physicians to stay away from materials that feature childhood cartoons and silliness. Pare down the number of words in each sentence by removing modifiers and avoiding dependent clauses and commas. Using simple sentence structure is not belittling, it’s just clear.
All of this also applies to the way you speak to your patients. Think about your verbal presentation, the length of the sentences and the modifiers. Phrase your thoughts at a 3rd-grade reading level. Literacy levels will of course vary in different healthcare settings and demographics, so adjust your approach accordingly.
Q. Your research describes an association between impulsive/careless problem—solving style and glycemic control in African Americans with diabetes. Can you define features of this style? How can primary care physicians target this style for intervention in improving health care behaviors?
A problem-solving model helps us to understand what patterns are preventing patients from changing their health behaviors. If you tackle the knowledge issue, patients will know what they need to do for disease prevention. If you tackle the socioeconomic and familial issues by offering strategies for overcoming these barriers, then they know what they need to do. But if after all of that, for some reason patients are not making healthy lifestyle changes, problem solving skills come into play.
A first step is to probe and ask what the patient believes the problem is. They may say, for example, they simply don’t like taking medicine. Find out why and whether there is something you can alter about that. Is it a time-of-day issue, or perhaps the fact that they think medicine will make them sick? To some, it goes back to priorities; with all the things they need to pay for, medication may not be a high priority. The goal is to come up with strategies to deal with whatever the particular barrier is. Sometimes patients simply don’t believe in taking medicine. That becomes more challenging to deal with. Sometimes changing how the need for medication is communicated can change the “I don’t believe in it” problem. Make sure your patients understand the benefits of the medication, but also on a very personal level, communicate to them what is likely to happen if they don’t take the medicine. Be very detailed and personal about how their day-to-day lives might change.
Q. What is the single most important thing a primary care physician can do to change health behaviors in the African American population?
Listen. Listen. And listen. If physicians are going to help, listening is the most important step towards making patients feel respected. If a patient says “I don’t want to take medicine,” you need to deal with that. You need to believe the patient and work with her to change that attitude. Don’t just write the prescription. We are far past the day when we thought, if the physician says it, I’ll do it. Know exactly what your patient is thinking and planning to do about what she has heard. And make sure the patient has heard and understood the information you have communicated. Ask the patient to repeat what you’ve ex­plained back to you to make sure they’ve gotten it.