Discussion
health behaviors
HIGH BLOOD PRESSURE
The results from the PTSC-RCT study indicate that the intervention contributed to a modest reduction in BP. However, it had no impact on BMI. The modest reduction in BP could be attributed to PTSC limited impact on health behaviors. The relationship between participation in the PTSC intervention and changes in participants’ BP and BMI in our study were not as strong as the relationships estimated in the prior pre and post evaluations of the PTSC program, or other community-based lifestyle change interventions targeting African American women [The results observed among those who participated in the intervention group, as well as the size of the ITT group, illuminates the realities of intervention delivery and receipt among a largely low-income population. In our protocol paper, we noted the results of a brief survey administered to those in the ITT group, which sought to uncover some of the barriers to participation. Transportation, scheduling, and not feeling well were the most frequently cited responses. These experiences underscore two critical factors. First, that structural factors shaping the social environments and contexts of PTSC-RCT participants fundamentally affected the ability to participate in the program (the ITT group) and may have blunted the impact of the intervention (the PTSC intervention group). Although the women overwhelmingly appreciated the PTSC intervention, their ability to implement the lifestyle changes encouraged by PTSC may have been compromised by the realities of residing in structurally disadvantaged neighborhoods within the most impoverished Wards in Washington, D.C. A paucity of healthy food options [The second factor is related to the intersection of adverse social determinants of health that our study participants faced indicates the need to incorporate socially contextualized intervention strategies to meet the psychosocial, material, and health needs of a low-income population. PTSC participants faced constant threats to their ability to maintain their health. The constant pressures associated with residing in marginalized, disinvested communities influenced their self-reported stress, even as they attempted to adopt adaptive stress management techniques. Inasmuch as there were barriers to intervention receipt, there may have also been conceptual deficiencies in our deployment of the intervention for low-income women. The core components of the PTSC intervention (didactic training, peer support, and role modeling) were likely inadequate in promoting self-management of high blood pressure in the face of the previously noted adverse social determinants of health. Our results show that interventions intended to support low-income African American women must account for the preponderance of social risk factors they navigate. Enhancing the standard PTSC intervention with direct links to community-based resources, such as transportation, food, and other forms of assistance, may mitigate the impact of social risk factors on participants’ lives. In addition, it is possible that the certain elements of the program are more salient for low-income African American women than others—for instance, maintaining regular contact with others within the Sister Circles may offer invaluable social support and peer learning, with implications for sustaining newly acquired health behaviors.