Project summary There is a fundamental gap in the availability of interventions that 1) sustainably improve adherence to pre- scribed blood pressure (BP) medications, 2) identify underlying behavior change mechanisms, and 3) demon- strate efficacy by sex and race in older adults. Accordingly, interventions to improve adherence and BP control remain minimally effective. The long-term goal is to improve medication adherence, BP control, and healthy aging in older hypertensive adults. The overall objective for this R01 application is to determine the efficacy of the Supporting Tailored Adaptive change and Reinforcement for Medication Adherence Program (STAR- MAP), which integrates the transformative Overcoming Immunity-to-Change (OITC) health coaching process, on improving adherence, BP control, and quality of life (QOL). The OITC approach that has proven useful in other arenas was successfully applied to BP management in the research team's recent pilot study. Based on this prior work, the central hypothesis is that STAR-MAP, designed to help nonadherent older hypertensive adults to identify and alter implicit attitudes that hinder medication adherence, will change mindsets and im- prove daily taking of prescribed medications, leading to lowered BP and better QOL. The rationale for the pro- posed study is that demonstration of the efficacy of STAR-MAP would provide new opportunities to overturn nonadherent behavior and improve BP control and healthy aging for the growing population of older adults with hypertension, overall and in sex and race subgroups. The central hypothesis will be tested by pursuing two specific aims: (1) Determine the efficacy, underlying mechanism, and sustainability of the STAR-MAP interven- tion, aimed at improving medication-taking behavior, on medication adherence and clinical outcomes; and (2) Explore the efficacy of STAR-MAP in sex and race subgroups. Under the first aim, a randomized controlled trial will be conducted in 402 nonadherent (proportion of days covered (PDC) <0.8) adults ≥65 years with un- controlled BP (201 per arm – intervention versus usual care; 50% women; 50% black) and fully insured by Blue Cross Blue Shield of Louisiana. The study will have 90% statistical power to detect a 15% difference at 12 months in the proportion of participants with PDC ≥0.8 between those randomized to intervention versus usual care with attention control. Under the second aim, efficacy of STAR-MAP in sex and race subgroups will be explored. The approach is innovative because it will be the first large clinical trial to rigorously test a new intervention that targets negative implicit attitudes toward medications with a goal to improve adherence, BP control, and QOL. The proposed research is significant because it will represent an important step in a contin- uum of research that is expected to lead to an efficacious, scalable intervention (with data on the underlying behavior change mechanism). Finally, the results are expected to provide new insights on an underappreciated psychological mechanism (i.e., implicit attitudes) of nonadherence that could be useful for improving the effec- tiveness of other medication adherence interventions.

Project Narrative This proposed research is highly relevant to public health because the discovery of an efficacious approach, and the associated underlying mechanism, to improve adherence to blood pressure-lowering medications is expected to represent an important step toward improving blood pressure control, reduce disease and disability, and improve quality of life in older adults. Thus, the proposed research, which evaluates a novel method to improve adherence and blood pressure control, aligns with top research priorities of the NHLBI and NIH Adherence Research Network that pertain to advancing knowledge that will help to reduce the burden of chronic diseases and improve life-long health and well-being. When this innovative behavioral intervention trial is complete, it is expected to provide a new and scalable evidence-based approach to reducing low medication adherence and CVD burden and to improving healthy aging among older women and men.