# Presentation: 489227

## Addressing Health Disparities in Minority and Low SES Communities

- Helena O. Mishoe, PhD, MPH
**Department of Health and Human Services**
- National Heart, Lung, and Blood Institute
- National Institutes of Health

**Notes:**
I have been asked to speak today about the issue of health disparities and NHLBI programs designed to address these issues.  Throughout its history, the NHLBI has been a leader in conducting and supporting research to alleviate the health disparities that exist between various segments of the U.S. population.

The Institute has supported programs with strong minority components to permit comparisons among populations and provide information about their causes.  The Institute has also placed a high priority on programs that are specifically addressed to minority health issues. 

We have developed an NHLBI Strategic Plan for addressing health disparities that you will here about in more detail later in my talk.  Our Strategic Plan was developed as a result of discussions with representatives of the scientific community, healthcare-related organizations, and the general public.

My talk will focus in 3 areas; First we will take a brief look at health disparities as this topic relates to diseases and conditions addressed by the NHLBI; (2) next I will share selected NHLBI health research programs that encompass the NHLBI Strategic Plan designed to address health disparities in minority and low SES populations; and (3) finally, I will share some progress we are making in closing the gaps in health disparities. 

First, the challenges.

## Scope of the NHLBI’s Responsibilities

**Preventing, treating, and curing diseases of the**
**Heart **
**Lung**
**Blood Vessels**
**Blood **
**Ensuring ****safe blood resources**** **
**Combating ****sleep disorders**

## Death Rates* for Heart Disease by Gender, Race, and Ethnicity, U.S., 1985-2000

- Male

- Female

- *Age

- -

- adjusted.

- **Non

- -

- Hispanic.

- Note: Each line is a log linear regression derived from the actu

- al rates.

- Source: Vital statistics of the U.S., NCHS.

**Notes:**

Between 1985 and 2000, death rates for heart disease declined for all groups.  However, a significant gap remains between blacks males and females and other racial and ethnic groups.

## Death Rates* for Stroke by Gender, Race, and Ethnicity, U.S., 1985-2000

**Notes:**

Similarly, between 1985 and 2000, although death rates for stroke declined for all groups, a significant gap remains between blacks males and females and other racial and ethnic groups.

## Age-Adjusted Death Rates for Asthma by Race and Sex, U.S., 2000

- Deaths/100,000 Population

- National Center for Health Statistics, National Vital Statistics Reports, 2001, Volume 49, no. 12

**Notes:**

Again, the increased prevalence of asthma in Blacks leads to increase in death rates.  In 2000, asthma mortality was 3 times higher in black males than in white males, more than 2.5 times higher in black females than in white females, and 42 percent higher overall in females than males.

## NHLBI Strategic Plan for Addressing Health Disparities

**NHLBI Strategic Plan for Addressing Health Disparities**

**Notes:**

I would like to take this opportunity to share with you the NHLBI’s Strategic Plan to address the kinds of health disparities seen.  Our Strategic Plan is located on the NHLBI web site. 

## Areas of Emphasis

**Areas of Emphasis**

**Outreach and Education**

**Capacity Development**

**Health Research Programs**

**Notes:**
The plan focuses on 3 areas of emphasis, viz.,

Health Research Programs: Our programs target development and progression of disease, diagnosis and treatment, and disease prevention and delay of onset.  

Capacity Development: (approaches are Research Infrastructure and Resources and Research Workforce)

Outreach and Education

We will begin with Health Research Programs designed to address health disparities. 

## Jackson Heart Study
- Investigate the causes and means of prevention of CVD in African- Americans
6,500 African-Americans between the ages of 35 and 84

**Jackson Heart Study**
**- Investigate the causes and means of prevention of CVD in African- Americans**
**6,500 African-Americans between the ages of 35 and 84**

- (continued)

**Health Research Programs****Disease Development and Progression**

**Notes:**

Jackson Heart Study -- evolution and progression of CVD in blacks

## Jackson Heart Study
Largest study of CVD ever undertaken in an African-American population

Partnership (NHLBI, NCMHD) and Jackson State University, Tougaloo College, and the University of Mississippi Medical Center 

**Jackson Heart Study**
**Largest study of CVD ever undertaken in an African-American population**
**Partnership (NHLBI, NCMHD) and Jackson State University, Tougaloo College, and the University of Mississippi Medical Center**

**Health Research Programs****Disease Development and Progression**

**Notes:**

Jackson Heart Study -- evolution and progression of CVD in blacks

## Strong Heart Study

**Strong Heart Study**

-   **Objective: investigate CVD and its risk factors **
**   ****-  Had a particular focus on the effects of diabetes on CVD and its risk factors for CVD  **
**NHLBI initiated in 1988**
**  ****Conducted in 13 American Indian Tribes**
**  ****Major Finding: AIs are at lower risk of developing CVD compared to general population was wrong**
**  ****Confirmed diabetes as a major risk factor for CVD**

## Community-Responsive Intervention to Reduce CVD in AI/AN

**Community-Responsive Intervention to Reduce CVD in AI/AN**

-  Approximately 30% of AI deaths for all ages is associated with diseases of the heart
-  Assess ways to improve behavior associated with CVD risk factors – focus on primary prevention
-  Consulted AI/AN Tribes –  government to government relationships

**Notes:**
Comments on great need

## NHLBI Intervention Trials with Primary Care Participation

**Disease Diagnosis and Treatment**
- Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)
- Thiazide type diuretic superior as initial drug for treatment of hypertension and less expensive than newer drugs (JAMA 2002; 288:2981.)

**Notes:**
Some of the trials have elements built in for quality of life assessment, as well as prospectively designed cost-effectiveness components. ALLHAT is an effectiveness trial, based upon the initial choice of antihypertensive agents. It uses agents that vary in costs, from cheaper diuretics to more expensive calcium channel blockers.

## Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial

**Design: Randomization of 42, 418 to 1 of 4 initial antihypertensive drugs, and subrandomization for open-label lipid-lowering treatment**
**Follow-up: 5 year average**
**Setting:  623 clinical sites**
**9 Regional oversight centers**
**55% Private & group practices**
**8% Community health centers**
**3% HMOs**
**23% academic medical centers or VA clinics**
**> 22% PIs reported no previous clinical research experience. **

**Notes:**
The Antihypertensive and Lipid‐Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), a randomized, double‐blind, multi‐center, clinical trial sponsored by the National Heart Lung and Blood Institute (NHLBI), was designed to determine whether the occurrence of fatal CHD or nonfatal myocardial infarction (MI) is lower for high‐risk hypertensive patients treated with a CCB (represented by amlodipine), an ACEI  (represented by lisinopril), or an alpha blocker (represented by doxazosin), each compared with diuretic treatment (represented by chlorthalidone).  42,418 high-risk hypertensive patients age 55 and older were randomized.

## Slide 14

## Opportunities for Primary Care Networks in Clinical Research 

| Intervention Trials | Translation Research  |
| --- | --- |
| Testing effects of potential preventive or therapeutic interventions for efficacy or effectiveness  
 | Testing enhanced delivery of proven interventions in clinical and public-health practice
 |

## Opportunities for Primary Care Physicians

**Explore geographic areas where primary care networks and other networks exist for exchange of information and potential collaborations.**
**Primary care networks consider conducting studies to improve implementation and adherence to relevant treatment guidelines. **
**Enhance the development of a clinical research workforce.**

## Cardiovascular Disease Enhanced Dissemination and Utilization Centers (EDUCs) 
Mission Possible
CVD Public Housing Initiative
Health Information Networks (HIN) 

**Outreach and Education **

**Cardiovascular Disease Enhanced Dissemination and Utilization Centers (EDUCs) **
**Mission Possible**
**CVD Public Housing Initiative**
**Health Information Networks (HIN) **

**Notes:**
CV EDUCs -- partnerships with community-based organizations to promote community-based CV health in high-risk populations -- located in rural communities with CV death rates in excess of the national average

Asthma Coalition Network -- asthma EDUCs to improve asthma control in high risk communities

Morehouse Safety-Net Practice Based Research Network - The NHLBI is partnering with the National Center for Primary Care at Morehouse School of Medicine to develop a prototype asthma intervention that can be tailored to meet the needs of each community health center in its network of 147 centers across 8 southeastern states.  

Our education and outreach efforts provide an important link to our  research and research training programs.

## Addressing High Blood PressureProgress and Challenges

- Significant progress made BUT BP control rates are low
- Improved treatment, BUT HBP effective therapies are underutilized
- Mobilization needed at provider, systems, patient, and community levels
- HBP now affects 65 million Americans
- Another 59 million Americans have prehypertension
- Aging US population
- Obesity epidemic presents challenges for HBP control

## EDUCs

**One element of a larger heart-health agenda**
**Located within high-risk health service areas (AK, TX, NC, VA, WV)**
**Serve areas with high CHD and stroke mortality rate**
**Implement strategies at the local level**

## Dissemination and Evaluation Project:  Mission Possible

**Purpose – to promote improved high blood pressure prevention and control among high risk audiences**
**Collaboration between NHLBI, CDC, National Association of Chronic Disease Directors Cardiovascular Health (CVH)   Council, State Health Departments, and American Heart Association, Indian Health Service **
**22 states volunteered to participate**

## Dissemination and Evaluation Project:  Mission Possible

**Assessment of materials**
**Usefulness**
**Extent of dissemination**
**Partner engagement**
**Added value to increase action among organizations and the community and to support existing activities to prevent and control high blood pressure**
**Report results in fall 2006**

## Prevent and Control High Blood Pressure:  Mission Possible

**Package of Materials and Resources**
**“****Call to Action” Paper**
**Partners Sheets -  (businesses, community, health industry, teachers, and schools)**
**Fact Sheets in English and Spanish – (general public/patients, health professionals, partners)**
**Web site**

## NHLBI and HRSACollaboration Public Housing Initiative

- GOAL: to connect clinical care with community-based health promotion for public housing residents at high-risk of CVD using Community Health Workers (CHWs) as members of the health team to teach patients using NHLBI’s _*With Every Heartbeat is Life*_ Heart Health Curriculum.

**NHLBI and HRSA****Collaboration ****Public Housing Initiative**

## Public Housing CVD Initiative

**Train CHWs using the *****With Every Heartbeat is Life***** curriculum**
**Integrate patient education by trained CHWs into clinical care using the *****With Every Heartbeat is Life***** curriculum **
**Use CHWs as part of health team to conduct follow-up with patients/families to promote adherence and relate back to clinic supervisor**
**Measure changes in knowledge, attitudes, health behaviors, and CVD risk factors**

**Notes:**
CHW-community health worker

## With Every Heartbeat is Life  Core Elements/Content

**Easy to follow**
**12 sessions (1-1.5 hours) **
**Builds basic competencies**
**Personal CVD risk assessment**
**Heart attack recognition and response**
**Introduction to heart health and CVD risk factors**
**Heart health behavior modification activities**
**Train-the-Trainer **
**Program logistics**
**Teaching tips and strategies**

**Table of Contents**
**How to Use This Manual**
**Session 1- Knowledge is Power: Know Your Risk for Heart Disease**
**Session 2- Act in Time to Heart Attack Signs**
**Session 3- Get Energized! Say YES to Physical Activity**
**Session 4- Help Your Heart: Control Your High Blood Pressure**
**Session 5- Be Heart Smart! Aim for a Healthy Weight**
**Session 7- Protect Your Heart: Take Good Care of Your Diabetes for Life**
**Session 8- Make Heart Healthy Eating an Everyday Family Reunion**
**Session 9- Eat in a Heart Healthy Way—Even When Time or Money is Tight**
**Session 10- Enjoy Living Smoke-Free**
**Session 11- Review and Graduation**
**Session 12- Use Evaluation to Track Your Progress**
**Appendix- Activities for Training Community Health Educators**

**Notes:**
Heart health- anatomy & function of the heart, identifying personal risk
CVD clinical risk factors (high blood pressure, high blood cholesterol, diabetes, smoking, overweight and obesity)
Acute event symptoms-recognizing and acting on heart attack symptoms
Heart health behavior modifications-physical activity and nutrition
Participant-focused activities- role-community, scenarios, and demonstrations
Supporting material is also available including the Integrated Risk Factor booklet and Heart-Healthy Home Cooking.  Both booklets are being updated but we can provide the pre-revised versions.
Appendix is the Train-the-Trainer component

## Join the Health Information Network (HIN) 

**  ****NHLBI’s online link to health professionals**
**Quick, convenient access to trustworthy information applicable to everyday practice**
**Delivered via e-mail approximately twice a month**
**Easy registration form at: **_**[http://emall.nhlbihin.net/hp2010/default.asp](http://emall.nhlbihin.net/hp2010/default.asp)**_** **

## Example of Recent HIN e-mail

## HIN Membership Benefits

**E-mailed summaries of NHLBI’s new publications and their practical application to clinical care and individual health**
**New Personal Digital Assistant (PDA) applications of clinical guidelines and reports on the NHLBI Web site**
**Kits with ideas and materials for National High Blood Pressure Education Month and National Cholesterol Education Month**
**Press releases providing breaking health news online**

## Increases in Life Expectancies 

**Increases in Life Expectancies **
**of Patients with Sickle Cell Anemia**

***Life Expectancy***
***(Years)***

***Year***

**Sickle cell disease identified**

**National Sickle Cell Anemia Control Act passed**

**Comprehensive Sickle Cell Centers established**

**First statewide newborn screening program implemented**

**PROPS results published **

**MSH trial results published**

**STOP results published**

**0**

**10**

**20**

**30**

**40**

**50**

**60**

**70**

**80**

**1900**

**1910**

**1920**

**1930**

**1940**

**1950**

**1960**

**1970**

**1980**

**1990**

**2000**

**All Americans**

**Sickle **
**Cell Anemia**

**Bone marrow transplantation shows promise**

**Notes:**
In addition, 

In October 2002, NHLBI recognized the 30th anniversary of the National Sickle Cell Disease Program.  The institute’s sustained efforts targeted at sickle cell disease have significantly increased the life expectancy of patients with sickle cell disease.  This summary slide of the program’s success shows the increases in life expectancies over 30 years.  Of particular note, previous research has shown the benefits of hydroxyurea in reducing the symptoms of the most severely affected sickle cell patients.  We have now just taken another important step forward in the treatment of sickle cell disease.   (NEXT SLIDE) 

## We still have miles to go before we sleep.

_***Contact Information***_
**Helena O. Mishoe, PhD, MPH**
**Mishoeh@nhlbi.nih.gov**
**301-451-5081**