Working Together to Bridge the Disparity Gap in Cardiovascular Health

Although population-based prevalence and trend data indicate that cardiovascular mortality is decreasing in the United States, disparities in cardiovascular health continue to persist among vulnerable populations.1,2 Cardiovascular diseases account for almost one-third of the disparity in potential life-years lost between blacks and whites.3 American Indians and Alaska Natives experience cardiovascular disease at twice the rate of the overall population and die of heart disease earlier than expected.4,5 Non-Hispanic blacks and Mexican Americans have higher rates of diabetes and obesity than the overall population does.5 These cardiovascular inequities are linked to a variety of complex social factors including income and education, access to care, as well as communication barriers.6 Over the last 3 decades, increasing attention has been devoted to addressing the nation’s health disparities. National conversations around health equity began in the 1980s when there was an increasing awareness that racial and ethnic minority populations experienced disproportionately higher rates of disease, disability, and death compared with the general population. In 1985, charged by a Task Force on Black and Minority Health convened by the Secretary of Health and Human Services, the National Institutes of Health began to work to understand and reduce these disparities.7 In 2010, the establishment of the National Institute on Minority Health and Health Disparities reflected renewed congressional commitment to achieving health equity through translational, transformational, and transdisciplinary research.8 One of the 4 overarching goals of Healthy People 2020 is “to achieve health equity, eliminate disparities, and improve the health of all groups,”9 and in 2011, building upon the Affordable Care Act, Health and Human Services issued the first-ever Action Plan to Reduce Racial and Ethnic Health Disparities.10 The American Heart Association has been engaged in health equity initiatives aimed at bridging the cardiovascular disparity gap, such as the WISEWOMAN program that provides free screening and lifestyle intervention services to low-income, uninsured or underinsured women.11 However, despite collective prioritization of achieving health equity in the United States, over the past 3 decades, cardiovascular disparities have only worsened among minority and vulnerable groups. Similar to other health disparities, these are likely to be “rooted in social structure inequalities and exist because of inequitable distribution of goods, resources, power, and poverty in American society.”8(p23) Entrenched inequities in cardiovascular health have clearly motivated and informed interventions over the past 2 decades. Davis and colleagues12 completed a systematic review of clinically oriented interventions, published between 1995 and 2006, that were designed to reduce cardiovascular disparities among racial and ethnic minorities. They reported a paucity of high-quality research addressing reduction of cardiovascular racial and ethnic disparities; however, they concluded that nurse-led interventions have been most effective in improving the cardiovascular management of communities of color. Building on and extending this important work, the 2006–2011 systematic review of Walton-Moss and colleagues13 on community-based cardiovascular health interventions in vulnerable populations included urban and rural poor populations as well as racial and ethnic minorities. They found that educational interventions were the most common, that blood pressure interventions were the most promising, that behavior-change interventions were the most challenging, and that almost all of the interventions were directed at the individual level. These findings are central and essential for shaping our understanding of how best to proceed in our efforts to eliminate cardiovascular health inequities. Community-based participatory research (CBPR) provides a powerful framework for addressing health disparities, particularly those related to complex chronic conditions, such as cardiovascular disease, in which it is essential that researchers understand and value the cultural context of individuals and their respective communities.14 The National Institutes of Health Office of Behavioral and Social Science Research (OBSSR) defines CBPR as a collaborative approach to research that begins with a research topic of importance to the community and combines “knowledge and action for social change to improve community health and reduce disparities.”15 Nurses are well prepared to partner with vulnerable communities in CBPR given their familiarity with the real-world context of their patients’ lives and their experiences in building and maintaining trust and mutual relationships with patients, families, and communities. Community-based participatory research has numerous benefits including facilitating relevant, sensitive intervention development and community buy-in as well as recruiting and retaining participants who have been historically underrepresented in research.14 However, this approach can also present complicated, challenging issues. For instance, community members may object to the use of a control group, even a delayed-intervention control group, if they perceive the intervention as beneficial in the community. In addition, in a community-based intervention trial, it might be impossible to control certain variables or prevent “contamination” related to exposure to the intervention given participants’ close relationships with each other and others in the community. These types of challenges inherent in the real-world context of community-based research create a unique kind of “noise” not typically encountered by academic researchers in traditional clinical research settings. Subsequently, a common mantra among experienced community-based researchers is “if you can’t control it, measure it.” Involving community members in the design phase of the research increases the research team’s ability to identify, measure, and potentially control multiple confounders.14 Tailoring interventions directed toward health-related behavior change in culturally relevant ways through a CBPR approach has emerged as one effective approach to address health disparities.16 However, given the challenges inherent in behavior-change interventions, many have suggested intervening at community or societal levels, addressing health-disabling environmental factors, neighborhood living conditions, community safety and walkability, food availability, social cohesion, as well as education access could produce more meaningful results.13,14 As Dankwa-Mullan and colleagues stated so succinctly, “We do not simply seek to improve health by informing individuals and populations of their health risks; we also seek to use science to influence society and the policies that shape health.”8(p23) Addressing social determinants to improve cardiovascular health is a largely uncharted territory, yet it is clear that nurses are positioned to lead transdisciplinary teams in addressing health disparities at these broader levels. Placing immense value on patient-centered care, nurses are well suited to lead culturally relevant, prevention-focused practice and policy initiatives with community and interdisciplinary partners with the goal of advancing cardiovascular health and eliminating disparities among the most marginalized and underserved in our country.