Introduction
The American Heart Association (AHA) developed a behavioral roundtable to address
cardiovascular disease (CVD) disparities, with a focus on the primary prevention of
obesity. This roundtable considered the preventable differences in the indicators
of health of different population groups, often defined by race, ethnicity, sex, educational
level, socioeconomic status, and geographic location of residence. To reduce the rates
of CVD in disproportionately affected population groups, we explored behavioral strategies
for each of the 5 risk stages: 1) no known cardiovascular risk, 2) known cardiovascular
risk, 3) acute CVD, 4) rehabilitation, and 5) chronic CVD. We examined sample AHA
programs targeting each of the risk stages to consider how to pose questions about
reach, efficacy/effectiveness, adoption, implementation, and maintenance (the RE-AIM
evaluation framework). The strategies outlined in this article can be used to develop
collaborations for planning, implementing, and evaluating possible interventions to
reduce CVD disparities.
Disparate CVD Rates: The Rationale for Identifying Special Populations
The AHA Nutrition Committee, with support from its Industry Nutrition Advisory Panel
(INAP), established several behavioral roundtables to address behavioral issues and
translation to practice focusing on the AHA mission. Each roundtable, with representatives
from the Nutrition Committee, INAP, and AHA staff, brainstormed ideas to help the
Nutrition Committee integrate behavioral issues into strategic and program planning.
The special population behavioral roundtable, which focused on behavioral issues for
populations with disparate rates of cardiovascular risk, included 2 Nutrition Committee
members who became the authors of the report. Using an iterative process, we examined
potential applications of the roundtable's recommendations to existing AHA programs.
Our goal was to provide a framework to help AHA staff and volunteers at the national
and affiliate levels as they plan and implement AHA programs that address the needs
of special population groups. This article can also help other agencies as they implement
AHA programs and focus on reducing health disparities.
Our roundtable focused on preventable differences in the widening gap in CVD morbidity
and mortality (1,2). To explore how to develop behavioral strategies for reducing
the disparate rates of CVD in special population groups, we examined CVD risk stages
and needs among people who may have 1) no known or identified cardiovascular risk
factors (possibly with undiagnosed CVD risk factors), 2) known or identified risk
factors (eg, obesity, diabetes, hypertension), 3) acute CVD problems, 4) rehabilitation,
or 5) chronic CVD problems and a need for secondary prevention.
The Institute of Medicine's multilevel approach (3) provides a framework for examining
the environment in relation to risk using concentric circles starting with the individual
and moving outward to the family, community, and society. Using this multilevel approach
is helpful in examining how individual socioeconomic and racial/ethnic status link
to health and social systems as determinants of individual and population health (3).
Because of the current obesity epidemic, much of our roundtable discussion addressed
environmental issues and policies that may promote obesity or leanness (4-6). A recent
statement from the AHA emphasized the need for population-based strategies that target
the social and physical environment as a means to promote healthy eating and physical
activity (6). Our roundtable considered infrastructures that are associated with socioeconomic
status and with low-income families living in increasingly obesogenic environments,
and we discussed the importance of using techniques that examine the interrelationship
among variables associated with poverty (7-9). Although food insecurity has been associated
with a 2-fold greater risk of obesity, these differences can also be accounted for
by differences in education, income, race/ethnicity, marital status, and general health
(9). We considered lack of transportation, safety concerns, care responsibilities,
and the availability of parent/adult volunteer coaches. We noted poverty's effects
on food-purchasing habits, for example, that low-cost options in grocery stores are
often limited. Of particular concern was the cost difference between fresh vegetables
and fruits and more highly processed foods with added sugar and fat (8).
The variables that we thought were important in addressing special population needs
at each risk stage are listed in the Appendix. For the earlier stages, we considered
1) environmental factors that focused on different rates of access and economic opportunity
and 2) psychosocial factors that focused on cultural and individual beliefs in relation
to life experiences and competing priorities. Our consideration of more advanced risk
stages focused on health care systems as well as factors that influence people at
high risk of CVD within vulnerable population groups.
CVD Disparity and Program Evaluation Focusing on Special Population Groups
We considered the importance of community partnerships — in which community representatives
participate in defining research problems, interpreting data, and applying findings
— in fostering community-based participatory research methods for the evaluation of
disparate rates of CVD or its risk factors (10,11). Our discussion of evaluation focused
on the RE-AIM framework (12), which is well suited to the community-based participatory
research approach that focuses on disparity. The components and evaluation target
includes Reach (What proportion of the target population participated in the intervention?),
Efficacy/Effectiveness (What is the success rate if implemented according to the plan
or protocol?), Adoption (What proportion of community organizations, classes/schools,
and practices opted for the intervention?), Implementation (To what extent is the
intervention implemented as intended in the real-world setting?), and Maintenance
(To what extent is the program sustainable over time?). We discussed how the RE-AIM
evaluation questions could be applied to existing AHA programs and partnerships.
Potential Application of RE-AIM Evaluation Questions
No known CVD risk factors
The Alliance for a Healthier Generation (www.HealthierGeneration.org) is a joint initiative
between the AHA and the William J. Clinton Foundation. The Alliance for a Healthier
Generation was created to stop the nationwide increase in childhood obesity by 2010
and is taking bold, innovative steps to help all children live longer and healthier
lives. The 4 strategic initiatives target industry, health care, schools, and children
themselves.
Reach
How many schools, children, health care organizations, or food manufacturers participate
in selected prevention activities compared to target (eg, attendance and distribution
numbers for programs or materials available)? How many of the participating schools
are in vulnerable communities with disparate rates of obesity, diabetes, and heart
disease?
Efficacy/Effectiveness
What was the impact of programs on fitness and weight measures (preintervention and
postintervention and compared to national trends)? Does the target population buy
or use (or intend to buy or use) the products or services (eg, lunch, snack options)
that promote a healthful lifestyle? How did beverage consumption change in the schools?
Does the program efficacy vary by community demographics and resources?
Adoption
How many of the potential providers or stakeholders (eg, schools) provide the intervention
components? How does this compare to the need and the goal? Is variability in providing
components related to resource disparities in the community? What are the community
resources for promoting a healthy lifestyle? How much are the available resources
used? How did beverage policy change in the schools?
Implementation
What are the barriers to providing the targeted service? Are the programs developed
consistent with the AHA and Alliance recommendations for a healthful lifestyle? How
feasible is intervention implementation in a variety of real-world settings?
Maintenance
Are school and other programs sustainable based on annual reviews? Will the target
population continue to use the facility (eg, path for walking), goods or services
(eg, purchasing low-fat milk) after the program or campaign is over?
Known or identified risk factors
The AHA does not provide direct services to people with cardiovascular risk factors.
However, the AHA's Web site provides decision trees to guide health professionals
in treating risk factors and self-help programs for people who have cardiovascular
risk factors, for example, diabetes or hypertension (www.americanheart.org/presenter.jhtml?identifier=2114
and www.americanheart.org/presenter.jhtml?identifier=3044887).
Reach
How many people with the identified risk factor (diabetes or hypertension) use the
Web site? How many health professionals accessed risk factor reduction information?
Efficacy/Effectiveness
How well did patient users achieve goals for a healthy lifestyle and reduce CVD risk
status? Potential measures include self-reported control of CVD risk factors such
as lipid profile, blood pressure, and blood glucose as well as measures such as body
weight, dietary intake, and physical activity. Do rates of achieving goals differ?
Adoption
How do Web site users compare with the general population and the vulnerable subgroups
with diabetes or hypertension? Are population groups with disparate rates of risk
factors using the Web site? How do these health professionals compare to others in
their profession?
Implementation
Which components of the programs were used? Were the Web site features used as planned?
What are the barriers to implementing the recommendations for patients and health
care providers? Are there more barriers for population groups with diabetes and hypertension
health disparities? What is needed to make effective programs more translatable to
the real world?
Maintenance
Will program users continue desired patient or self-care behaviors? Will Web site
links continue to have sponsorship and be available on the AHA Web site?
Acute CVD
At this risk stage, the focus shifts to immediate emergency care issues. The AHA has
a national network of community-based programs designed to reduce response times to
cardiac emergencies by improving access to automatic external defibrillators among
laypeople. Success of these Operation Heartbeat programs depends in part on the public's
knowledge of the warning signs of a myocardial infarction (MI) and the appropriate
response to cardiac arrest victims (www.americanheart.org/presenter.jhtml?identifier=10000046&title=Operation
Heartbeat).
Reach
What is the availability of acute cardiac services in the target community? What is
the estimated need? How many people in the community know about or know how to use
the service? How does the availability of service compare to the number of people
who need the service?
Efficacy/Effectiveness
Do community residents receive needed treatment in a timely manner (eg, emergency
response time)? Does response time vary based on community characteristics?
Adoption
How many public facilities employ staff who know how to use emergency services? How
available are catheterization and revascularization services? Are some communities
with excess morbidity and mortality lacking access to these services?
Implementation
What are the barriers to increasing access to emergency or cardiac services? Can the
findings be generalized and translated to programs elsewhere? What resources and other
factors are needed to do so?
Maintenance
How can a program continue to address service needs? Examination of program sustainability
can be based on audits of emergency responses, and cardiac event mortality can be
evaluated based on medical charts and review of emergency service logs.
Rehabilitation
The AHA promotes a partnership between patients and their doctors, nurses, pharmacists,
and other health care professionals to help patients change their health habits. Patients
take an active role in making these changes (www.americanheart.org/presenter.jhtml?identifier=3047638
and www.americanheart.org/presenter.jhtml?identifier=4713).
Reach
How many people receive AHA-recommended rehabilitation services (eg, after having
a heart attack or stroke)? What is the availability of cardiac rehabilitation in the
target community? What is the estimated need? How many people in the community know
about or know how to use the service? Are some communities lacking access to rehabilitation
services?
Efficacy/Effectiveness
What is the overall quality of life and health for people who have had a CVD event?
How are demographic and community characteristics related to health and quality-of-life
measures?
Adoption
How many facilities provide recommended components of rehabilitation? How does the
quality of rehabilitation facilities relate to disparities in outcomes?
Implementation
What are the barriers to offering comprehensive (including lifestyle counseling) rehabilitation
services in underserved communities? Staff and patient interviews can provide insights
about services offered and their use.
Maintenance
How well do patients maintain recommended lifestyle changes after participating in
a rehabilitation program? What resources are institutionalized as ongoing rehabilitation
services? Is a comprehensive rehabilitation program available over time?
Chronic CVD
The AHA launched the Get With the Guidelines (GWTG) program in 2000 to help hospitals
treat patients with evidence-based medicine known to improve health outcomes (www.americanheart.org/presenter.jhtml?identifier=3049656).
The GWTG program has 3 modules: coronary artery disease, heart failure, and stroke.
Each module addresses specific clinical practices and lifestyle changes.
Reach
How many hospitals participate in the GWTG program? How many patients are treated
with the GWTG program? What is the estimated need? How many people in the community
know about or know how to use the service? Do underserved communities have access
to hospitals in the GWTC program?
Efficacy/Effectiveness
How do the statistics for second MI compare to rates where the GWTG program is not
available? Do community residents receive treatment needed in a timely manner? How
many stroke and MI patients receive treatment within the recommended time window?
What are the disparities in the rates of secondary prevention of stroke and MI?
Adoption
What percentage of the staff and hospital programs follow the guidelines as recommended?
Do GWTG hospitals in underserved communities implement guidelines at the same level
as other hospitals?
Implementation
What are the barriers to secondary prevention? What are the views with regard to secondary
prevention in patients, families, and health providers? Is there sufficient coordination
to meet patients' needs? Can the findings be generalized and translated to programs
elsewhere? What resources and other factors are needed to do so?
Maintenance
How many hospitals continue to meet the guidelines every year? Do hospitals in underserved
communities continue to meet guidelines at the same rate as those in other communities?
Practice Implications
The RE-AIM evaluation rubric provides a framework for examining AHA programs and collaborative
projects. Applying the rubric to each of the identified stages of risk reduction can
provide insights for addressing disparities. Creating innovative partnerships and
enhancing community-based participatory research (community organizations, community
clinics) will allow the AHA to increase healthy lifestyle educational programs and
the number of community organizations that implement these programs. These efforts
could lead to changes in policies, including access to care, physician training on
cultural awareness, and treatment guidelines sensitive to ethnic differences.
Acknowledgments
We thank the AHA Industry Nutrition Advisory Panel for providing an unrestricted grant
to address the needs of special populations in the nutrition behavioral roundtable,
which led to the development of this paper. We are especially grateful to JoAnn Hamamura,
MS, CNS, who served as industry cochair for the special populations workgroup, and
Vickie Peters, MS, who served as the AHA facilitator.