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Closing the Cardiovascular Disease Gap

Experts agree that culturally competent preventive education can play a key role in reducing CVD disparities in minority communities. And who better to provide that education than nurses?

By Susan Wessling

Mary B. Green, MN, RNC

Cardiovascular disease (CVD), principally heart disease and stroke, is the leading cause of death for all racial and ethnic groups in the United States. That's the bad news, and there is even worse news for people of color: Minority and low-income populations shoulder a disproportionate burden of death and disability from CVD.

To cite just a few examples, statistics from the Centers for Disease Control and Prevention (CDC) indicate that in 2000 the rates of death from diseases of the heart were 29% higher for African-American adults than for Caucasian adults, and death rates from stroke were 40% higher. African-American and Hispanic women face the highest risk of death from heart disease and stroke, but they have the lowest risk factor awareness of any racial or ethnic groups, according to a survey published in the Journal of the American Heart Association.

How can health care providers start to close this gap? Many minority health experts believe education is a key factor in preventing CVD and reducing heart disease risks. Because minority communities often do not have adequate access to health care, coronary heart disease is not identified early in patients of color, says Dorothy Hamilton, MSN, CNP, RN, a nurse practitioner at the University Hospitals of Cleveland.

Shirley Smith, MNEd, RN, CRNP

"[Minorities] tend to present after an acute episode, whether that be cardiac or stroke," explains Hamilton, who is African American. "For prevention, [health care professionals] need to be more visible in the community by going out to [settings] where we can make contact with people, whether it be at grocery stores or at churches. The sooner cardiovascular disease is identified [in a patient], the better chance they have of decreased mortality and morbidity and improvement of their lifestyle and health."

The good news is that cardiovascular disease is one of the six target areas of the federal Initiative to Eliminate Racial and Ethnic Disparities in Health. As a result, an unprecedented number of CVD preventive education projects are currently reaching out to communities of color coast to coast. Here's a look at three such model programs and the leadership roles minority nurses are playing within them.

Search Your Heart

Targeting African Americans and Hispanics, the American Heart Association (AHA)'s Search Your Heart program is a national model that provides cardiovascular health education through faith-based organizations. Mary B. Green, MN, RNC, who works for the State of Louisiana Metropolitan Human Services District's Chartres-Pontchartrain Mental Health Center in New Orleans, is actively involved in presenting the program at African-American churches in her area.

Cordelia Clapp, BSN, RN

"African Americans are the people who are dying disproportionately, compared to any other race, from cardiovascular disease and stroke and the co-morbidities of kidney failure and diabetes," notes Green, who has also been involved with Search Your Heart on a national level as immediate past president of the AHA's National Women & Minorities Leadership Committee.

She not only directs the program at churches but also works at spreading the word in a number of other community arenas, from company boardrooms to housing projects. "I have gone all over the country 'training the trainer'-as a speaker and presenter to pastors, administrators, whomever will listen," says Green, who is African American.

Search Your Heart encourages participants to change unhealthy lifestyles and develop heart-healthy habits through seven activity modules. These include screenings, fitness activities, nutritional habits, stress reduction and stroke prevention. There is also an advocacy module called Lift Every Voice, which teaches participants how to become advocates for heart health in their own communities.

Nurses from Duquesne University School of Nursing teach Operation Churchbeat participants how to perform CPR and uses a defibbrilator.

Nurses are a good fit with this project, Green says, primarily because they are patient advocates. "In addition, African-American nurses are compassionate and sensitive to the plight of the target population, because we all either suffer from CVD or know someone who suffers from it," she explains. "We can relate and we feel it's our duty to help, because if we don't do it, it won't get done."

Green believes the program's community outreach-based approach is helping to break down barriers that have traditionally made it difficult to level the heart health playing field for people of color. These barriers include limited finances and other resources, lack of access to health care and distrust of the majority health care system.

"You have to take it to the people [to overcome these obstacles]," Green emphasizes. "That is what makes this Search Your Heart program so powerful. You must meet people where they are, both literally and figuratively. You have to educate them not only about the disease process but also about the available resources and how to access them. Show them alternative ways of doing the things they've always done-for example, [conduct] heart-healthy cooking/ nutrition demonstrations and tastings. [You must also] try to empower them to ask questions when they want to know something."

The personal reward from working on this project, Green adds, is seeing people access resources that have eluded them for years. "Search Your Heart is a program that works. It is changing people's behaviors every day," she says. "The most notable [example from] throughout my 17-year involvement with AHA has been getting Southern churches to move from [serving] fried chicken and fried fish dinners to baked and/or oven-fried. If you know anything about the South, you know that's a monumental accomplishment. The payoff has been a marked, continual decline in blood pressures and fewer strokes and myocardial infarctions compared to 10 years ago."

Operation Churchbeat

Another faith-based initiative that is taking aim at reducing the rates of CVD in minority communities is a research project being conducted at Duquesne University School of Nursing in Pittsburgh, in collaboration with AHA and the City of Pittsburgh Emergency Medical Services. Joan Such Lockhart, PhD, RN, CORLN, AOCN, FAAN, professor and associate dean for academic programs at the school of nursing, is the principal investigator for the project, called "Developing a Model 'Chain of Survival' Community in a Predominately African-American Urban [Pennsylvania] Neighborhood: Operation Churchbeat."

Funded through a Commonwealth Universal Research Enhancement (CURE) grant from the Pennsylvania Department of Health-with funds from the tobacco settlement-the project uses a collaborative team of diverse members, including African Americans and whites, males and females, nurses and EMS personnel. Project workers were involved in training approximately 142 lay individuals from 10 churches in the Hill District-a community in the same neighborhood as Duquesne University School of Nursing-to recognize cardiac emergencies and respond to them by performing CPR and using an automated external defibrillator (AED).

Nurses from Duquesne University School of Nursing teach Operation Churchbeat participants how to perform CPR and uses a defibbrilator.

"Operation Churchbeat is a pilot intervention study, designed in response to a previous study of Pennsylvania and Delaware residents conducted by an interdisciplinary group of volunteers through the AHA Operation Heartbeat initiative, which I chaired," explains Lockhart. That study found that many of these states' residents didn't have recent CPR or AED training. "[Operation Churchbeat's] focus is on the chain of survival and identifying risk factors, signs and symptoms of heart attack," she adds.

Shirley Smith, MNEd, RN, CRNP, an assistant professor at the school of nursing, is a co-investigator in the project. "As a community health nurse, I am interested in health promotion and health education within the community," says Smith, who is African American. "We especially want to target the communities that are more vulnerable." Operation Churchbeat is aimed at black Americans, she continues, "because there is so much heart disease and death from heart disease within that population. Plus, this community is right in our backyard."

She was responsible for bringing the program to two of the participating churches. "I am the person who contacted the church and made appointments with the key people to talk about the program, because we thought it was very important that [church leaders] be very much involved with this," says Smith, who also taught CPR to church members. "We described to them what we wanted to do and tried to get their participation."

One of the purposes of the research, she notes, was to determine whether educational programs were effective in the community. "We wanted to see if a community-based program would help make people aware of the chain of survival in terms of calling 911 early and doing early CPR."

In the churches where Smith worked, about 15 to 18 people attended each of the 10 training sessions, which lasted three to four hours. Plus, in an effort to sustain the project after the initial training, at least three parishioners from each church were trained as CPR instructors and each of the 10 churches was supplied with a set of CPR mannequins, an AED trainer and other materials and supplies.

The program participants' knowledge was tested before the training began and they also took a post-test. The study is currently in the data analysis phase and the investigators will share the results with the churches. "We want to find out what the people want and then help them facilitate that wherever we can," Smith explains.

Nurses are well equipped to provide this type of preventive education, she adds. "They can teach people how to reduce their risk factors and live healthier lives. That is what nurses do so well, and especially nurses in the community. It has been found that many African-American health care professionals will go back to their communities to practice. That is why it is so important that African-American nurses become involved in [projects like] this."

The Kaw Nation Project

Because CVD is also a serious health threat in American Indian and Alaska Native communities, it's important for Native American nurses to be involved as well. Patient education is the cornerstone to successful changes in lifestyle that will positively impact CVD, heart attack and stroke awareness, agrees Cordelia Clapp, BSN, RN, acting health director at the Kaw Nation of Oklahoma's tribal clinic, Kanza Health Clinic, in Newkirk, Oklahoma.

She also serves as the clinic's public health nurse (PHN) and diabetic coordinator. "CVD and diabetes go hand in hand because they are twin brothers," explains Clapp, who directs the Kaw Nation PHN Health Promotion/Disease Prevention Project for Cardiovascular Disease Prevention in Native American Women. The project is funded by a PHN Heart Awareness Grant for Native American Women and by the Indian Health Service (IHS).

"Education and screening must begin at early ages in life and continue throughout all age groups for prevention efforts to be effective in reducing the risk of CVD in Native American women," says Clapp, whose mother is full blood Pawnee from the Skidi Band. "The prevalence of this disease among Native American women will continue to grow unless prevention and intervention services are developed to address the contributing factors that put women at an increased risk of developing CVD, such as diabetes, hypertension, obesity, high cholesterol, poor diet and lack of exercise."

The Kaw Nation opened the doors of the Kanza Health Clinic in 1998 to all Native Americans who are members of a federally recognized tribe. Currently there are 3,343 established patients and approximately 845 of them have been diagnosed with CVD. Oklahoma has the second largest American Indian population of any state, Clapp reports, and in the United Health Foundation's 2002 rankings of the healthiest states, it placed perilously close to the bottom at number 46.

"The Kanza Health Clinic is located in Kay County, which has been ranked by the American Heart Association as the highest in Oklahoma for developing cardiovascular disease," she adds. Located in the north central part of the state, within the IHS Pawnee Service Unit, the clinic serves the Native American population in 20 rural counties in Oklahoma, plus five south central counties in Kansas. To reach out to people who do not routinely go to the clinic, Clapp conducts health screenings at Native gatherings, including powwows, tribal health fairs and tribal community events.

The KAW Nation CVD prevention project-which targets Native American females six years of age and older-has five goals:

• Provide educational/awareness presentations on CVD in Native American females at designated Indian health care access sites and/or Native American gatherings;
  
• Provide screening services (lipid panel, body mass index, blood pressure and blood sugar) for Native American females;
  
• Increase access to existing health care facilities through the referral of patients identified by abnormal lab results;
  o Increase access to existing wellness or community exercise and nutritional facilities through the referral of identified patients; and
  
• Increase overall public and professional awareness regarding intervention and prevention services in regards to CVD in Native American women.

Historically, Native Americans have had low incidences of CVD but that has changed dramatically in recent years. "Changes [to their traditional] diet and lifestyles have resulted in CVD now being recognized as the leading cause of death among American Indians and Alaska Natives. The mortality from CVD among Native American people has now surpassed that of the general U.S. population," Clapp reports.

"A woman's ethnic heritage influences her risk of CVD," she continues. "For example, Native American women are more likely to develop hypertension and diabetes than other women, [and each of these conditions] is a strong predictor of heart disease and a poor outcome."

Because the IHS, part of the U.S. Department of Health and Human Services, is severely underfunded, many Native American women do not have access to proper diagnostic testing or treatment in a timely manner, and they have to fight to see specialists. "The Indian Health Service can't spend money it doesn't have, and it doesn't have much," Clapp says. "America spends an average of about $5,000 per person per year on health care. For government programs that deliver health care directly, the per-person expenditure varies enormously: $5,200 by the Veterans Health Administration, more than $3,300 by the armed forces, $3,800 per federal prisoner [but only] $1,900 by the IHS."

Clapp is a national spokesperson for the AHA and for the National Coalition for Women with Heart Disease (WomenHeart). She was honored for her work in her community when the National Indian Health Board presented her with its Local Impact Award at its 21st Annual Consumer Conference last August. And this April she will receive the AHA's Louis B. Russell, Jr., Memorial Award in recognition of her service to minority and underserved communities.

"Being a Native American nurse who is well known throughout the [local] Indian population due to family ties and participation at the Native American gatherings has made it possible [for me to] campaign for women's self-empowerment to prevent heart disease," says Clapp. The gap of unequal outcomes can be closed, she adds, by increasing this population's access to information about how to reduce CVD risk factors and by increasing awareness of the signs and symptoms of heart disease in women, which differ significantly from those in men.

"In the Native American tribal communities we have different cultural backgrounds and a different heritage," she stresses. "[Health care providers need to] respect our elders and provide culturally sensitive teaching guides. A Native American [nurse who] is well accepted within the tribal communities and is trusted among the elders [can effectively foster] teaching opportunities and genuine relationships between a patient and nurse."

Susan Wessling, who lives in Worcester, Mass., is a free-lance writer specializing in health articles.

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