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Reducing Cardiovascular Disease in African American and Women in North Carolina through
Community Health Programs
by
Mazalo Looky
Applied Research Project Paper
Submitted in Partial Fulfillment
of the Requirements for the Degree of
Master in Public Health
MPH 530 Methods of Research in Public Health Concordia University, Nebraska
August, 2014
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Abstract
Cardiovascular disease (CVD) is a major health problem among women globally. In North
Carolina (NC), 28% of women are diagnosed with heart disease and about 30 of them die every
day. In 2009, about 8,249 women die making heart disease the leading cause of death in NC
women. This study addressed the four major types of the CVD, Coronary Artery Disease, Heart
Attack also known as myocardial infarction (MI), Arrhythmia and Heart Failure. The focus of
this study was to determine whether a community-based risk reduction project affected
behavioral risk factors of CVD. Methods: the study focused on a joint project implemented in the
Northwest Corridor of Charlotte in a community of 20000 African American from 2001-2005
involving community coalition, a lay health advisor program, and policy and community
environment change strategies. Each year, investigators administered to a cross-section of the
community Health behavior questions from the Behavioral Risk Factor Surveillance System
survey. The results were compared with African Americans’ responses from a statewide survey
which showed that low physical activity, high-fat, low-fiber diet and smoking improved in the
study population. These improvements were statistically significant for physical activity (P=.02)
and smoking (P=.03) among women and for physical activity among middle-aged adults (P=.01).
Lower baseline physical activity rates improved to levels comparable to those of African
Americans statewide (2001, P<.001; 2005, P=.38), and comparable fruit and vegetables
consumption rates became significantly higher (2001, P=.68; 2005, P<.001). Investigators
findings supported the emerging role of policy and community environment change strategies
and community participation as promising practices to improve health behaviors and to reduce
health disparities compared residents with African Americans across the state.
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Table of Contents
Abstract……………………………………………………………………………………………ii
Chapter 1: Introduction (Level 0 Heading)…………………………………………...…………...4
Background of Applied Research Project……………………………………………........4
Thesis Statement………………………………………………………………………......7
Purpose of the Study………………………………………………………………………8
Research Hypotheses……………………………………………………………………...9
Theoretical Base …………………………………………………………………………..9
Definition of Terms……………………………………………………………………....10
Assumptions……………………………………………………………………………...11
Limitations……………………………………………………………………………….11
Delimitations…………………………………………………………………………......11
Significance of the Study………………………………………………………………..11
Summary and Transition…………………………………………………………………12
Chapter 2: Literature Review…………………………………………………………………….12
Figure 1…………………………………………………………………………………..14
Table 1…………………………………………………………………………………...16
Chapter 3: Research Method…………………………………………………………………….18
Setting and Sample………………………………………................................................20
The role of the researcher in the design……………………………………………….…21
Measures for ethical protection of participants…………………………………………..22
Chapter 4: Results………………………………………………………………………………..23
Table 2…………………………………………………………………………...24
Chapter 5: Conclusion……………………………………………………………………………27
Recommendations………………………………………………………………………………..29
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References…………………………………………………………………………………….…31
Appendix ………………………...………………………………………………………………35
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Chapter 1: Introduction to the Applied Research
Background of Applied Research Project
CCD is currently a leading cause of death among women. About 600,000 people die of
CVD in the United States every year. CVD is also the leading cause of death for people of most
ethnicities in the United States, including African Americans, Hispanics, and Whites. In the U.S.,
24% of women die yearly of CVD. Coronary Artery Disease (CAD) killed nearly 24.4 % of
African American and 24% of white female in 2009. In NC, 28% of women are diagnosed with
CVD and 30 die every day from the disease (CDC, 2014).
Risk Factors of CVD
Coronary Artery Disease (CAD), Heart Attack, also known as myocardial infarction
(MI), Arrhythmia; and Heart Failure are the primary diseases associated with CVD. Risk factors
include conditions, behavior and heredity. Conditions include High Blood Cholesterol Levels:
cholesterol is a waxy substance produced by the liver or consumed in certain foods. This can
lead to narrowing of the arteries, heart disease, and other complications. Not all cholesterols are
bad. The good one is called density lipoprotein cholesterol (HDL) and the bad one is low–density
lipoprotein, or LDL that can lead to heart diseases. High blood pressure, another major risk
factor for heart disease, is a condition where the arterial blood pressure is too high, but symptoms
are not detectable. Diabetes Mellitus increases a person's risk for heart disease. With diabetes,
the body either doesn't make enough insulin, cannot use its own insulin as well as it should, or
both. This causes sugars to build up in the blood. About 75% of people with diabetes die
annually from some type of heart or blood vessel disease (CDC, 2012). Risky behavior such as
tobacco use can lead to heart attack and heart disease. Cigarette smoking promotes
atherosclerosis and increases the levels of blood clotting factors. People who are exposed to
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smoke are called second hand smokers. They are also at risk for having heart diseases. People
who consume foods that are high in saturated fats and LDL (bad) cholesterol are at risk for
atherosclerosis. High salt or sodium in the diet causes raised blood pressure levels. Physical
inactivity is related to the development of heart disease and can impact other risk factors,
including obesity, high blood pressure, high triglycerides, a low level of HDL (good) cholesterol,
and diabetes. Obesity is excess body fat. It is linked to higher LDL (bad) cholesterol and
triglyceride levels and to lower HDL (good) cholesterol, high blood pressure, and diabetes.
People who abuse alcohol are increasing their blood pressure and their risk of having heart
diseases. People with family histories of high blood pressure, heart diseases and other vascular
conditions are at risk for CVD; their risk increases even more when heredity is combined with
unhealthy lifestyle choices, such as smoking cigarettes and eating a poor diet (CDC, 2012).
Risk Factors of CVD in African American Women
Stroke and congestive heart failure have increased in American women because of
cigarette smoking. About one in five African American woman smokes. They develop high
blood pressure earlier in life and have higher average blood pressures compared to white women.
Currently approximately 37% of black women have high BP, compared to 37.8% of white
women. High Blood Cholesterol: About half of African American women have high L DL (bad
cholesterol). Nearly 80 percent of these women are overweight or obese, which increases their
chances of having heart disease and other conditions including stroke, gallbladder disease,
arthritis, and some cancers.
Physical Inactivity: lifestyle (sitting in the coach to watch television for long hours) plays
an important role in African American women. The prevalence of watching television more than
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three hours per day was highest among black girls. About 55 % of them are physically inactive.
They do no spare-time physical activity (NHLBI Health Information Center, 2009).
Diabetes: In 2009, 15.4% of black women were diagnosed with Diabetes Mellitus and
about 6,472 black females die of diabetes mellitus. The overall death rates for diabetes for black
women in 2009 were 35.9 (American Heart Association, 2013).
Risk Factors of CVD in White Women
In 2009, CVD caused the deaths of 343,955 White Women. Smoking: There are 37.8% of
White Women who live with hypertension. The prevalence of smoking was higher among White
girl students (53.9%). High Blood Cholesterol: about 29.3% of White Women have an LDL
cholesterol of 130 mg/dl or higher. Physical Inactivity: The prevalence of physical inactivity was
among White girls, (13.7%). About 23.9% of White girls spend more than three hours watching
television. Diabetes: about 4.3% of White women have diabetes. In 2009, Physician-diagnosed
diabetes for White women is 6.2%, 1.8% of White Women are undiagnosed with diabetes and
about 30.0% of White Women have pre-diabetes. In the same year, diabetes caused the deaths of
25,908 White Women. Additional risk factors include menopause, stress and depression
(American Heart Association, 2013).
Thesis Statement
Cardiovascular disease (CVD) is a major health problem among women globally.
Research has shown that there are differences between women and men in the presentation,
epidemiology, and outcomes of CVD. Women are more at risk for CVD, but research has
targeted only men. Recent studies showed that more women die of CVD than men each year
because they do not usually present any symptoms. Genetic, physiological, behavioral and
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socioeconomic risk factors of CVD include family history of heart disease, age, smoking, high
blood pressure, high serum cholesterol, low fruit and vegetable consumption, obesity, physical
inactivity, depression and psychological stress (Coulter, 2011). There is a high prevalence of
physiological risk factor of CVD in women. These physiological risk factors for women are high
blood pressure (hypertension), high cholesterol, physical inactivity, diabetes, unhealthy diets,
body mass index (BMI), and obesity and harmful use of alcohol (World Heart Federation, 2014).
A survey given to women conducted by the AHA about their knowledge of CVD risk
factors showed that about half of them knew heart disease is the leading cause of death among
women showed that about half of the women interviewed knew that heart disease is the leading
cause of death in them, yet only 13% said it was their greatest personal health risk. The same
survey has determined that women are more knowledgeable about breast cancer than the CVD
and researchers still do not know why it is like that. These modifiable risk factors are behavioral,
psychological and socioeconomically (SES) factors (depression, stress management, coping,
physical inability, unhealthy eating habit, obesity, overweight, smoking, BMI, hypertension and
high cholesterol level, levels of education and family income, lack of health insurance and
poverty (Plescia, Herrick and Chavis, 2008). Coronary heart disease (CHD) is the most type of
heart diseases that kills both men and women. Studies have shown that women demonstrate a
higher morbidity rate of CHD than men in the United State (U.S.).
In summary, findings regarding risk factors of CVD are primarily from studies with men
and developed countries; however, women are more likely to die of the disease than men.
Coronary heart disease (CHD) is the most type of heart diseases that kills both men and women.
Women have the most recurrence of CVD than men.
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Purpose of the Study
The purpose of this project was to examine the effect of modifiable risk factors for heart
diseases. The aim is to assess the modifiable and contextual risk factors and the severity of CVD
among men and women and African Americans; the study also aims to show the
moderator/interaction effects of the relationships between major risk factors and contextual risk
factors in contribution to the severity of CVD in the entire community.
Research Hypotheses
1. Women ages 40 and over are more at risk for getting heart disease because of the prevalence
of high body mass index (BMI), smoking, high blood pressure, and physical inactivity.
2. This study used 3 behavioral risk factors for heart disease including diabetes, low physical
activity, and cigarette smoking that can be modified.
3. The community and providers encouraged positive changes in health-related behaviors, and
made referrals to health professionals as necessary.
Theoretical Base
Quantitative studies are based in the first and the most common heart disease, coronary
heart diseases: several cohort studies have examined the relation between fruit and vegetable
intake and coronary heart disease. The results of the meta-analysis of cohort studies indicate that
fruit and vegetable consumption are inversely associated with the occurrence of CHD (Dauchet,
Amouyel, Hercberg & Dallongeville, 2006).
Qualitative study was conducted to educate women and men about the risk factors and
how to prevent heart diseases (Emslie, 2005).
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Definition of Terms
Arrhythmia: an irregular heartbeat. The heart may beat too fast (tachycardia), too slowly
(bradycardia), too early (premature contraction) or too irregularly (fibrillation). Arrhythmia is
heart-rhythm problems that occur when the electrical impulses to the heart coordinate heart beats
are not working properly, making the heart to beat too fast, slow or inconsistently (Nordqvist,
2009).
Cardiovascular diseases (CVD): are a group of disorders of the heart and blood vessels
that include coronary heart disease: disease of the blood vessels supplying the heart muscle;
cerebrovascular disease: disease of the blood vessels supplying the brain; peripheral arterial
disease: disease of blood vessels supplying the arms and legs; rheumatic heart disease: damage to
the heart muscle and heart valves from rheumatic fever, caused by streptococcal bacteria;
congenital heart disease: malformations of heart structure existing at birth; deep vein thrombosis
and pulmonary embolism: blood clots in the leg veins, which can dislodge and move to the heart
and lungs (World Health Organization, 2014).
Coronary Artery Disease (CAD): is a disease in which a waxy substance called plaque
builds up inside the coronary arteries. These arteries supply oxygen-rich blood to one’s heart
muscle (National Heart, Lungs and Blood Institute, 2012).
Heart Attack, also known as myocardial infarction (MI): is a clinical syndrome
characterized by systemic perfusion inadequate to meet the body's metabolic demands as a result
of impaired cardiac pump function (Hobbs & Boyle, 2014).
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Assumptions
Women are more likely to have a second occurrence of heart attack. Low fruit and
vegetable consumption, low physical activity, and cigarette smoking can lead to severe heart
diseases.
Limitations
Health behavior questions from the Behavioral Risk Factor Surveillance System survey
were administered to a cross section of the community each year. Non-modifiable risks factors
and the severity of CVD were not addressed. Biomedical or anthropometric markers were not
collected to confirm reported behaviors. Investigators did not ask survey respondents if they had
participated in or heard of the project or any of its interventions. Therefore, the behavioral
changes observed could not be directly linked with specific components of the project. Cultural
and geographic characteristics were not measured which could have play a significant role in
health disparity.
Delimitations
Investigations were conducted African American and White Women in North Carolina.
Heart diseases can also be study on men and on different ethnics groups. Age of onset of CVD
can be considered as well.
Significance of the Study
This project addressed a phenomenon of interest to nursing science since it would expand
the theoretical perspectives of risk factors for CVD in African American and White Women
(race and ethnic group). It provided an explanation of modifiable risk factors for CVD in this
population based on cultural perspectives. Results from this project were expected to improve
the health of urban Charlotte community including White and African American women. This
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knowledge could be utilized to reduce personal, policy, and environmental barriers that
contribute to health disparities among not only African American and White women, but also for
the community and the policy makers. Interventions could be formulated for the control and the
prevention of CVD before CVD emerges as a public health problem (Plescia & et.al, 2008).
Summary and Transition
This section summarizes Chapter 1 and the gives an overview of the next four chapters.
Chapter 1 ends with a transition statement that contains a summary of key points of the study and
an overview of the content of the remaining chapters in the study.
Chapter 2: Literature Review
Chapter 2 emphasized on the current research and knowledge about the risk factors for
cardiovascular diseases (CVD) of women. It provided theoretical aspects related to the study of
CVD risk factors while many studies have been conducted to explain the development of CVD
risk factors for both men and women. The chapter highlighted studies done within three major
clusters: non-modifiable, modifiable, and contextual risk factors and how they could impact
women’s cardiovascular health. Chapter 2 also discussed what these risk factors are within each
cluster and how they could impact women’s cardiovascular health. The conceptual framework
guiding the present study of CVD risk factors was provided as well.
Cardiovascular diseases are a group of disorders of the heart and blood vessels that
include coronary heart disease: is a disease of the blood vessels. It supplies the heart muscle.
Heart attacks also known as myocardial infarction (MI), and strokes are both usually acute
events and are mainly caused by a blockage that prevents blood from flowing to the heart or
brain, Arrhythmia, Heart Failure, high blood pressure, cerebrovascular disease, is a disease of
the blood vessels that supplies the brain, peripheral arterial disease: disease of blood vessels
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supplying the arms and legs, rheumatic heart disease: damage to the heart muscle and heart
valves from rheumatic fever, caused by streptococcal bacteria, congenital heart disease:
malformations of heart structure existing at birth, deep vein thrombosis and pulmonary
embolism: blood clots in the leg veins, which can dislodge and move to the heart and lungs
(World Health Organization, 2014).
Cardiovascular diseases are the leading cause of death in women, not only in the United
States, but also worldwide. In 2008, 7.3 million people died of coronary heart diseases (CHD),
and 6.2 million people died from cerebrovascular disease. CVD has been considered a male
disease; however, more women die from CVD than any other disease. Death rates from CVD
have recently declined, but the burden of disease remains high. The number of women dying has
continued to rise. CVD is projected to increase over the next 2 years as a result of both adverse
lifestyle changes and aging populations (Worrall-Carter, 2011).
A review of available literature yielded studies from a meta-analysis on risk-factors for
CVD among women conducted by the National Heart, Lung, and Blood Institute in the late
1980s, and lay health advisors (LHAs) or community peers, and the Charlotte Racial and Ethnic
Approaches to Community Health (REACH) 2010 program.
The goal of the project was to improve modifiable risk factors across the entire
community through extensive community involvement, use of lay health advisors, and an
emphasis on community environment and public policy interventions. The Charlotte REACH
2010 project was designed to apply and expand promising strategies and public policy
interventions by addressing health disparities in cardiovascular disease and diabetes in an urban,
African American community.
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Findings from this project revealed that low physical activity, a high-fat, low-fiber diet,
and smoking are established antecedents of cardiovascular disease and diabetes and were
considered the most realistic outcome goals for the 5-year time frame of this project.
When the prevalence of risk factors are compared between men and women, findings
have indicated that total cholesterol, body mass index (BMI), diabetes (DM) high blood pressure
(HTN), obesity were more prevalent among women than men. However, the findings regarding
fasting blood glucose (FBG) were inconsistent. These modifiable risk factors associated with
heart disease through lifestyle changes (quitting smoking and increasing physical activity) or the
use of medications (lowering blood pressure and reducing cholesterol levels) have decreased
death associated with CVD in women by 23% since 2000. Tobacco use in women has decreased
by 3.6% (from 23% to 19.7%) since 2000, and 3% more women report regular physical activity.
Death from stroke has decreased significantly since 1998 due to improved medical therapies for
hypertension.
Figure 1.
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The prevalence of other modifiable cardiac risk factors among women has increased in
the past decade. Obesity and diabetes rates continue to climb and show a marked variation by
race or ethnicity. Studies show that currently there are 31.3% of white women, 53.2% of black
women, and 41.8% of Mexican-American women who are obese (body mass index, ≥30 kg/m2),
which corresponds to a gradient in the incidence of diabetes of 8.2% in white women, 15.3% in
black women, and 16.9% in Mexican-American women.
Women of a lower socioeconomic status and education level and those with little access
to medical care have an increased risk for CVD. Hispanic women more frequently have biologic
risk factors such as obesity and diabetes than do white women, but the rates of obesity and
hypertension among Hispanic women are lower than in black women. Therefore, a greater
magnitude of earlier exposure to, and longer duration of hypertension in black women may
contribute to their increased CVD mortality rate.
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The prevalence of smoking, one of the behavioral risk factors, was much higher among
men than women. Alcohol consumption was higher in men than women. Men drink 11.1 % more
than women, a trend that has increased over the past several years (Rufus, 2014). However, other
cardiovascular risk factors such as socioeconomic status were known to have a significant effect
on rates of hypertension, obesity, and diabetes. Rates of obesity have increased only slightly (by
0.3%) in the past decade for women living just below the poverty level. However, in those with
income levels at 100% to 199% of the poverty level, obesity rates have increased 1.8%; in those
with income levels at greater than 200% of the poverty level, obesity rates have increased by
3.6% (Coulter, 2011).
Non-modifiable risk factors (Family History of CVD), other physiological risk factors
(abdominal obesity, and menopause status), some behavioral factors such as alcohol
consumption, psychological risk factors (stress, depression, and coping), and some contextual
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factors such as education levels and family income have not been included as risk factors for
CVD in this project.
The percentage of current smokers was significantly greater in males (23.5%) than in
females (17.9%). Between 1965 and 2009 smoking rates decreased 55% among men, 47%
among women, and 51% overall. Black males have higher smoking rates than white males.
Smoking rates in 2009 for black and white males were 24.0% and 23.7%, respectively. Rates
among females are lower than male, with black females tending to smoke less than white females
(American Lung Association, 2011).
Another issue contributing to the prevalence of CVD among women is that heart disease
is under-detected in women, particularly younger women. Also, because physicians may lack of
awareness of CVD in women since women have been largely excluded from CVD clinical trials,
resulting in unclear diagnostic criteria and treatment for women with CVD. Also, physicians may
not categorize women’s atypical syndrome. Women are more likely to have a second heart attack
after their first diagnostic.
Risks or prevalence of CVD such as tobacco use and high triglyceride levels are higher in
women than men. Prevalence includes diabetes, obesity and depression is more in women than
men as well. Similar risk factors between genders include high blood pressure, high total
cholesterol, low HDL-cholesterol, combined hyperlipidemia, physical inactivity, unhealthy diet,
and stress. Risks factors of CVD applied to women only include the use of oral contraceptive and
hormone replacement therapy (HRT). The loss of natural estrogen as women age may contribute
to the higher risks of heart disease seen after menopause; changes in the walls of the blood
vessels, making it more likely for plaque and blood clots to form, changes in the level of fats in
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the blood (LDL, or "bad" cholesterol increases and HDL, or "good" cholesterol decreases),
increase in blood fibrinogen levels, and increased levels of blood fibrinogen which are related to
heart disease and stroke since it makes it more likely for blood clots to form, narrowing the
arteries and reducing blood flow to the heart after postmenopausal (Beckerman, 2012).
Higher IL‐6 and D‐dimer levels in the blood reflecting enhanced inflammation and
coagulation associated with HIV are associated with a greater risk of fatal CVD and a greater
risk of death after a nonfatal CVD event (Nordell, McKenna, Borges, Duprez, Neuhaus, &
Neaton, 2014).
Risk factors for CVD include non-modifiable risk factors (family history, ethnicity and
age), modifiable risk factors include physiological (high blood pressure, high cholesterol,
obesity, menopause and diabetes) behavioral factors include Poverty, Cigarette smoking,
Physical inactivity, Alcohol consumption. Psychological factors include stress, depression, and
coping.
Contextual risk factors include socioeconomic status (Education levels, family income and
poverty (World Heart Federation, 2014).
The literature review has specified the importance and significance of the study of risk
factors for CVD in women. Major risk factors had not been indicated in this project. Also, the
best predictors of CVD in women such as non-modifiable and other physiological risk factors
((high blood pressure, high cholesterol, obesity, menopause and RHT), some behavioral risk
factors such as poverty and alcohol consumption, psychological risk factors (stress, depression,
and coping), and SES (education levels and family income) had not been included as risk factors
for CVD. As a result, it is important to examine the predictors of CVD in women since these
information are limited.
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Chapter 3: Research Method
Qualitative design was used in this study. Investigators used a survey to target the
populations. There were 60 questions that were given to the participants who had 15 minutes to
respond to those questions about their health behavior. Those questions were administered to the
cross-sectional each year from 2001-2005 and results were compared with African American
responses from a statewide survey. Health behaviors that need to be improved are modified
health behaviors including, diet, low physical activity, and cigarette smoking.
Survey weights were constructed for the Northwest Corridor questionnaire. The survey
weights adjusted for the probability of the phone number being selected, the probability that the
screening interview failed to yield a response, and the number of telephone lines per household
and persons living in the household. Investigators applied a final scale adjustment to restore the
sample proportion by age and gender to the target population. To evaluate the effect of
intervention, the overall rates for the study measures among the northwest corridor survey
population and among African Americans in the state BRFSS population for the baseline year,
2001 and 2005 were compared. Investigators tried to determine whether health behaviors under
investigation were similar for the Northwest Corridor and state African American populations at
baseline, health behaviors improved in the Northwest Corridor population over the intervention
years, and improvements in the rates among the study population were seen in the statewide.
Separate analysis of the northwest corridor and BRFSS study populations, were conducted to
compare the difference in rates between 2001 and 2005 by age, gender, and educational level.
Investigators examined which demographic groups were most likely to experience a change in
health behaviors over the course of the project and whether trends observed in the Northwest
Corridor population were also reflected in the state trends. Investigators used a 2-tailed t test for
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independent samples to assess the statistical significance of the proportional changes or changes
in prevalence rates. The standard errors for these tests were derived from SUDAAN (Research
Triangle Institute, Research Triangle Park, North Carolina) and were formulated for proper
variance estimation of correlated data from complex, stratified sampling designs, such as the
Northwest Corridor and BRFSS surveys. All prevalence estimates and confidence intervals were
derived from weighted data (Plescia, Herrick & Chavis, 2008).
Setting and sample population
A community coalition, a lay health advisor program, and policy and community
environment change strategies were implemented in a community of 20, 000 African Americans
in 2001 to 2005. Health behavior questions from the Behavioral Risk Factor Surveillance System
survey were administered to a cross-section of the community annually. The interviews were
conducted with any Racial and Ethnic Approaches to Community Health (REACH) household
member aged 18 years or older to confirm geographic eligibility. Adults from 2 demographic
categories: 1. women aged 40 to 64 years, 1 per household, and 2. Men 18 years and older and
women aged18 to 39 years or 65 years and older, 1 or more women per household were also
selected and interviewed randomly. Women were oversampled to ensure a sufficient sample size
to evaluate use of mammography and cervical cancer screening, which was a focus of the
national REACH project. It took 15 minutes to administer a survey of 60 questions on health
status, health care access, fruit and vegetable consumption, adherence to national physical
activity recommendations, cigarette smoking, hypertension, cholesterol and cardiovascular
disease, diabetes and diabetes care, and the use of preventive services. Responses from the
northwest corridor survey were compared with responses of African Americans in the state’s
concurrent BRFSS survey. Modeling the northwest corridor survey and sample design after the
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BRFSS survey allowed researchers to use state BRFSS respondents as a control group for
evaluating the effectiveness of the Charlotte REACH Project.
The role of the researcher in the design.
Clinical professionals and trained lay health advisers led programs to improve the health
of neighborhood residents, with a focus on promoting healthy eating, exercise, smoking
cessation, and access to primary care. The lay health advisers also served as liaisons between
community residents and the primary care center and promoted disease prevention and
management within the community. Investigators located in a primary care center and at the
county health department including a diabetes nurse educator, nutritionist, and smoking cessation
educator regularly counseled community members about specific health needs. They promoted
exercise, healthy diet, and smoking cessation in their interactions with community residents,
distributed educational materials, provided peer education, made referrals to clinical
professionals as needed, encouraged residents to join preventive health activities, and served as
liaisons between community residents and the primary care center. They also developed and
offered multiple programs that focused on promoting healthy eating, physical activity, smoking
cessation, and access to primary care. Investigators supported each other in implementing their
ideas. They made door-to-door visits in their neighborhoods to give information about the
REACH initiative, providing descriptions of the various available community activities, helping
people determine which activities might be best for them, and assisting individuals in accessing
these activities and in obtaining needed care from the primary care center. They ran exercise
programs to help participants design personalized physical activity goals and programs. They
also recruited and led residents in walking programs held 3 days a week. Lay health advisers
developed and ran a weekly diabetes support group in a neighborhood center where they
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discussed the impact of lifestyle choices and led participants in discussions of strategies to cope
with the disease. A diabetes nurse attended these sessions to address participant questions. Lay
health advisers supported this program by attending meetings and encouraging participation
during their regular interactions with residents. Lay health advisers led house parties that were
hosted by a neighbor in the community where they presented information related to the
prevention of cardiovascular disease and diabetes. Attendees received healthy snacks and door
prizes. In 2001, a neighborhood farmers’ market opened on the grounds of the county health
department, with the goal of improving access to fresh produce. The program also offered
periodic hypertension classes, grocery store tours, health fairs, and demonstrations on healthy
cooking.
Measures for ethical protection of participants
The project was designed to improve modifiable risk factors across the entire
community through extensive community involvement, use of lay health advisors, and an
emphasis on community environment and public policy interventions. Problems include: greater
risk of getting, dying from diabetes and heart disease: African American adults in particularly
women, limited access to healthy foods, particularly fresh produce, and to safe places to engage
in physical activities such as biking and walking, and largely unrealized potential of lay health
advisers: lay health advisers: widely respected community residents seen as natural helpers by
their neighbors. This project was externally funded. Agency used in this project included Centers
for Disease Control and prevention (CDC). The CDC funded the program via a 1-year planning
grant of approximately $250,000 and a 7-year implementation grant of roughly $1 million a year;
these funds covered all staff and other program-related costs.
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The sampling population: A lay health advisor program and policy and community environment
change strategies were implemented in a community of 20 000 African Americans in 2001 to
2005. Health behavior questions were administered to a cross-section of the community annually
and the results were compared with African Americans’ responses from a statewide survey. A
quasi-experimental evaluation design compared residents with African Americans across the
state and a cross-sectional and cohort study. A 2-tailed t test for independent samples was
conducted as well to assess the statistical significance of these proportional changes or changes
in prevalence rates. Investigators included copies of scripts, flyers, advertisements, posters or
letters to be used in the project. Telephone calls, Health behavior questions from the Behavioral
Risk Factor Surveillance System survey were administered to a cross-section of the community
annually. The number of subjects expected to participate was 20000. The project involved two
distinct project periods (1999-2000 for planning and 2000-2007 for implementation), duration: 7
years. There was no follow up plans. This project did not require the permission of the IRB.
Chapter 4: Results
The purpose of this project was to examine the effect of modifiable risk factors for heart
diseases. Women ages 40 and over are more at risk for getting heart disease because of the
prevalence of high body mass index (BMI), smoking, high blood pressure, and physical
inactivity. Investigators used 3 behavioral risk factors for heart disease including diabetes, low
physical activity, and cigarette smoking that can be modified. Women who sit and watch
television for longer than 40 hours a week have a 94% increased risk of developing obesity and a
70% increased risk of developing diabetes. Sedentary behavior is associated with increased
adipocyte inflammation, increased triglyceride levels, insulin insensitivity, and glucose
intolerance. The negative effects of sitting for long periods of time are not greatly mitigated by
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following weekly exercise recommendations. The community and providers encouraged positive
changes in health-related behaviors, and made referrals to health professionals as necessary
(Barnes, 2013).
Table 2: Demographic characteristics of African American respondents in Charlotte
REACH Population and in the Statewide BRFSS survey.
Charlotte REACH Population No. (Weighted %) Statewide BRFSS No. (Weighted %)
Gender
1419 (36.6)
3160 (44.2)
Men
Women
3311 (63.4)
6654 (55.8)
Age, Y
18-34
674 (20.2)
2403 (33.1)
35-44
730 (17.3)
2017 (20.9)
45-54
960 (19.6)
2021 (19.0)
55-64
≥65
64 881 (16.2)
1442 (26.0)
1494 (11.8)
1790 (14.4)
43 (0.7)
89 (0.8)
1039 (22.9)
1742 (37.1)
l 1124 (23.7)
2072 (19.8)
3407 (36.8)
2405 (25.1)
809 (16.0)
809 (16.0)
16 (0.4)
36 (0.5)
948 (19.7)
1807 (14.6)
1449 (29.8)
762 (16.9)
559 (11.6)
493 (11.1)
519 (10.9)
2281 (23.2)
1371 (14.5)
1127 (12.3)
1295 (14.4)
1933(21.0)
4730 (100.0)
9814 (100.0)
Did not know
Education
High school or less
High school
Some college/technical
school
College degree or post
grad
No answer
Annual salary
<15000
15,000-24999
25 000–34 999
35 000–49 999
≥50 000
No answer
Total sample
(Plescia et al., 2008)
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The number of completed interviews per year ranged from 904 to 1028 over 5 years. The
interviewers’ response rate varied from 63% to 69%. The respondents in the Northwest Corridor
survey were predominantly African American (95%).
Demographic characteristics of the Northwest Corridor respondents and African
American respondents were compared with the state BRFSS survey in the Table 2. The groups
were the same number of age although women and older persons were slightly overrepresented
in the Northwest Corridor group. Education categories were used as a proxy for socioeconomic
class and were similar for the Northwest Corridor and state populations. Investigators compared
prevalence rates of selected health behavior among the Northwest Corridor and statewide
African-American communities for 2001 and 2005 (Table 2). At baseline in 2001, Northwest
Corridor respondents were significantly more likely than were state respondents to be classified
as physically inactive, which means that they did not meet some or all of the national physical
activity recommendations (31.9% in the Northwest Corridor vs 23.1% among statewide
respondents; P=.003). The difference in these rates was no longer significant in 2005 (Northwest
Corridor, 27.4% vs statewide, 25.5%; P = .38). Although fruit and vegetable consumption
among the local and statewide groups was similar at baseline (Northwest Corridor, 23.1% vs
statewide, 21.7%; P = .68), by 2005 Northwest Corridor residents were more likely than
statewide African American respondents to eat at least 5 servings of fruits and vegetables each
day (Northwest Corridor, 25.3% vs statewide, 17.5%; P < .001). African Americans in the
statewide sample were consistently less likely to smoke than were Northwest Corridor residents
(Plescia et al., 2008).
Investigators also compared the prevalence of health behaviors in the Northwest
Corridor and statewide African American communities for 2001 and 2005. The results showed
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that there was a decrease in the percentage of respondents in the Northwest Corridor community
who were classified as physically inactive; the rates for the statewide sample increased.
Investigators observed statistically significant decreases among women (33% Northwest
Corridor respondents were physically inactive in 2001 vs 26.1% in 2005; P=.02), college
graduates (28.5% vs 14.1%; P =.01), and respondents aged 35 to 54 years (30.3% vs 20.8%; P =
.01). By contrast, they found a significant increase among respondents in the statewide survey
aged 35 to 54 years in physical inactivity (19.4% in 2001 vs 27.2% in 2005; P=.02).
The Northwest Corridor population has increased their fruit and vegetable consumption
while there was a decrease in consumption of fruit and vegetables among the statewide
respondents.
These improvements were statistically significant among Northwest Corridor respondents
with some college or technical school (21.4% in 2001 vs 33.3% in 2005; P=.02). There was also
a decrease in smoking rates across both sample populations, but only the decline among
Northwest Corridor women reached statistical significance (26.8% in 2001 vs 20.9% in 2005;
P=.03) (Plescia et al., 2008).
Summary
This project examined risk factors of CVD in most women, a population for which CVD
is a major health problem. In order to prevent and treat CVD, investigating risk factors and the
moderator effects thereof is essential. Findings for research hypothesis 1 (Women ages 40 and
over are more at risk of getting heart disease because of the prevalence of high body mass index
(BMI), smoking, high blood pressure, and physical inactivity) showed that physiological risk
factors, e.g., age (positive), high blood pressure (positive), and BMI (negative); behavioral risk
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factors, e.g., cigarette smoking (positive), and physical activity (negative); psychological risk
factors, e.g., stress (positive) and contextual risk factors, e.g., educational levels (negative),
family income (negative), and poverty (positive), were all significantly related to the severity of
CVD. However, family history, total serum cholesterol, diabetes mellitus, menopause status and
alcohol consumption, was not significantly related to the severity of CVD.
Findings for research hypothesis 2 (This study used 3 behavioral risk factors for heart
disease including diabetes, low physical activity, and cigarette smoking that can be modified) are
based on the result analysis; they showed that, high blood pressure, cigarette smoking, physical
activity, stress, family income, and poverty were significant predictors of CVD. Investigators
observed statistically significant decreases among women (33% Northwest Corridor respondents
were physically inactive in 2001 vs 26.1% in 2005; P=.02), than anyone else in this project.
For research hypothesis 3 (The community and providers encouraged positive changes in healthrelated behaviors, and made referrals to health professionals as necessary), and the results
showed that smoking rates decreased across both sample populations, but only the decline among
Northwest Corridor women reached statistical significance (26.8% in 2001 vs 20.9% in 2005;
P=.03). There was an increase of fruit and vegetable in the Northwest Corridor population and a
decrease among the statewide respondent.
Chapter 5: Conclusions
The two generations of community-based research used in this project are the large,
communitywide studies funded by the National Heart, Lung, and Blood Institute in the 1980s
and the smallest, more community service–oriented studies of the 1990s. The REACH projects,
funded by the Centers for Disease Control and Prevention, represent a new generation of
community-based interventions that focus on racial and ethnic minority communities. This
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program involved two distinct project periods: the planning years started from 1999-2000 and
the implementation years started from 2000-2007. In the 8-year Charlotte, North Carolina Racial
and Ethnic Approaches to Community Health (REACH) 2010 project, a primary care center, the
county health department, community organizations, and lay health advisers jointly developed
and implemented a variety of activities designed to reduce risk factors for cardiovascular disease
and diabetes in a low-income women and largely in African American population. Activities
included support groups, health and nutrition education classes, exercise programs, smoking
cessation classes, and a farmers’ market.
The projects used a logic model to assess the population progress in addressing health
disparities through 5 progressive stages including capacity building, targeted actions, change
within systems and among change agents, risk and protective behavior change, and elimination
of health disparities. In between 1999-2001, investigator findings showed that the project’s
progress in changing risk and protective behavior and they also said that they found statistically
significant declines in physical inactivity and smoking among women and in physical inactivity
among middle-aged adults. There also was a greater decrease in physical inactivity and a higher
increase in fruit and vegetable consumption in the Northwest Corridor than in the statewide
African American sample. These findings are an important addition to the public health literature
because only a few well-designed studies have documented community-wide improvement in
cardiovascular risk and protective behaviors among African Americans. There were two factors
that led to the project’s success including community participation and a focus on changing
policy and the community environment. The Charlotte REACH project originated as an
application of the community-oriented primary care model and was one of only a few examples
of a fully implemented project derived from this model that yielded population-based outcomes.
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The legacy of racial discrimination in the Northwest Corridor population was a difficult issue for
a collaborative investigation. The initial planning year of the national REACH funding process
and the use of a consultant to facilitate coalition processes were essential to developing strong
community involvement and support. Recruited from local neighborhoods, the lay health
advisers served as liaisons between the community and providers. They encouraged positive
changes in health-related behaviors, and made referrals to health professionals as necessary.
They improved health-related skills and behaviors (eating more healthy, engaging in more
physical activity), leading to anecdotal reports of better health. The REACH coalition was
charged with overseeing the project and targeting specific changes in institutions, the community
environment, and public policy through community involvement. Most components of the
program ended in 2007 after grant funding ran out, although some aspects continued past this
time and others continue to operate today (Plescia et al., 2008).
Recommendations
According to the centers for disease control and prevention, activities that can reduce
cardiovascular diseases include, but are not limited to the following:
•Eat a healthy diet: choosing healthy meal and snack options can help one avoid heart
disease and its complications. It is important to eat plenty of fresh fruits and vegetables as well.
Eating foods low in saturated fat and cholesterol and high in fiber can help prevent high blood
cholesterol. Limiting salt or sodium in your diet can also lower blood pressure.
Moderate-intense exercise for 2 hours and 30 minutes every week to reduce
cardiovascular diseases is recommended.
•Exercise regularly: physical activity can help individuals maintain a healthy weight and lower
cholesterol and blood pressure.
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
Do not smoke: cigarette smoking greatly increases one’s risk for heart disease. If you do
smoke, quitting will lower your risk for heart disease. Your doctor can suggest ways to
help you quit.

Limit alcohol use: avoid drinking too much alcohol, which causes high blood pressure.
People need to check their cholesterol level at least once annually, monitor their blood
pressure regularly because high blood pressure has no symptoms, and manage their diabetes. It is
very important to monitor one’s blood sugar levels and talk with his or her health care provider
about treatment options if he or she has diabetes, one should take his or her medicine. If you're
taking medication to treat high cholesterol, high blood pressure, or diabetes, follow your doctor's
instructions carefully and always ask questions if you don't understand something.
These are websites to search for help in reducing cardiovascular diseases:

CDC's Assessing Your Weight

CDC's Nutrition and Physical Activity Program

CDC's Smoking & Tobacco Use

CDC's Alcohol and Public Health (CDC, 2013).
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References
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American Heart Association. (2013). Whites & Cardiovascular Diseases. Retrieved from
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Khan, M, & Mensah, G. A. (2010). Promoting Cardiovascular Health in the Developing World:
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2509594/
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Appendix
2005 Behavioral Risk Factor Surveillance System Questionnaire. Refers from this site:
http://www.cdc.gov/brfss/annual_data/pdf-ques/2005brfss.pdf
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