Reducing Cardiovascular Disparities Through Community-Engaged Implementation Research: A National Heart, Lung, and Blood Institute Workshop Report

doi:10.1161/CIRCRESAHA.117.312243

Review

. 2018 Jan 19;122(2):213-230.

doi: 10.1161/CIRCRESAHA.117.312243.

Reducing Cardiovascular Disparities Through Community-Engaged Implementation Research: A National Heart, Lung, and Blood Institute Workshop Report

George A Mensah¹, Richard S Cooper², Anna Maria Siega-Riz², Lisa A Cooper², Justin D Smith², C Hendricks Brown², John M Westfall², Elizabeth O Ofili², LeShawndra N Price², Sonia Arteaga², Melissa C Green Parker², Cheryl R Nelson², Bradley J Newsome², Nicole Redmond², Rebecca A Roper², Bettina M Beech², Jada L Brooks², Debra Furr-Holden², Samson Y Gebreab², Wayne H Giles², Regina Smith James², Tené T Lewis², Ali H Mokdad², Kari D Moore², Joseph E Ravenell², Al Richmond², Nancy E Schoenberg², Mario Sims², Gopal K Singh², Anne E Sumner², Roberto P Treviño², Karriem S Watson², M Larissa Avilés-Santa², Jared P Reis², Charlotte A Pratt², Michael M Engelgau², David C Goff Jr², Eliseo J Pérez-Stable²

Affiliations

¹ From the Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.A.M., L.N.P., M.C.G.P., B.J.N., R.A.R., M.M.E.); Loyola University Medical School, Department of Public Health Sciences, Chicago, IL (R.S.C.); University of Virginia School of Nursing, Charlottesville (A.M.S.-R.); Johns Hopkins School of Medicine, Department of Medicine, Baltimore, MD (L.A.C.); Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior, and Society, Baltimore, MD (L.A.C.); Center for Prevention Implementation Methodology (Ce-PIM), Northwestern University Feinberg School of Medicine, Chicago, IL (J.D.S., C.H.B.); Department of Family Medicine, University of Colorado Anschutz Medical Campus, Aurora (J.M.W.); Morehouse School of Medicine, Department of Medicine, Atlanta, GA (E.O.O.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (S.A., C.R.N., N.R., M.L.A.-S., J.P.R., C.A.P., D.C.G.); University of Mississippi Medical Center, John D. Bower School of Population Health, Jackson (B.M.B.); University of North Carolina at Chapel Hill School of Nursing (J.L.B.); Michigan State University College of Human Medicine, Department of Epidemiology and Biostatistics, East Lansing (D.F.-H.); National Human Genome Research Institute, Bethesda, MD (S.Y.G.); School of Public Health, University of Illinois at Chicago (W.H.G., K.S.W.); Office of the Director, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD (R.S.J., E.J.P.-S.); Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (T.T.L.); Institute for Health Metrics and Evaluation, University of Washington, Seattle (A.H.M.); Department of Neurology, University of Louisville, KY (K.D.M.); Department of Population Health, Center for Healthful Behavior Change, New York University School of Medicine, New York (J.E.R.); Community-Campus Partnerships for Health, Raleigh, NC (A.R.); UK Medical Center, University of Kentucky, Department of Medical Behavioral Science, Lexington (N.E.S.); Department of Medicine, Jackson Heart Study, University of Mississippi Medical Center (M.S.); Office of Health Equity, Health Resources and Services Administration, Rockville, MD (G.K.S.); National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD (A.E.S.); and Social and Health Research Center, San Antonio, TX (R.P.T.). george.mensah@nih.gov.
² From the Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.A.M., L.N.P., M.C.G.P., B.J.N., R.A.R., M.M.E.); Loyola University Medical School, Department of Public Health Sciences, Chicago, IL (R.S.C.); University of Virginia School of Nursing, Charlottesville (A.M.S.-R.); Johns Hopkins School of Medicine, Department of Medicine, Baltimore, MD (L.A.C.); Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior, and Society, Baltimore, MD (L.A.C.); Center for Prevention Implementation Methodology (Ce-PIM), Northwestern University Feinberg School of Medicine, Chicago, IL (J.D.S., C.H.B.); Department of Family Medicine, University of Colorado Anschutz Medical Campus, Aurora (J.M.W.); Morehouse School of Medicine, Department of Medicine, Atlanta, GA (E.O.O.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (S.A., C.R.N., N.R., M.L.A.-S., J.P.R., C.A.P., D.C.G.); University of Mississippi Medical Center, John D. Bower School of Population Health, Jackson (B.M.B.); University of North Carolina at Chapel Hill School of Nursing (J.L.B.); Michigan State University College of Human Medicine, Department of Epidemiology and Biostatistics, East Lansing (D.F.-H.); National Human Genome Research Institute, Bethesda, MD (S.Y.G.); School of Public Health, University of Illinois at Chicago (W.H.G., K.S.W.); Office of the Director, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD (R.S.J., E.J.P.-S.); Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (T.T.L.); Institute for Health Metrics and Evaluation, University of Washington, Seattle (A.H.M.); Department of Neurology, University of Louisville, KY (K.D.M.); Department of Population Health, Center for Healthful Behavior Change, New York University School of Medicine, New York (J.E.R.); Community-Campus Partnerships for Health, Raleigh, NC (A.R.); UK Medical Center, University of Kentucky, Department of Medical Behavioral Science, Lexington (N.E.S.); Department of Medicine, Jackson Heart Study, University of Mississippi Medical Center (M.S.); Office of Health Equity, Health Resources and Services Administration, Rockville, MD (G.K.S.); National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD (A.E.S.); and Social and Health Research Center, San Antonio, TX (R.P.T.).

PMID: 29348251
PMCID: PMC5777283
DOI: 10.1161/CIRCRESAHA.117.312243

Review

Reducing Cardiovascular Disparities Through Community-Engaged Implementation Research: A National Heart, Lung, and Blood Institute Workshop Report

George A Mensah et al. Circ Res. 2018.

. 2018 Jan 19;122(2):213-230.

doi: 10.1161/CIRCRESAHA.117.312243.

Authors

Affiliations

¹ From the Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.A.M., L.N.P., M.C.G.P., B.J.N., R.A.R., M.M.E.); Loyola University Medical School, Department of Public Health Sciences, Chicago, IL (R.S.C.); University of Virginia School of Nursing, Charlottesville (A.M.S.-R.); Johns Hopkins School of Medicine, Department of Medicine, Baltimore, MD (L.A.C.); Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior, and Society, Baltimore, MD (L.A.C.); Center for Prevention Implementation Methodology (Ce-PIM), Northwestern University Feinberg School of Medicine, Chicago, IL (J.D.S., C.H.B.); Department of Family Medicine, University of Colorado Anschutz Medical Campus, Aurora (J.M.W.); Morehouse School of Medicine, Department of Medicine, Atlanta, GA (E.O.O.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (S.A., C.R.N., N.R., M.L.A.-S., J.P.R., C.A.P., D.C.G.); University of Mississippi Medical Center, John D. Bower School of Population Health, Jackson (B.M.B.); University of North Carolina at Chapel Hill School of Nursing (J.L.B.); Michigan State University College of Human Medicine, Department of Epidemiology and Biostatistics, East Lansing (D.F.-H.); National Human Genome Research Institute, Bethesda, MD (S.Y.G.); School of Public Health, University of Illinois at Chicago (W.H.G., K.S.W.); Office of the Director, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD (R.S.J., E.J.P.-S.); Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (T.T.L.); Institute for Health Metrics and Evaluation, University of Washington, Seattle (A.H.M.); Department of Neurology, University of Louisville, KY (K.D.M.); Department of Population Health, Center for Healthful Behavior Change, New York University School of Medicine, New York (J.E.R.); Community-Campus Partnerships for Health, Raleigh, NC (A.R.); UK Medical Center, University of Kentucky, Department of Medical Behavioral Science, Lexington (N.E.S.); Department of Medicine, Jackson Heart Study, University of Mississippi Medical Center (M.S.); Office of Health Equity, Health Resources and Services Administration, Rockville, MD (G.K.S.); National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD (A.E.S.); and Social and Health Research Center, San Antonio, TX (R.P.T.). george.mensah@nih.gov.
² From the Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.A.M., L.N.P., M.C.G.P., B.J.N., R.A.R., M.M.E.); Loyola University Medical School, Department of Public Health Sciences, Chicago, IL (R.S.C.); University of Virginia School of Nursing, Charlottesville (A.M.S.-R.); Johns Hopkins School of Medicine, Department of Medicine, Baltimore, MD (L.A.C.); Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior, and Society, Baltimore, MD (L.A.C.); Center for Prevention Implementation Methodology (Ce-PIM), Northwestern University Feinberg School of Medicine, Chicago, IL (J.D.S., C.H.B.); Department of Family Medicine, University of Colorado Anschutz Medical Campus, Aurora (J.M.W.); Morehouse School of Medicine, Department of Medicine, Atlanta, GA (E.O.O.); Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (S.A., C.R.N., N.R., M.L.A.-S., J.P.R., C.A.P., D.C.G.); University of Mississippi Medical Center, John D. Bower School of Population Health, Jackson (B.M.B.); University of North Carolina at Chapel Hill School of Nursing (J.L.B.); Michigan State University College of Human Medicine, Department of Epidemiology and Biostatistics, East Lansing (D.F.-H.); National Human Genome Research Institute, Bethesda, MD (S.Y.G.); School of Public Health, University of Illinois at Chicago (W.H.G., K.S.W.); Office of the Director, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD (R.S.J., E.J.P.-S.); Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (T.T.L.); Institute for Health Metrics and Evaluation, University of Washington, Seattle (A.H.M.); Department of Neurology, University of Louisville, KY (K.D.M.); Department of Population Health, Center for Healthful Behavior Change, New York University School of Medicine, New York (J.E.R.); Community-Campus Partnerships for Health, Raleigh, NC (A.R.); UK Medical Center, University of Kentucky, Department of Medical Behavioral Science, Lexington (N.E.S.); Department of Medicine, Jackson Heart Study, University of Mississippi Medical Center (M.S.); Office of Health Equity, Health Resources and Services Administration, Rockville, MD (G.K.S.); National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD (A.E.S.); and Social and Health Research Center, San Antonio, TX (R.P.T.).

PMID: 29348251
PMCID: PMC5777283
DOI: 10.1161/CIRCRESAHA.117.312243

Abstract

Cardiovascular disparities remain pervasive in the United States. Unequal disease burden is evident among population groups based on sex, race, ethnicity, socioeconomic status, educational attainment, nativity, or geography. Despite the significant declines in cardiovascular disease mortality rates in all demographic groups during the last 50 years, large disparities remain by sex, race, ethnicity, and geography. Recent data from modeling studies, linked micromap plots, and small-area analyses also demonstrate prominent variation in cardiovascular disease mortality rates across states and counties, with an especially high disease burden in the southeastern United States and Appalachia. Despite these continued disparities, few large-scale intervention studies have been conducted in these high-burden populations to examine the feasibility of reducing or eliminating cardiovascular disparities. To address this challenge, on June 22 and 23, 2017, the National Heart, Lung, and Blood Institute convened experts from a broad range of biomedical, behavioral, environmental, implementation, and social science backgrounds to summarize the current state of knowledge of cardiovascular disease disparities and propose intervention strategies aligned with the National Heart, Lung, and Blood Institute mission. This report presents the themes, challenges, opportunities, available resources, and recommended actions discussed at the workshop.

Keywords: cardiovascular diseases; community-based participatory research; geography; social class; social determinants of health.

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Conflict of interest statement

Conflict of Interest Disclosure: None

Figures

**Figure 1. Death rates among Blacks and Whites, by age group (years) – United States, 1999–2015**
Among adults aged ≥65 years, the death rate in 2015 relative to that in 1999 declined 27% for Blacks and 17% for Whites, resulting in a crossover in death rates beginning in 2010, when Blacks had lower death rates than Whites. Reproduced from Cunningham TJ, et al. Vital Signs: Racial Disparities in Age-Specific Mortality Among Blacks or African Americans - United States, 1999-2015. *MMWR Morb Mortal Wkly Rep*. May 05 2017;66(17):444-456.

**Figure 2. United States County-Level Mortality from Cardiovascular Diseases**
A: Age-standardized mortality rate for both sexes combined in 2014. B: Percent change in the age-standardized mortality rate for both sexes combined between 1980 and 2014. In panel A, the color scale is truncated at approximately the 1st and 99th percentiles as indicated by the range given on the scale. In panel B, the color scale is similarly truncated at the 1st percentile but not at the 99th percentile to avoid combining counties with decreases in the mortality rate and counties with increases in the mortality rate into a single group. C: Age-standardized mortality rate in 1980, 1990, 2000, and 2014. The bottom border, middle line, and top border of the boxes indicate the 25th, 50th, and 75th percentiles, respectively, across all counties; whiskers, the full range across counties; and circles, the national-level rate. Reproduced from Roth GA, et al. Trends and Patterns of Geographic Variation in Cardiovascular Mortality Among US Counties, 1980-2014. *JAMA.* May 16 2017;317(19):1976-1992; with permission from the American Medical Association.

**Figure 3. The Robert Wood Johnson Foundation Action Cycle for Improving a Community’s Health**
At the core of the Action Cycle are key stakeholders for taking action. Each step on the Action Cycle is considered a critical component for creating healthier communities and offers a guide that describes key activities within each step that includes suggested tools, resources, and additional reading. In this Action Cycle, “Work Together” and “Communicate” are distal because they are needed throughout the Cycle. Reproduced from The Robert Wood Johnson Foundation *County Health Rankings & Roadmaps Action Center, 2017*; Take Action Cycle. http://www.countyhealthrankings.org/take-action-cycle.

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References

1. National Center for Health Statistics. Health, united states, 2015: With special feature on racial and ethnic health disparities. CDC, NCHS; 2016. http://www.cdc.gov/nchs/data/hus/hus15.pdf. Accessed. - PubMed
1. Woolf SH, Aron LY. The us health disadvantage relative to other high-income countries: Findings from a national research council/institute of medicine report. JAMA. 2013;309:771–772. - PubMed
1. Mensah GA, Mokdad AH, Ford ES, Greenlund KJ, Croft JB. State of disparities in cardiovascular health in the united states. Circulation. 2005;111:1233–1241. - PubMed
1. Cunningham TJ, Croft JB, Liu Y, Lu H, Eke PI, Giles WH. Vital signs: Racial disparities in age-specific mortality among blacks or african americans - united states, 1999-2015. MMWR Morb Mortal Wkly Rep. 2017;66:444–456. - PMC - PubMed
1. Jones K, Mansfield CJ. Premature mortality in north carolina: Progress, regress, and disparities by county and race, 2000-2010. North Carolina medical journal. 2014;75:159–168. - PubMed

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[1] National Center for Health Statistics. Health, united states, 2015: With special feature on racial and ethnic health disparities. CDC, NCHS; 2016. http://www.cdc.gov/nchs/data/hus/hus15.pdf. Accessed. - PubMed

[2] National Center for Health Statistics. Health, united states, 2015: With special feature on racial and ethnic health disparities. CDC, NCHS; 2016. http://www.cdc.gov/nchs/data/hus/hus15.pdf. Accessed. - PubMed

[3] Woolf SH, Aron LY. The us health disadvantage relative to other high-income countries: Findings from a national research council/institute of medicine report. JAMA. 2013;309:771–772. - PubMed

[4] Woolf SH, Aron LY. The us health disadvantage relative to other high-income countries: Findings from a national research council/institute of medicine report. JAMA. 2013;309:771–772. - PubMed

[5] Mensah GA, Mokdad AH, Ford ES, Greenlund KJ, Croft JB. State of disparities in cardiovascular health in the united states. Circulation. 2005;111:1233–1241. - PubMed

[6] Mensah GA, Mokdad AH, Ford ES, Greenlund KJ, Croft JB. State of disparities in cardiovascular health in the united states. Circulation. 2005;111:1233–1241. - PubMed

[7] Cunningham TJ, Croft JB, Liu Y, Lu H, Eke PI, Giles WH. Vital signs: Racial disparities in age-specific mortality among blacks or african americans - united states, 1999-2015. MMWR Morb Mortal Wkly Rep. 2017;66:444–456. - PMC - PubMed

[8] Cunningham TJ, Croft JB, Liu Y, Lu H, Eke PI, Giles WH. Vital signs: Racial disparities in age-specific mortality among blacks or african americans - united states, 1999-2015. MMWR Morb Mortal Wkly Rep. 2017;66:444–456. - PMC - PubMed

[9] Jones K, Mansfield CJ. Premature mortality in north carolina: Progress, regress, and disparities by county and race, 2000-2010. North Carolina medical journal. 2014;75:159–168. - PubMed

[10] Jones K, Mansfield CJ. Premature mortality in north carolina: Progress, regress, and disparities by county and race, 2000-2010. North Carolina medical journal. 2014;75:159–168. - PubMed

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Reducing Cardiovascular Disparities Through Community-Engaged Implementation Research: A National Heart, Lung, and Blood Institute Workshop Report

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Reducing Cardiovascular Disparities Through Community-Engaged Implementation Research: A National Heart, Lung, and Blood Institute Workshop Report

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