Hypertension in minority populations. Access to care

Life-Style and Cardiovascular Health Among Urban Black Elderly

This study assessed life-style behaviors in a cross-sectional random sample of urban Black elderly with and without cardiovascular disease. Those with cardiac disease reported behavior modifications for salt mtake, fat intake, and smoking but more often reported being overweight and performing less exercise than did those elderly without cardiac disease. There remains substantial room for improvement in health maintenance and health promotion behaviors in this population, suggesting the need of intensive educational interventions. Additionally, Black elderly with cardiac disease had worse scores on a depression scale and a health locus-of-control question, suggesting the need for psychological assessment and intervention in this population.

Correlates of blood pressure control behaviors among Korean Americans in the greater Philadelphia area

This cross-sectional study was designed to identify correlates of blood pressure control behaviors, including participation in physical activity, maintaining a healthy diet, limiting alcohol and tobacco use, discussing blood pressure with a doctor, and getting screened for blood pressure. The study sample included 116 Korean American men and women aged 42 to 77 years (M = 58.7) who resided in the greater Philadelphia area. Intention to exercise, comfort exercising in the neighborhood, and confidence in the ability to find time to exercise were positively correlated with participating in physical activity. Knowledge about the benefits of a healthy diet and confidence in the ability to maintain a healthy diet were positively correlated with maintaining a healthy diet. Intention to visit a doctor, having a regular doctor, satisfaction with the doctor, having confidence in the doctor, and confidence in the ability to ask doctors about health issues were positively correlated with medical adherence (including adhering to medication regimen and seeing a doctor regularly).

Including African Americans in health care research

The inclusion of minority populations, particularly African Americans (AAs), in health care research has been and continues to be challenging. Including AAs in health care research will address the health disparities observed between Caucasian and AA populations and may reduce the disparities in disease incidence and prevalence between these groups. To include more AAs in health care research, the research team must strive to build relationships, linkages, and mutual respect with the target AA community they wish to study.

Adherence to treatment factors in hypertensive African American women

Hypertension (HTN) is a major public health problem in African American women. The disproportionate rate of HTN in African American women makes it a high-priority national health objective. Lack of access to a regular continuous source of care may be particularly significant among African American women because such a source of care is a prerequisite to early diagnosis and successful treatment. Understanding the factors that influence access to care for HTN in African American women will provide the information needed to improve the use of healthcare services and enhance adherence to treatment. Despite the known importance of adherence to successful HTN treatment, few attempts have been made to incorporate the indicators of adherence to HTN treatment into a theoretical model that can be used to guide research and practice with African American women. The adapted Hill-Levine model offers an appropriate framework for studying these phenomena in African American women because factors frequently associated with seeking and using healthcare services are organized in three dimensions, including predisposing, enabling, and reinforcing factors. This article discusses the magnitude of the problem presented by HTN and lack of HTN control in African American women, identifies from the literature the factors related to adherence to treatment in HTN management, in general, and in African American women, specifically, and uses the adapted Hill-Levine model to organize the identified predisposing, enabling, and reinforcing factors associated with adherence to HTN treatment recommendations among African American women.

Awareness of hypertension and diabetes in the Hispanic community

Major barriers to awareness and control of hypertension and diabetes in Hispanic Americans include poor language comprehension, poor physician-patient communication, cultural differences, low educational level, and lack of health insurance. To better communicate the concerns about the risk factors for cardiovascular disease, physicians could use patient-education materials that include illustrations, familiarize themselves with their Hispanic patients and their preferences regarding communication (e.g., formality, close proximity, appropriately used touch), and advocate government action to make health insurance more affordable. An increase in Spanish-speaking physicians would help alleviate some of the confusion that Hispanic patients experience in their interactions with health care providers.

Coronary heart disease mortality for six ethnic groups in California, 1990–2000

PURPOSE

To investigate ethnic variations in coronary heart disease death in California, the authors examined total and CHD-specific mortality among non-Hispanic white (white), Hispanic, non-Hispanic black (black), Chinese, Japanese, and Asian Indian Americans. Deaths were identified in the California Mortality Database and population information was derived from the 1990 and 2000 censuses.

METHODS

Age-standardized death rates per 100,000 population were calculated for ages 25 to 84 years from 1990 to 2000. Proportional mortality ratios (PMRs) for each sex and age group were calculated by dividing the proportion of deaths due to CHD in each ethnic group by the proportion of deaths due to CHD in the total population.

RESULTS

Blacks had the highest all-cause age-standardized death rates among men (1614) and women (1014). Blacks had the highest CHD death rates among men (272) and women (190). PMRs for CHD were highest in Asian Indian men (161) and women (144), reflective of the higher percentage of CHD deaths compared with all cause deaths in this group. All sex-ethnic groups showed a decline in all cause and CHD mortality compared with the period between 1985 and 1990, except Asian Indian women, who experienced a 16% increase in all cause mortality and 5% increase in CHD mortality.

CONCLUSIONS

There is considerable heterogeneity in CHD mortality among ethnic subgroups, and additional research is needed to guide treatment and prevention efforts. Blacks and Asian Indians in California are identified as particularly high risk populations.

Education: nationally achievable solutions

Despite the efficacy of hypertension treatment, knowledge and compliance remain poor in Hispanic patients because of language barriers, low educational levels, and cultural differences. Yet effective physician-patient communication is crucial to patient compliance, satisfaction, and understanding of medical issues. Physicians and health care providers therefore need to develop "cultural competence" skills to achieve effective health education and good treatment outcomes in this patient population. Various strategies such as mnemonic devices can help practitioners communicate with Hispanic patients. National initiatives and research studies continue to address the provision of culturally and linguistically appropriate health care.

Hispanic Chronic Disease Self-Management

BACKGROUND

In light of health disparities and the growing prevalence of chronic disease, there is a need for community-based interventions that improve health behaviors and health status. These interventions should be based on existing theory.

OBJECTIVE

This study aimed to evaluate the health and utilization outcomes of a 6-week community-based program for Spanish speakers with heart disease, lung disease, or type 2 diabetes.

METHOD

The treatment participants in this study (n = 327) took a 6-week peer-led program. At 4 months, they were compared with randomized wait-list control subjects (n = 224) using analyses of covariance. The outcomes for all the treatment participants were assessed at 1 year, as compared with baseline scores (n = 271) using t-tests.

RESULTS

At 4 months, the participants, as compared with usual-care control subjects, demonstrated improved health status, health behavior, and self-efficacy, as well as fewer emergency room visits (p <.05). At 1 year, the improvements were maintained and remained significantly different from baseline condition.

CONCLUSIONS

This community-based program has the potential to improve the lives of Hispanics with chronic illness while reducing emergency room use.

Race and the response to adrenergic blockade with carvedilol in patients with chronic heart failure

BACKGROUND

The benefits of angiotensin-converting-enzyme inhibitors and beta-blockers may be smaller in black patients than in patients of other races, but it is unknown whether race influences the response to carvedilol in patients with chronic heart failure.

METHODS

In the U.S. Carvedilol Heart Failure Trials Program, 217 black and 877 nonblack patients (in New York Heart Association class II, III, or IV and with a left ventricular ejection fraction of no more than 0.35) were randomly assigned to receive placebo or carvedilol (at doses of 6.25 to 50 mg twice daily) for up to 15 months. The effects of carvedilol on ejection fraction, clinical status, and major clinical events were retrospectively compared between black and nonblack patients.

RESULTS

As compared with placebo, carvedilol lowered the risk of death from any cause or hospitalization for any reason by 48 percent in black patients and by 30 percent in nonblack patients. Carvedilol reduced the risk of worsening heart failure (heart failure leading to death, hospitalization, or a sustained increase in medication) by 54 percent in black patients and by 51 percent in nonblack patients. The ratios of the relative risks associated with carvedilol for these two outcome variables in black as compared with nonblack patients were 0.74 (95 percent confidence interval, 0.42 to 1.34) and 0.94 (95 percent confidence interval, 0.43 to 2.05), respectively. Carvedilol also improved functional class, ejection fraction, and the patients' and physicians' global assessments in both the black patients and the nonblack patients. For all these measures of outcome and clinical status, carvedilol was superior to placebo within each racial cohort (P<0.05 in all analyses), and there was no significant interaction between race and treatment (P> 0.05 in all analyses).

CONCLUSIONS

The benefit of carvedilol was apparent and of similar magnitude in both black and nonblack patients with heart failure.

Stroke in Hispanic Americans

The Hispanic American population is the fastest growing minority group with increasing representation among the older age strata. Current ethnic-specific cerebrovascular disease data regarding stroke outcomes and risk factor status reveal significant differences compared with other race/ethnic groups. The authors discuss the literature on stroke incidence and mortality among Hispanic populations. Traditional risk factors, access to care and stroke mechanism differences are also discussed. Advances in Hispanic American specific stroke prevention and treatment efforts demand further investigation to better define Hispanic American stroke prevention and acute treatment strategies.

Association of mitral annular calcium with prior thromboembolic stroke in older White, African-American, and Hispanic men and women

Prior thromboembolic stroke was present in 57 of 188 white men (30%) with mitral annular calcium (MAC) and in 62 of 303 white men (20%) without MAC, in 42 of 65 African-American men (65%) with MAC and in 50 of 123 African-American men (41%) without MAC, and in 13 of 27 Hispanic men (48%) with MAC and in 21 of 58 Hispanic (36%) without MAC. Prior thromboembolic stroke was present in 164 of 614 white women (27%) with MAC and in 85 of 516 white women (16%) without MAC, in 111 of 193 African-American women (58%) with MAC and in 77 of 225 African-American women (34%) without MAC, and in 36 of 69 Hispanic women (52%) with MAC, and in 17 of 58 Hispanic women (29%) without MAC.

Prevalence of coronary artery disease, ischemic stroke, peripheral arterial disease, and coronary revascularization in older African-Americans, Asians, Hispanics, whites, men, and women

The prevalence of coronary artery disease and of peripheral arterial disease was similar in older African-Americans, Asians, Hispanics, and whites, and the prevalence of ischemic stroke was lower in older whites than in older African-Americans and Hispanics. The prevalence of coronary revascularization in older persons with coronary artery disease was lower in African-Americans than in whites and Hispanics and was lower in women than in men.

Risk factors for new coronary events in older African-American men and women

Independent risk factors for new coronary events in older African-American men were (1) age (risk ratio = 1.037), (2) cigarette smoking (risk ratio = 2.231), (3) hypertension (risk ratio = 2.531), (4) serum total cholesterol (risk ratio = 1.012), (5) serum high-density lipoprotein (HDL) cholesterol (inverse association) (risk ratio = 0.948), and (6) prior coronary artery disease (CAD) (risk ratio = 2.288). Independent risk factors for new coronary events in older African-American women were (1) cigarette smoking (risk ratio = 2.202), (2) hypertension (risk ratio = 2.344), (3) diabetes mellitus (risk ratio = 1.632), (4) serum total cholesterol (risk ratio = 1.008), (5) serum HDL cholesterol (inverse association) (risk ratio = 0.936), (6) age (risk ratio = 1.026), and (7) prior CAD (risk ratio = 2.368).

Why are African Americans under-represented in medical research studies? Impediments to participation

OBJECTIVES

In accordance with the NIH Revitalization Act of 1993, the National Institutes of Health and the Alcohol, Drug and Mental Health Administration require grant applicants and cooperative agreement participants to include minorities in human subject research. In an environment characterized by diminishing research dollars, this mandate has increased the pressure on investigators to determine factors that impede minority participation and to develop strategies to overcome these impediments.

METHODS

An extensive review of the literature was conducted to identify the factors possibly responsible for the low participation levels of African Americans in medical research studies and to highlight areas for further research. The items examined included the historical relationship between African Americans and medical researchers and the attitudes, perceptions and beliefs of potential participants and researchers as they relate to the low representation of African Americans in medical research.

RESULTS

The factors identified as possible impediments to African American participation included distrust of the medical/scientific community, poor access to primary medical care, the failure of researchers to recruit African Americans actively, the alienation of minority health professionals, lack of knowledge about clinical trials, language and cultural barriers.

CONCLUSIONS

Well-designed, relevant, ethical research in conjunction with an appreciation of the many barriers to participation are paramount to increasing African American presence in clinical research.

Race, resource use, and survival in seriously ill hospitalized adults. The SUPPORT Investigators

OBJECTIVE

To examine the association between patient race and hospital resource use.

DESIGN

Prospective cohort study.

SETTING

Five geographically diverse teaching hospitals.

PATIENTS

Patients were 9,105 hospitalized adults with one of nine illnesses associated with an average 6-month mortality of 50%.

MEASUREMENTS AND MAIN RESULTS

Measures of resource use included: a modified version of the Therapeutic Intervention Scoring System (TISS); performance of any of five procedures (operation, dialysis, pulmonary artery catheterization, endoscopy, and bronchoscopy); and hospital charges, adjusted by the Medicare cost-to-charge ratio per cost center at each participating hospital. The median patient age was 65; 79% were white, 16% African-American, 3% Hispanic, and 2% other races; 47% died within 6 months. After adjusting for other sociodemographic factors, severity of illness, functional status, and study site, African-Americans were less likely to receive any of five procedures on study day 1 and 3 (adjusted odds ratio [OR] 0.70; 95% confidence interval [CI] 0.60, 0.81). In addition, African-Americans had lower TISS scores on study day 1 and 3 (OR -1.8; 95% CI-1.3, -2.4) and lower estimated costs of hospitalization (OR (-)$2,805; 95% CI (-)$1,672, (-)$3,883). Results were similar after adjustment for patients' preferences and physicians' prognostic estimates. Differences in resource use were less marked after adjusting for the specialty of the attending physician but remained significant. In a subset analysis, cardiologists were less likely to care for African-Americans with congestive heart failure (p < .001), and cardiologists used more resources (p < .001). After adjustment for other sociodemographic factors, severity of illness, functional status, and study site, survival was slightly better for African-American patients (hazard ratio 0.91; 95% CI 0.84, 0.98) than for white or other race patients.

CONCLUSIONS

Seriously ill African-Americans received less resource-intensive care than other patients after adjustment for other sociodemographic factors and for severity of illness. Some of these differences may be due to differential use of subspecialists. The observed differences in resource use were not associated with a survival advantage for white or other race patients.

Cardiovascular health among Asian Americans/Pacific Islanders: an examination of health status and intervention approaches

PURPOSE OF THE REVIEW. The purpose of this review is to examine the cardiovascular health status of Asian Americans/Pacific Islanders by primary risk factor and review current intervention approaches targeting this population. Asian Americans/Pacific Islanders in the United States have experienced triple digit percentage increases in population for every decade since 1970. Despite their rapidly increasing numbers, little is known about their cardiovascular health status. SEARCH METHODS USED. This article reviews the literature on the demographics, mortality, and prevalence of major cardiovascular risk factors among Asian Americans/Pacific Islanders. Selected intervention programs are also described. SUMMARY OF IMPORTANT FINDINGS. Data on cardiovascular disease mortality for Asian Americans/Pacific Islanders are relatively limited because few states collect ethnically specific mortality statistics. Data on cardiovascular risk factors, particularly smoking and hypertension, for certain Asian American/Pacific Islander groups portend excessive cardiovascular disease burdens. MAJOR CONCLUSIONS. Data specific to ethnic groups comprising Asian Americans and Pacific Islanders need to be called. Also, scientifically valid and linguistically appropriate interventions approved by ethnic community leaders are needed to address Asian Americans/Pacific Islanders.

Coronary artery disease in Hispanic Americans. How does ethnic background affect risk factors and mortality rates?

A concerted national effort has reduced cardiovascular mortality rates in the general US population. Unfortunately, not all ethnic groups have benefited equally from these improvements in our national health. The author presents insights into social and clinical factors that affect cardiovascular disease among Hispanic Americans.