Association of Socioeconomic Status With Life's Essential 8 in the National Health and Nutrition Examination Survey: Effect Modification by Sex

BACKGROUND

Higher scores for the American Heart Association Life's Essential 8 (LE8) metrics, blood pressure, cholesterol, glucose, body mass index, physical activity, smoking, sleep, and diet, are associated with lower risk of chronic disease. Socioeconomic status (SES; employment, insurance, education, and income) is associated with LE8 scores, but there is limited understanding of potential differences by sex. This analysis quantifies the association of SES with LE8 for each sex, within Hispanic Americans, non-Hispanic Asian Americans, non-Hispanic Black Americans, and non-Hispanic White Americans.

METHODS AND RESULTS

Using cross-sectional data from the National Health and Nutrition Examination Survey, years 2011 to 2018, LE8 scores were calculated (range, 0-100). Age-adjusted linear regression quantified the association of SES with LE8 score. The interaction of sex with SES in the association with LE8 score was assessed in each racial and ethnic group. The US population representatively weighted sample (13 529 observations) was aged ≥20 years (median, 48 years). The association of education and income with LE8 scores was higher in women compared with men for non-Hispanic Black Americans and non-Hispanic White Americans (P for all interactions <0.05). Among non-Hispanic Asian Americans and Hispanic Americans, the association of SES with LE8 was not different between men and women, and women had greater LE8 scores than men at all SES levels (eg, high school or less, some college, and college degree or more).

CONCLUSIONS

The factors that explain the sex differences among non-Hispanic Black Americans and non-Hispanic White Americans, but not non-Hispanic Asian Americans and Hispanic Americans, are critical areas for further research to advance cardiovascular health equity.

Addressing Social Determinants of Health in Maternal Cardiovascular Health

Cardiovascular diseases (CVDs) remain the number-one cause of maternal mortality, with over two-thirds of cases being preventable. Social determinants of health (SDoH) encompass the nonmedical social and environmental factors that an individual experiences that have a significant impact on their health. These stressors disproportionately affect socially disadvantaged and minority populations. Pregnancy is a physiologically stressful state that can unmask underlying CVD risk factors and lead to adverse pregnancy outcomes (APOs). Disparities in APOs are particularly pronounced among individuals of color and those from economically disadvantaged backgrounds. This variation underscores healthcare inequity and access, a failure of the healthcare system. Besides short-term negative effects, APOs also are associated strongly with long-term CVDs. APOs therefore must be identified as a cue for early intervention, for the prevention and management of CVD risk factors. This review explores the intricate relationship among maternal morbidity and mortality, SDoH, and cardiovascular health, and the implementation of health policy efforts to reduce the negative impact of SDoH in this patient population. The review emphasizes the importance of comprehensive strategies to improve maternal health outcomes.

Factors Facilitating Academic-Community Research Partnerships With African American Churches: Recruitment Process for a Community-Based, Cluster Randomized Controlled Trial During the COVID-19 Pandemic

African American (AA) churches are valuable partners in implementing health promotion programming (HPP) to combat health disparities. The study purpose was to evaluate AA church characteristics associated with enrollment into the FAITH! (Fostering African American Improvement in Total Health) Trial, a community-based, cluster randomized controlled trial (RCT) of a mobile health intervention for cardiovascular health promotion among AA churches. Churches located in Minneapolis-St. Paul and Rochester, Minnesota were invited to complete an electronic screening survey and follow-up telephone interview including the PREACH (Predicting Readiness to Engage African American Churches in Health) tool to assess church characteristics and infrastructure for HPP. The primary outcome was church enrollment in the FAITH! Trial. Key predictors included overall PREACH scores and its subscales (Personnel, Physical Structure, Faith-based Approach, Funding), congregation size, and mean congregation member age. Of the 26 churches screened, 16 (61.5%) enrolled in the trial. The enrolled churches had higher overall mean PREACH scores (36.1 vs. 30.2) and subscales for Personnel (8.8 vs. 5.6), Faith-based Approach (11.0 vs. 9.6), and Funding (7.3 vs. 4.8) compared with non-enrolled churches; all differences were not statistically significant due to small sample size. Twelve (75.0%) of the enrolled churches had >75 members versus six (60.0%) of the non-enrolled churches. Twelve (80.0%) of the enrolled churches had an average congregation member age ≤54 years versus six (67.0%) of the non-enrolled churches. AA churches enrolling into a community-based RCT reported greater infrastructure for HPP, larger congregations, and members of younger age. These characteristics may be helpful to consider among researchers partnering with AA churches for HPP studies.

A Christian Faith-Based Facebook Intervention for Smoking Cessation in Rural Communities (FAITH-CORE): Protocol for a Community Participatory Development Study

BACKGROUND

Tobacco smoking remains the leading cause of preventable morbidity and mortality in the United States, with significant rural-urban disparities. Adults who live in rural areas of the United States have among the highest tobacco smoking rates in the nation and experience a higher prevalence of smoking-related deaths and deaths due to chronic diseases for which smoking is a causal risk factor. Barriers to accessing tobacco use cessation treatments are a major contributing factor to these disparities. Adults living in rural areas experience difficulty accessing tobacco cessation services due to geographical challenges, lack of insurance coverage, and lack of health care providers who treat tobacco use disorders. The use of digital technology could be a practical answer to these barriers.

OBJECTIVE

This report describes a protocol for a study whose main objectives are to develop and beta test an innovative intervention that uses a private, moderated Facebook group platform to deliver peer support and faith-based cessation messaging to enhance the reach and uptake of existing evidence-based smoking cessation treatment (EBCT) resources (eg, state quitline coaching programs) for rural adults who smoke.

METHODS

We will use the Integrated Theory of Health Behavior Change, surface or deep structure frameworks to guide intervention development, and the community-based participatory research (CBPR) approach to identify and engage with community stakeholders. The initial content library of moderator postings (videos and text or image postings) will be developed using existing EBCT material from the Centers for Disease Control and Prevention Tips from Former Smokers Campaign. The content library will feature topics related to quitting smoking, such as coping with cravings and withdrawal and using EBCTs with faith-based message integration (eg, Bible quotes). A community advisory board and a community engagement studio will provide feedback to refine the content library. We will also conduct a beta test of the intervention with 15 rural adults who smoke to assess the recruitment feasibility and preliminary intervention uptake such as engagement, ease of use, usefulness, and satisfaction to further refine the intervention based on participant feedback.

RESULTS

The result of this study will create an intervention prototype that will be used for a future randomized controlled trial.

CONCLUSIONS

Our CBPR project will create a prototype of a Facebook-delivered faith-based messaging and peer support intervention that may assist rural adults who smoke to use EBCT. This study is crucial in establishing a self-sufficient smoking cessation program for the rural community. The project is unique in using a moderated social media platform providing peer support and culturally relevant faith-based content to encourage adult people who smoke to seek treatment and quit smoking.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/52398.

Role of Sex in the Association of Socioeconomic Status With Cardiovascular Health in Black Americans: The Jackson Heart Study

BACKGROUND

Socioeconomic status (SES) is associated with cardiovascular health (CVH). Potential differences by sex in this association remain incompletely understood in Black Americans, where SES disparities are posited to be partially responsible for cardiovascular inequities. The association of SES measures (income, education, occupation, and insurance) with CVH scores was examined in the Jackson Heart Study.

METHODS AND RESULTS

American Heart Association CVH components (non-high-density-lipoprotein cholesterol, blood pressure, diet, tobacco use, physical activity, sleep, glycemia, and body mass index) were scored cross-sectionally at baseline (scale: 0-100). Differences in CVH and 95% CIs (Estimate, 95% CI) were calculated using linear regression, adjusting for age, sex, and discrimination. Heterogeneity by sex was assessed. Participants had a mean age of 54.8 years (SD 12.6 years), and 65% were women. Lower income, education, occupation (non-management/professional versus management/professional occupations), and insurance status (uninsured, Medicaid, Veterans Affairs, or Medicare versus private insurance) were associated with lower CVH scores (all P<0.01). There was heterogeneity by sex, with greater magnitude of associations of SES measures with CVH in women versus men. The lowest education level (high school) was associated with 8.8-point lower (95% CI: -10.2 to -7.3) and 5.4-point lower (95% CI: -7.2 to -3.6) CVH scores in women and men, respectively (interaction P=0.003). The lowest (<25 000) versus highest level of income (≥$75 000) was associated with a greater reduction in CVH scores in women than men (interaction P=0.1142).

CONCLUSIONS

Among Black Americans, measures of SES were associated with CVH, with a greater magnitude in women compared with men for education and income. Interventions aimed to address CVH through SES should consider the role of sex.

Efficacy and Adherence Rates of a Novel Community-Informed Virtual World-Based Cardiac Rehabilitation Program: Protocol for the Destination Cardiac Rehab Randomized Controlled Trial

BACKGROUND

Innovative restructuring of cardiac rehabilitation (CR) delivery remains critical to reduce barriers and improve access to diverse populations. Destination Cardiac Rehab is a novel virtual world technology-based CR program delivered through the virtual world platform, Second Life, which previously demonstrated high acceptability as an extension of traditional center-based CR. This study aims to evaluate efficacy and adherence of the virtual world-based CR program compared with center-based CR within a community-informed, implementation science framework.

METHODS

Using a noninferiority, hybrid type 1 effectiveness-implementation, randomized controlled trial, 150 patients with an eligible cardiovascular event will be recruited from 6 geographically diverse CR centers across the United States. Participants will be randomized 1:1 to either the 12-week Destination Cardiac Rehab or the center-based CR control groups. The primary efficacy outcome is a composite cardiovascular health score based on the American Heart Association Life's Essential 8 at 3 and 6 months. Adherence outcomes include CR session attendance and participation in exercise sessions. A diverse patient/caregiver/stakeholder advisory board was assembled to guide recruitment, implementation, and dissemination plans and to contextualize study findings. The institutional review board-approved randomized controlled trial will enroll and randomize patients to the intervention (or control group) in 3 consecutive waves/year over 3 years. The results will be published at data collection and analyses completion.

CONCLUSIONS

The Destination Cardiac Rehab randomized controlled trial tests an innovative and potentially scalable model to enhance CR participation and advance health equity. Our findings will inform the use of effective virtual CR programs to expand equitable access to diverse patient populations.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05897710.

Health Disparities, Clinical Trials, and the Digital Divide

In the past few years, there have been rapid advances in technology and the use of digital tools in health care and clinical research. Although these innovations have immense potential to improve health care delivery and outcomes, there are genuine concerns related to inadvertent widening of the digital gap consequentially exacerbating health disparities. As such, it is important that we critically evaluate the impact of expansive digital transformation in medicine and clinical research on health equity. For digital solutions to truly improve the landscape of health care and clinical trial participation for all persons in an equitable way, targeted interventions to address historic injustices, structural racism, and social and digital determinants of health are essential. The urgent need to focus on interventions to promote health equity was made abundantly clear with the coronavirus disease 2019 pandemic, which magnified long-standing social and racial health disparities. Novel digital technologies present a unique opportunity to embed equity ideals into the ecosystem of health care and clinical research. In this review, we examine racial and ethnic diversity in clinical trials, historic instances of unethical research practices in biomedical research and its impact on clinical trial participation, and the digital divide in health care and clinical research, and we propose suggestions to achieve digital health equity in clinical trials. We also highlight key digital health opportunities in cardiovascular medicine and dermatology as exemplars, and we offer future directions for development and adoption of patient-centric interventions aimed at narrowing the digital divide and mitigating health inequities.

Food Is Medicine: A Presidential Advisory From the American Heart Association

Unhealthy diets are a major impediment to achieving a healthier population in the United States. Although there is a relatively clear sense of what constitutes a healthy diet, most of the US population does not eat healthy food at rates consistent with the recommended clinical guidelines. An abundance of barriers, including food and nutrition insecurity, how food is marketed and advertised, access to and affordability of healthy foods, and behavioral challenges such as a focus on immediate versus delayed gratification, stand in the way of healthier dietary patterns for many Americans. Food Is Medicine may be defined as the provision of healthy food resources to prevent, manage, or treat specific clinical conditions in coordination with the health care sector. Although the field has promise, relatively few studies have been conducted with designs that provide strong evidence of associations between Food Is Medicine interventions and health outcomes or health costs. Much work needs to be done to create a stronger body of evidence that convincingly demonstrates the effectiveness and cost-effectiveness of different types of Food Is Medicine interventions. An estimated 90% of the $4.3 trillion annual cost of health care in the United States is spent on medical care for chronic disease. For many of these diseases, diet is a major risk factor, so even modest improvements in diet could have a significant impact. This presidential advisory offers an overview of the state of the field of Food Is Medicine and a road map for a new research initiative that strategically approaches the outstanding questions in the field while prioritizing a human-centered design approach to achieve high rates of patient engagement and sustained behavior change. This will ideally happen in the context of broader efforts to use a health equity-centered approach to enhance the ways in which our food system and related policies support improvements in health.

Leveraging Digital Health to Improve the Cardiovascular Health of Women

Purpose of Review

In this review, we present a comprehensive discussion on the population-level implications of digital health interventions (DHIs) to improve cardiovascular health (CVH) through sex- and gender-specific prevention strategies among women.

Recent Findings

Over the past 30 years, there have been significant advancements in the diagnosis and treatment of cardiovascular diseases, a leading cause of morbidity and mortality among men and women worldwide. However, women are often underdiagnosed, undertreated, and underrepresented in cardiovascular clinical trials, which all contribute to disparities within this population. One approach to address this is through DHIs, particularly among racial and ethnic minoritized groups. Implementation of telemedicine has shown promise in increasing adherence to healthcare visits, improving BP monitoring, weight control, physical activity, and the adoption of healthy behaviors. Furthermore, the use of mobile health applications facilitated by smart devices, wearables, and other eHealth (defined as electronically delivered health services) modalities has also promoted CVH among women in general, as well as during pregnancy and the postpartum period. Overall, utilizing a digital health approach for healthcare delivery, decentralized clinical trials, and incorporation into daily lifestyle activities has the potential to improve CVH among women by mitigating geographical, structural, and financial barriers to care.

Summary

Leveraging digital technologies and strategies introduces novel methods to address sex- and gender-specific health and healthcare disparities and improve the quality of care provided to women. However, it is imperative to be mindful of the digital divide in specific populations, which may hinder accessibility to these novel technologies and inadvertently widen preexisting inequities.

Association of Socioeconomic Status With Life's Essential 8 Varies by Race and Ethnicity

Background The American Heart Association's Life's Essential 8 (LE8) are 8 risk factors for cardiovascular disease, with poor attainment across all racial, ethnic, and socioeconomic groups. Attainment is lowest among Americans of low socioeconomic status (SES). Evidence suggests the association of SES with LE8 may vary by race and ethnicity. Methods and Results The association of 4 SES categories (education, income-to-poverty line ratio, employment, insurance) with LE8 was computed in age-adjusted linear regression models, with an interaction term for race and ethnicity, using National Health and Nutrition Examination Survey data, years 2011 to 2018. The sample (n=13 529) had a median age of 48 years (51% female) with weighting to be representative of the US population. The magnitude of positive association of college education (relative to ≤high school) with LE8 was greater among non-Hispanic White Americans (NHWA) compared with non-Hispanic Black Americans, Hispanic Americans, and non-Hispanic Asian Americans (all interactions P<0.001). NHWA had a greater magnitude of positive association of income-to-poverty line ratio with LE8, compared with non-Hispanic Black Americans, Hispanic Americans, and non-Hispanic Asian Americans (all interactions P<0.001). NHWA with Medicaid compared with private insurance had a greater magnitude of negative association with LE8 compared with non-Hispanic Black Americans, non-Hispanic Asian Americans, or Hispanic Americans (all interactions P<0.01). NHWA unemployed due to disability or health condition (compared with employed) had a greater magnitude of negative association with LE8 than non-Hispanic Black Americans, non-Hispanic Asian Americans, or Hispanic Americans (all interactions P<0.05). Conclusions The magnitude of association of SES with LE8 is greatest among NHWA. More research is needed on SES's role in LE8 attainment in minority group populations.

A Call to Action on Assessing and Mitigating Bias in Artificial Intelligence Applications for Mental Health

Advances in computer science and data-analytic methods are driving a new era in mental health research and application. Artificial intelligence (AI) technologies hold the potential to enhance the assessment, diagnosis, and treatment of people experiencing mental health problems and to increase the reach and impact of mental health care. However, AI applications will not mitigate mental health disparities if they are built from historical data that reflect underlying social biases and inequities. AI models biased against sensitive classes could reinforce and even perpetuate existing inequities if these models create legacies that differentially impact who is diagnosed and treated, and how effectively. The current article reviews the health-equity implications of applying AI to mental health problems, outlines state-of-the-art methods for assessing and mitigating algorithmic bias, and presents a call to action to guide the development of fair-aware AI in psychological science.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Community-Based Interventions to Address Disparities in Cardiometabolic Diseases Among Minoritized Racial and Ethnic Groups

PURPOSE OF REVIEW

Cardiometabolic diseases (CMDs) are leading causes of death and disproportionally impact historically marginalized racial/ethnic groups in the United States. The American Heart Association developed the Life's Essential 8 (LE8) to promote optimal cardiovascular health (CVH) through eight health behaviors and health factors. The purpose of this review is to summarize contemporary community-engaged research (CER) studies incorporating the LE8 framework among racial/ethnic groups.

REVIEW OF FINDINGS

Limited studies focused on the interface of CER and LE8. Based on synthesis of articles in this review, the application of CER to individual/collective LE8 metrics may improve CVH and reduce CMDs at the population level. Effective strategies include integration of technology, group activities, cultural/faith-based practices, social support, and structural/environmental changes. CER studies addressing LE8 factors in racial/ethnic groups play an essential role in improving CVH. Future studies should focus on broader scalability and health policy interventions to advance health equity.

Abstract P396: A Culturally Tailored Mobile Health Lifestyle Intervention Improves Cardiovascular Health Among African Americans With Preexisting Risk Factors

Background: African-American (AA) adults have a higher prevalence of cardiovascular (CV) risk factors, leading to higher CV disease mortality than White adults. Prior findings of our mobile health (mHealth) lifestyle intervention (FAITH! App) demonstrated efficacy in promoting ideal cardiovascular health (CVH) in AAs.

Hypothesis: We hypothesized that the intervention group with preexisting CV risk factors would have a greater increase in LS7 scores than the control group with the same risk factors following use of the FAITH! App.

Methods: A cluster randomized controlled trial was conducted among AAs from 16 churches in Minnesota. The intervention included culturally relevant, LS7-focused education modules, diet/physical activity self-monitoring and a group sharing board. A subgroup of participants with ≥1 diagnosis of overweight/obesity, hyperlipidemia, hypertension (HTN) or diabetes was examined. The primary outcome was change in LS7 score—a measure of CVH ranging from poor to ideal (range 0-14 points)—at 6 months post-intervention.

Results: Forty-nine participants (75.5% female) were included in the intervention (n=20; mean age [SD]: 58.8 [9.5]) or control (n=29, mean age [SD]: 52.5 [10.7]) groups (Table 1). There was no significant difference in the CV risk factor prevalence between the two groups. There was a greater increase in LS7 score in the intervention vs. control group across all CV risk factors, with significant differences among those with overweight/obesity (1.77, p<.0001) and with 2+ or 3+ CV risk factors (1.00, p=.03; 1.09, p=.04). Compared to the control group, the increase in the percentage of participants with ideal LS7 scores in the intervention group was higher among those with overweight/obesity, HTN, diabetes and 3+ CV risk factors.

Conclusions: Our culturally tailored mHealth lifestyle intervention was associated with notable increases in LS7 scores among AAs with preexisting CV risk factors, suggesting its efficacy in improving CVH among this population.

Abstract P251: Using Art to Mitigate Psychosocial Stress and Blood Pressure Among Black Women: A Pilot Trial

Background: Black women demonstrate higher levels of stress over the life course compared to Black men, White men, and White women, which may help to explain their higher cardiovascular disease (CVD) morbidity and mortality. Despite implications for primary and secondary CVD prevention and racial disparities, few interventions have targeted psychosocial stress to improve blood pressure (BP) levels among Black women.

Objective: To test whether a theory-driven, culturally tailored, community intervention focused on the stress experiences of Black women improves psychological outcomes and BP levels.

Methods: The “Art for Hearts” pilot trial sought to examine the feasibility, acceptability, and preliminary efficacy of a novel intervention encouraging creative self-expression. This individual level, single-arm pilot trial recruited self-identified Black women ≥18 years. Women participated in an 8-week program, including 4 art sessions with a community artist (a self-identified Black woman) accompanied by a moderated focus group discussion and 4 heart health education sessions (facilitated by a Black woman researcher) on home BP monitoring, stress management techniques, diet/physical activity, and patient-clinician communication. All sessions were conducted in-person in a community space. Participants completed a survey including self-rated stress (scale of 0 to 7), perceived stress (PSS-10), depressive symptoms (PHQ-8), and anxiety symptoms (GAD-7) at baseline and 8 weeks. BP was measured by a trained assessor at baseline and 8 weeks as well as before and after each session. We examined within-participant changes in psychological measures as well as mean systolic and diastolic BP from baseline to 8 weeks.

Results: The study included 18 Black women with a mean age of 44.1 (SD=15.4) years. Women were highly educated (36.8% with a graduate/professional degree) and 11.1% earned an income of ≥$100,000. Mean systolic BP was 114 mmHg and mean diastolic BP was 66 mmHg at baseline. From baseline to 8 weeks, self-rated stress level decreased by 1-point (from 4.36 to 3.18; p=0.005) (scale range: 0 -7). Perceived stress (-1.08; p=0.58) and anxiety (-1.33; p=0.09) decreased from baseline to 8 weeks; however, these changes did not achieve statistical significance. Depressive symptoms significantly improved from baseline to 8 weeks (19.13 to 13.38; p=0.044). There were no differences in systolic or diastolic BP from baseline to follow-up. The intervention was deemed feasible and acceptable with an attendance rate of >80%; participants expressed high overall satisfaction with the intervention.

Conclusion: A tailored 8-week pilot intervention using painting self-expression demonstrated feasibility, acceptability, and preliminary efficacy for improving self-rated stress and depressive symptoms. No effects were demonstrated on BP in this sample.

Community engagement and clinical trial diversity: Navigating barriers and co-designing solutions-A report from the "Health Equity through Diversity" seminar series

INTRODUCTION

In recent years, there has been increasing awareness of the lack of diversity among clinical trial participants. Equitable representation is key when testing novel therapeutic and non-therapeutic interventions to ensure safety and efficacy across populations. Unfortunately, in the United States (US), racial and ethnic minority populations continue to be underrepresented in clinical trials compared to their White counterparts.

METHODS

Two webinars in a four-part series, titled "Health Equity through Diversity," were held to discuss solutions for advancing health equity through diversifying clinical trials and addressing medical mistrust in communities. Each webinar was 1.5 hours long, beginning with panelist discussions followed by breakout rooms where moderators led discussions related to health equity and scribes recorded each room's conversations. The diverse groups of panelists included community members, civic representatives, clinician-scientists, and biopharmaceutical representatives. Scribe notes from discussions were collected and thematically analyzed to uncover the central themes.

RESULTS

The first two webinars were attended by 242 and 205 individuals, respectively. The attendees represented 25 US states, four countries outside the US, and shared various backgrounds including community members, clinician/researchers, government organizations, biotechnology/biopharmaceutical professionals, and others. Barriers to clinical trial participation are broadly grouped into the themes of access, awareness, discrimination and racism, and workforce diversity. Participants noted that innovative, community-engaged, co-designed solutions are essential.

CONCLUSIONS

Despite racial and ethnic minority groups making up nearly half of the US population, underrepresentation in clinical trials remains a critical challenge. The community engaged co-developed solutions detailed in this report to address access, awareness, discrimination and racism, and workforce diversity are critical to advancing clinical trial diversity.

Optimizing Prepregnancy Cardiovascular Health to Improve Outcomes in Pregnant and Postpartum Individuals and Offspring: A Scientific Statement From the American Heart Association

This scientific statement summarizes the available preclinical, epidemiological, and clinical trial evidence that supports the contributions of prepregnancy (and interpregnancy) cardiovascular health to risk of adverse pregnancy outcomes and cardiovascular disease in birthing individuals and offspring. Unfavorable cardiovascular health, as originally defined by the American Heart Association in 2010 and revised in 2022, is prevalent in reproductive-aged individuals. Significant disparities exist in ideal cardiovascular health by race and ethnicity, socioeconomic status, and geography. Because the biological processes leading to adverse pregnancy outcomes begin before conception, interventions focused only during pregnancy may have limited impact on both the pregnant individual and offspring. Therefore, focused attention on the prepregnancy period as a critical life period for optimization of cardiovascular health is needed. This scientific statement applies a life course and intergenerational framework to measure, modify, and monitor prepregnancy cardiovascular health. All clinicians who interact with pregnancy-capable individuals can emphasize optimization of cardiovascular health beginning early in childhood. Clinical trials are needed to investigate prepregnancy interventions to comprehensively target cardiovascular health. Beyond individual-level interventions, community-level interventions must include and engage key stakeholders (eg, community leaders, birthing individuals, families) and target a broad range of antecedent psychosocial and social determinants. In addition, policy-level changes are needed to dismantle structural racism and to improve equitable and high-quality health care delivery because many reproductive-aged individuals have inadequate, fragmented health care before and after pregnancy and between pregnancies (interpregnancy). Leveraging these opportunities to target cardiovascular health has the potential to improve health across the life course and for subsequent generations.

A Community-Informed Virtual World-Based Cardiac Rehabilitation Program as an Extension of Center-Based Cardiac Rehabilitation: MIXED-METHODS ANALYSIS OF A MULTICENTER PILOT STUDY

PURPOSE

Innovative methods for delivering cardiac rehabilitation (CR) that provide strategies to circumvent the mounting barriers to traditional CR have the potential to widen access to a well-established secondary prevention strategy. Our study assesses the feasibility and acceptability of a novel virtual world-based CR (VWCR) program, Destination Rehab , as an extension of a conventional center-based CR program.

METHODS

Adult cardiac patients hospitalized at Mayo Clinic hospitals with a diagnosis for CR and ≥1 modifiable, lifestyle risk factor target-sedentary lifestyle (<3 hr physical activity/wk), unhealthy diet (<5 servings fruits and vegetables/d), or current smoking (>1 yr)-were recruited. Patients participated in an 8-wk health education program using a virtual world (VW) platform from a prior proof-of-concept study and a post-intervention focus group. Primary outcome measures included feasibility and acceptability. Secondary outcome measures included changes from baseline to post-intervention in cardiovascular (CV) health behaviors and biometrics, CV health knowledge, and psychosocial factors.

RESULTS

Of the 30 enrolled patients (age 59.1 ± 9.7 yr; 50% women), 93% attended ≥1 session and 71% attended ≥75% of sessions. The overall VWCR experience received an 8 rating (scale 0-10) and had high acceptability. Clinically relevant trends were noted in CV health behaviors and biometrics, although not statistically significant.

CONCLUSIONS

The VWCR program is a feasible, highly acceptable, and innovative platform to potentially influence health behaviors and CV risk and may increase accessibility to disadvantaged populations with higher CV disease burdens.

Factors Associated With COVID-19 Vaccine Acceptance Among Patients Receiving Care at a Federally Qualified Health Center

BACKGROUND

COVID-19 vaccine hesitancy in the United States is high, with at least 63 million unvaccinated individuals to date. Socioeconomically disadvantaged populations experience lower COVID-19 vaccination rates despite facing a disproportionate COVID-19 burden.

OBJECTIVE

To assess the factors associated with COVID-19 vaccine acceptance among under-resourced, adult patients.

METHODS

Participants were patients receiving care at a Federally Qualified Health Center (FQHC) in St. Paul, Minnesota. Data were collected via multiple modes over 2 phases in 2020 (self-administered electronic survey) and 2021 (study team-administered survey by telephone, self-administered written survey) to promote diversity and inclusion for study participation. The primary outcome was COVID-19 vaccine acceptance. Using logistic regression analysis, associations between vaccine acceptance and factors including risk perception, concerns about the COVID-19 vaccine, social determinants of health (SDOH), co-morbidities, pandemic-induced hardships, and stress were assessed by adjusted odds ratios (AORs) and 95% confidence intervals (CI).

RESULTS

One hundred sixty-eight patients (62.5% female; mean age [SD]: 49.9 [17.4] years; 32% <$20 000 annual household income; 69%

CONCLUSIONS

Our study in a socioeconomically disadvantaged population suggests that risk perception is associated with an increased likelihood of vaccine acceptance, while concerns about the COVID-19 vaccine are associated with a lower likelihood of vaccine acceptance. As these factors could impact vaccine uptake, consistent, innovative, and context-specific risk communication strategies may improve vaccine coverage in this population.

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Key Words

• COVID
• COVID-19 vaccines
• Federally Qualified Health Center
• community health
• health disparities
• health promotion
• prevention
• social determinants of health
• underserved communities
• vaccine hesitancy

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MESH Headings

• Adult
• Humans
• Female
• Adolescent
• Male
• COVID-19 Vaccines/therapeutic use
• COVID-19/prevention & control
• Communication
• Electronics
• Health Facilities
• Vaccination

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Grants

• KL2 TR002379 NCATS NIH HHS
• R21 MD013490 NIMHD NIH HHS
• UL1 TR000135 NCATS NIH HHS
• National Center for Advancing Translational Sciences
• National Institute on Minority Health and Health Disparities
• Centers for Disease Control and Prevention
• American Heart Association

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Affiliation(s)

Mathias Lalika Mayo Clinic, Rochester, MN, USA
Cynthia Woods Open Cities Health Center, St Paul, MN, USA
Aarti Patel Open Cities Health Center, St Paul, MN, USA
Christopher Scott Mayo Clinic, Rochester, MN, USA
Alexander Lee Mayo Clinic, Rochester, MN, USA
Jennifer Weis Mayo Clinic, Rochester, MN, USA
Clarence Jones Hue-Man Partnership, Minneapolis, MN, USA
Adeline Abbenyi Mayo Clinic, Rochester, MN, USA
Tabetha A. Brockman Mayo Clinic, Rochester, MN, USA
Irene G. Sia Mayo Clinic, Rochester, MN, USA
Richard O. White Mayo Clinic, Jacksonville, FL, USA
Chyke A. Doubeni The Ohio State University Wexner Medical Center, Columbus, OH, USA
LaPrincess C. Brewer Mayo Clinic, Rochester, MN, USA

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Guidelines to Establish an Equitable Mobile Health Ecosystem

Mobile health (mHealth)-that is, use of mobile devices, such as mobile phones, monitoring devices, personal digital assistants, and other wireless devices, in medical care-is a promising approach to the provision of support services. mHealth may aid in facilitating monitoring of mental health conditions, offering peer support, providing psychoeducation (i.e., information about mental health conditions), and delivering evidence-based practices. However, some groups may fail to benefit from mHealth despite a high need for mental health services, including people from racially and ethnically disadvantaged groups, rural residents, individuals who are socioeconomically disadvantaged, and people with disabilities. A well-designed mHealth ecosystem that considers multiple elements of design, development, and implementation can afford disadvantaged populations the opportunity to address inequities and facilitate access to and uptake of mHealth. This article proposes inclusion of the following principles and standards in the development of an mHealth ecosystem of equity: use a human-centered design, reduce bias in machine-learning analytical techniques, promote inclusivity via mHealth design features, facilitate informed decision making in technology selection, embrace adaptive technology, promote digital literacy through mHealth by teaching patients how to use the technology, and facilitate access to mHealth to improve health outcomes.

Community-based participatory research application of an artificial intelligence-enhanced electrocardiogram for cardiovascular disease screening: A FAITH! Trial ancillary study

Objective

With the emergence of artificial intelligence (AI)-based health interventions, systemic racism remains a concern as these advancements are frequently developed without race-specific data analysis or validation. To evaluate the potential utility of an AI-based cardiovascular diseases (CVD) screening tool in an under-resourced African-American cohort, we reviewed the AI-enhanced electrocardiogram (ECG) data of participants enrolled in a community-based clinical trial as a proof-of-concept ancillary study for community-based screening.

Methods

Enrollees completed cardiovascular testing including standard 12-lead ECG and a limited echocardiogram (TTE). All ECGs were analyzed using previously published institution-based AI algorithms. AI-ECG predictions were generated for age, sex, and decreased left ventricular ejection fraction (LVEF). Diagnostic accuracy of the AI-ECG for decreased LVEF and sex was quantified using area under the receiver operating characteristic curve (AUC). Correlation between actual age and AI-ECG predicted age was assessed using Pearson correlation coefficients.

Results

Fifty-four participants completed both an ECG and TTE (mean age 55 years [range 31-87 years]; 66.7% female). All participants were in sinus rhythm, and the median LVEF of the cohort was 60-65%. The AI-ECG for decreased LVEF demonstrated excellent performance with an AUC of 0.892 (95% confidence interval [CI] 0.708-1); sensitivity=50% (95% CI 9.5-90.5%; n=1/2) and specificity=96% (95% CI 86.8-98.9%; n=49/51). The AI-ECG for participant sex demonstrated similar performance with AUC of 0.944 (95% CI 0.891-0.998); sensitivity=100% (95% CI 82.4-100.0%; n=18/18) and specificity=77.8% (95% CI 61.9-88.3%; n=28/36). The AI-ECG predicted mean age was 55 years (range 26.9-72.6 years) with a strong correlation to actual age (R=0.769; p<0.001).

Conclusion

Our analyses of previously developed AI-ECG algorithms for prediction of age, sex, and decreased LVEF demonstrated reliable performance in this community-based, African-American cohort. This novel, community-centric delivery of AI could provide valuable screening resources and appropriate referrals for early detection of highly-morbid CVD for under-resourced patient populations.

Religiosity/Spirituality and Cardiovascular Health: The American Heart Association Life's Simple 7 in African Americans of the Jackson Heart Study

Background

Religiosity/spirituality is a major coping mechanism for African Americans, but no prior studies have analyzed its association with the American Heart Association Life's Simple 7 (LS7) indicators in this group.

Methods and Results

This cross‐sectional study using Jackson Heart Study (JHS) data examined relationships between religiosity (religious attendance, private prayer, religious coping) and spirituality (theistic, nontheistic, total) with LS7 individual components (eg, physical activity, diet, smoking, blood pressure) and composite score among African Americans. Multivariable logistic regression assessed the odds of achieving intermediate/ideal (versus poor) LS7 levels adjusted for sociodemographic, behavioral, and biomedical factors. Among the 2967 participants (mean [SD] age=54.0 [12.3] years; 65.7% women), higher religious attendance was associated with increased likelihood (reported as odds ratio [95% CI]) of achieving intermediate/ideal levels of physical activity (1.16 [1.06–1.26]), diet (1.10 [1.01–1.20]), smoking (1.50 [1.34–1.68]), blood pressure (1.12 [1.01–1.24]), and LS7 composite score (1.15 [1.06–1.26]). Private prayer was associated with increased odds of achieving intermediate/ideal levels for diet (1.12 [1.03–1.22]) and smoking (1.24 [1.12–1.39]). Religious coping was associated with increased odds of achieving intermediate/ideal levels of physical activity (1.18 [1.08–1.28]), diet (1.10 [1.01–1.20]), smoking (1.32 [1.18–1.48]), and LS7 composite score (1.14 [1.04–1.24]). Total spirituality was associated with increased odds of achieving intermediate/ideal levels of physical activity (1.11 [1.02–1.21]) and smoking (1.36 [1.21–1.53]).

Conclusions

Higher levels of religiosity/spirituality were associated with intermediate/ideal cardiovascular health across multiple LS7 indicators. Reinforcement of religiosity/spirituality in lifestyle interventions may decrease overall cardiovascular disease risk among African Americans.

Life's Essential 8: Updating and Enhancing the American Heart Association's Construct of Cardiovascular Health: A Presidential Advisory From the American Heart Association

In 2010, the American Heart Association defined a novel construct of cardiovascular health to promote a paradigm shift from a focus solely on disease treatment to one inclusive of positive health promotion and preservation across the life course in populations and individuals. Extensive subsequent evidence has provided insights into strengths and limitations of the original approach to defining and quantifying cardiovascular health. In response, the American Heart Association convened a writing group to recommend enhancements and updates. The definition and quantification of each of the original metrics (Life's Simple 7) were evaluated for responsiveness to interindividual variation and intraindividual change. New metrics were considered, and the age spectrum was expanded to include the entire life course. The foundational contexts of social determinants of health and psychological health were addressed as crucial factors in optimizing and preserving cardiovascular health. This presidential advisory introduces an enhanced approach to assessing cardiovascular health: Life's Essential 8. The components of Life's Essential 8 include diet (updated), physical activity, nicotine exposure (updated), sleep health (new), body mass index, blood lipids (updated), blood glucose (updated), and blood pressure. Each metric has a new scoring algorithm ranging from 0 to 100 points, allowing generation of a new composite cardiovascular health score (the unweighted average of all components) that also varies from 0 to 100 points. Methods for implementing cardiovascular health assessment and longitudinal monitoring are discussed, as are potential data sources and tools to promote widespread adoption in policy, public health, clinical, institutional, and community settings.

Disparities in Cardiovascular Mortality Between Black and White Adults in the United States, 1999 to 2019

BACKGROUND

Black adults experience a disproportionately higher burden of cardiovascular risk factors and disease in comparison with White adults in the United States. Less is known about how sex-based disparities in cardiovascular mortality between these groups have changed on a national scale over the past 20 years, particularly across geographic determinants of health and residential racial segregation.

METHODS

We used CDC WONDER (Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research) to identify Black and White adults age ≥25 years in the United States from 1999 to 2019. We calculated annual age-adjusted cardiovascular mortality rates (per 100 000) for Black and White women and men, as well as absolute rate differences and rate ratios to compare the mortality gap between these groups. We also examined patterns by US census region, rural versus urban residence, and degree of neighborhood segregation.

RESULTS

From 1999 to 2019, age-adjusted mortality rates declined overall for both Black and White adults. There was a decline in age-adjusted cardiovascular mortality among Black (602.1 to 351.8 per 100 000 population) and White women (447.0 to 267.5), and the absolute rate difference (ARD) between these groups decreased over time (1999: ARD, 155.1 [95% CI, 149.9-160.3]; 2019: ARD, 84.3 [95% CI, 81.2-87.4]). These patterns were similar for Black (824.1 to 526.3 per 100 000) and White men (637.5 to 396.0; 1999: ARD, 186.6 [95% CI, 178.6-194.6]; 2019: ARD, 130.3 [95% CI, 125.6-135.0]). Despite this progress, cardiovascular mortality in 2019 was higher for Black women (rate ratio, 1.32 [95% CI, 1.30-1.33])- especially in the younger (age <65 years) subgroup (rate ratio, 2.28 [95% CI, 2.23-2.32])-as well as for Black men (rate ratio, 1.33 [95% CI, 1.32-1.34]), compared with their respective White counterparts. There was regional variation in cardiovascular mortality patterns, and the Black-White gap differed across rural and urban areas. Cardiovascular mortality rates among Black women and men were consistently higher in communities with high levels of racial segregation compared with those with low to moderate levels.

CONCLUSIONS

During the past 2 decades, age-adjusted cardiovascular mortality declined significantly for Black and White adults in the United States, as did the absolute difference in death rates between these groups. Despite this progress, Black women and men continue to experience higher cardiovascular mortality rates than their White counterparts.

Community-Based, Cluster-Randomized Pilot Trial of a Cardiovascular Mobile Health Intervention: Preliminary Findings of the FAITH! Trial

BACKGROUND

African Americans continue to have suboptimal cardiovascular health (CVH) based on the American Heart Association Life's Simple 7 (LS7), 7 health-promoting behaviors and biological risk factors (eg, physical activity, blood pressure). Innovative, community-level interventions in partnership with trusted institutions such as African American churches are potential means to improve CVH in this population.

METHODS

Using a community-based participatory research approach, the FAITH! Trial (Fostering African American Improvement in Total Health) rigorously assessed the feasibility and preliminary efficacy of a refined, community-informed, mobile health intervention (FAITH! App) for promoting CVH among African Americans in faith communities using a cluster randomized controlled trial. Participants from 16 churches in Rochester and Minneapolis-St Paul, MN, were randomized to receive the FAITH! App (immediate intervention) or were assigned to a delayed intervention comparator group. The 10-week intervention core features included culturally relevant and LS7-focused education modules, diet/physical activity self-monitoring, and a group sharing board. Data were collected via electronic surveys and health assessments. Primary outcomes were average change in mean LS7 score (continuous measure of CVH ranging from poor to ideal [0-14 points]) from baseline to 6 months post-intervention (using generalized estimating equations) and app engagement/usability (by the Health Information Technology Usability Evaluation Scale; range, 0-5).

RESULTS

Of 85 enrolled participants (randomized to immediate [N=41] and delayed [control] intervention [N=44] groups), 76 and 68 completed surveys/health assessments at baseline and 6 months post-intervention, respectively (80% retention rate with assessments at both baseline and 6-month time points); immediate intervention [N=30] and control [N=38] groups). At baseline, the majority of participants (mean age [SD], 54.2 [12.3] years, 71% female) had <4-year college education level (39/66, 59%) and poor CVH (44% in poor category; mean LS7 score [SD], 6.8 [1.9]). The mean LS7 score of the intervention group increased by 1.9 (SD 1.9) points compared with 0.7 (SD 1.7) point in the control group (both P<0.0001) at 6 months. The estimated difference of this increase between the groups was 1.1 (95% CI, 0.6-1.7; P<0.0001). App engagement/usability was overall high (100% connection to app; >75% completed weekly diet/physical activity tracking; Health Information Technology Usability Evaluation Scale, mean [SD], 4.2 [0.7]).

CONCLUSIONS

On the basis of preliminary findings, the refined FAITH! App appears to be an efficacious mobile health tool to promote ideal CVH among African Americans.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03777709.

Relation of Household Income to Access and Adherence to Combination Sacubitril/Valsartan in Heart Failure: A Retrospective Analysis of Commercially Insured Patients

Background: Outcomes in heart failure with reduced ejection fraction (HFrEF), are influenced by access and adherence to guideline-directed medical therapy. Our objective was to study the association between annual household income and: (1) the odds of having a claim for sacubitril/valsartan among insured patients with HFrEF and (2) medication adherence (measured as the proportion of days covered [PDC]). We hypothesized that lower annual household income is associated with decreased odds of having a claim for and adhering to sacubitril/valsartan. Methods: Using the Optum de-identified Clinformatics® Data Mart, patients with HFrEF and ≥6 months of enrollment for follow up (2016-2020) were included. Covariates included age, sex, race, ethnicity, educational attainment, US region, number of prescribed medications, and Elixhauser Comorbidity Index. Prescription for sacubitril/valsartan was defined by the presence of a claim within 6 months of HFrEF diagnosis. Adherence was defined as PDC≥80%. We fit multivariable-adjusted logistic regression models and hierarchical logistic regression accounting for covariates. Results: Among 322,007 individuals with incident HFrEF, 135,282 had complete data for analysis. Of the patients eligible for sacubitril/valsartan, 4.7% (6,372) had a claim within 6 months of HFrEF diagnosis. Following multivariable adjustment, individuals in the lowest annual income category (<$40,000) were significantly less likely (OR=0.83, 95% CI [0.76, 0.90]) to have a sacubitril/valsartan claim within 6 months of HFrEF diagnosis than those in the highest annual income category (≥$100,000). Annual income <$40,000 was associated with lower odds of PDC≥80% compared with income ≥$100,000 (OR=0.70, 95% CI [0.59, 0.83]). Conclusions: Lower household income is associated with decreased likelihood of a sacubitril/valsartan claim and medication adherence within 6 months of HFrEF diagnosis, even after adjusting for sociodemographic and clinical factors. Future analyses are needed to identify additional social factors associated with delays in sacubitril/valsartan initiation and long-term adherence.

Utilizing Artificial Intelligence to Enhance Health Equity Among Patients with Heart Failure

Patients with heart failure (HF) are heterogeneous with various intrapersonal and interpersonal characteristics contributing to clinical outcomes. Bias, structural racism, and social determinants of health have been implicated in unequal treatment of patients with HF. Through several methodologies, artificial intelligence (AI) can provide models in HF prediction, prognostication, and provision of care, which may help prevent unequal outcomes. This review highlights AI as a strategy to address racial inequalities in HF; discusses key AI definitions within a health equity context; describes the current uses of AI in HF, strengths and harms in using AI; and offers recommendations for future directions.

Sign of the times: Community engagement to refine a cardiovascular mHealth intervention through a virtual focus group series during the COVID-19 Pandemic

Background

African-Americans are underrepresented in mobile health intervention research studies which can perpetuate health inequities and the digital divide. A community-based, user-centered approach to designing mobile health interventions may increase their sociocultural relevance and effectiveness, especially with increased smartphone use during the coronavirus disease 2019 pandemic. We aimed to refine an existing mobile health intervention via a virtual focus group series.

Methods

African-American community members (n = 15) from churches in Minneapolis-St. Paul and Rochester, Minnesota were enrolled in a virtual (via videoconferencing), three-session focus group series over five months to refine a cardiovascular health-focused mobile health application (FAITH! [Fostering African-American Improvement in Total Health!] App). Participants accessed the app via their smartphones and received a Fitbit synced to the app. Participants engaged with multimedia cardiovascular health-focused education modules, a sharing board for social networking, and diet/physical activity self-monitoring. Participant feedback on app features prompted iterative revisions to the FAITH! App. Primary outcomes were app usability (assessed via Health Information Technology Usability Evaluation Scale range: 0–5) and user satisfaction.

Results

Participants (mean age [SD]: 56.9 [12.3] years, 86.7% female) attended a mean 2.8 focus groups (80% attended all sessions). The revised FAITH! App exceeded the goal Health Information Technology Usability Evaluation Scale score threshold of ≥4 (mean: 4.39, range: 3.20–4.95). Participants positively rated updated app content, visual appeal, and use of social incentives to maintain engagement. Increasing user control and refinement of the moderated sharing board were identified as areas for future improvement.

Conclusions

Community-partnered, virtual focus groups can optimize usability and increase participant satisfaction of mobile health lifestyle interventions that aim to promote cardiovascular health in African-Americans.

Association of Cardiovascular Disease Risk Factors With Sociodemographic Characteristics and Health Beliefs Among a Community-Based Sample of African American Adults in Minnesota

OBJECTIVE

To assess cardiovascular disease (CVD) and CVD risk factors and their association with sociodemographic characteristics and health beliefs among African American (AA) adults in Minnesota.

METHODS

A cross-sectional analysis was conducted of a community-based sample of AA adults enrolled in the Minnesota Heart Health Program Ask About Aspirin study from May 2019 to September 2019. Sociodemographic characteristics, health beliefs, and self-reported CVD and CVD risk factors were collected. Prevalence ratio (PR) estimates were calculated using Poisson regression modeling to assess the association between participants' characteristics and age- and sex-adjusted CVD risk factors.

RESULTS

The sample included 644 individuals (64% [412] women) with a mean age of 61 years. Risk factors for CVD were common: hypertension (67% [434]), hyperlipidemia (47% [301]), diabetes (34% [219]), and current cigarette smoking (25% [163]); 19% (119) had CVD. Those with greater perceived CVD risk had a higher likelihood of prevalent hyperlipidemia (PR, 1.34; 95% CI, 1.14 to 1.57), diabetes (PR, 1.61; 95% CI, 1.30 to 1.98), and CVD (PR 1.61; 95% CI, 1.16 to 2.23) compared with those with lower perceived risk. Trust in health care provider was high (83% [535]) but was not associated with CVD or CVD risk factors.

CONCLUSION

In this community sample of AAs in Minnesota, CVD risk factors were high, as was trust in health care providers. Those with greater CVD risk perceptions had higher CVD prevalence. Consideration of sociodemographic and psychosocial influences on CVD and CVD risk factors could inform development of effective cardiovascular health promotion interventions in the AA Minnesota community.

Minnesota COVID-19 Lockdowns - The Effect on Acute Myocardial Infarctions and Revascularizations in the Community

Objective

To study associations between the Minnesota coronavirus disease 2019 (COVID-19) mitigation strategies on incidence rates of acute myocardial infarction (MI) or revascularization among residents of Southeast Minnesota.

Methods

Using the Rochester Epidemiology Project, all adult residents of a nine-county region of Southeast Minnesota who had an incident MI or revascularization between January 1, 2015, and December 31, 2020, were identified. Events were defined as primary in-patient diagnosis of MI or undergoing revascularization. We estimated age- and sex-standardized incidence rates and incidence rate ratios (IRRs) stratified by key factors, comparing 2020 to 2015–2019. We also calculated IRRs by periods corresponding to Minnesota’s COVID-19 mitigation timeline: “Pre-lockdown” (January 1–March 11, 2020), “First lockdown” (March 12–May 31, 2020), “Between lockdowns” (June 1–November 20, 2020), and “Second lockdown” (November 21–December 31, 2020).

Results

The incidence rate in 2020 was 32% lower than in 2015–2019 (24 vs 36 events/100,000 person-months; IRR, 0.68; 95% CI, 0.62-0.74). Incidence rates were lower in 2020 versus 2015–2019 during the first lockdown (IRR, 0.54; 95% CI, 0.44-0.66), in between lockdowns (IRR, 0.70; 95% CI, 0.61-0.79), and during the second lockdown (IRR, 0.54; 95% CI, 0.41-0.72). April had the lowest IRR (IRR 0.48; 95% CI, 0.34-0.68), followed by August (IRR, 0.55; 95% CI, 0.40-0.76) and December (IRR, 0.56; 95% CI, 0.41-0.77). Similar declines were observed across sex and all age groups, and in both urban and rural residents.

Conclusion

Mitigation measures for COVID-19 were associated with a reduction in hospitalizations for acute MI and revascularization in Southeast Minnesota. The reduction was most pronounced during the lockdown periods but persisted between lockdowns.

Improving the enrollment of women and racially/ethnically diverse populations in cardiovascular clinical trials: An ASPC practice statement

Cardiovascular disease (CVD) remains the leading cause of death for both women and men worldwide. In the United States (U.S.), there are significant disparities in cardiovascular risk factors and CVD outcomes among racial and ethnic minority populations, some of whom have the highest U.S. CVD incidence and mortality. Despite this, women and racial/ethnic minority populations remain underrepresented in cardiovascular clinical trials, relative to their disease burden and population percentage. The lack of diverse participants in trials is not only a moral and ethical issue, but a scientific concern, as it can limit application of future therapies. Providing comprehensive demographic data by sex and race/ethnicity and increasing representation of diverse participants into clinical trials are essential in assessing accurate drug response, safety and efficacy information. Additionally, diversifying investigators and clinical trial staff may assist with connecting to the language, customs, and beliefs of study populations and increase recruitment of participants from diverse backgrounds. In this review, a working group for the American Society for Preventive Cardiology (ASPC) reviewed the literature regarding the inclusion of women and individuals of diverse backgrounds into cardiovascular clinical trials, focusing on prevention, and provided recommendations of best practices for improving enrollment to be more representative of the U.S. society into trials.

Improvements in Diet and Physical Activity-Related Psychosocial Factors Among African Americans Using a Mobile Health Lifestyle Intervention to Promote Cardiovascular Health: The FAITH! (Fostering African American Improvement in Total Health) App Pilot Study

BACKGROUND

African Americans continue to have suboptimal cardiovascular health (CVH) related to diet and physical activity (PA) behaviors compared with White people. Mobile health (mHealth) interventions are innovative platforms to improve diet and PA and have the potential to mitigate these disparities. However, these are understudied among African Americans.

OBJECTIVE

This study aims to examine whether an mHealth lifestyle intervention is associated with improved diet and PA-related psychosocial factors in African Americans and whether these changes correlate with diet and PA behavioral change.

METHODS

This study is a retrospective analysis evaluating changes in diet and PA-related self-regulation, social support, perceived barriers, and CVH behaviors (daily fruit and vegetable intake and moderate-intensity PA [MPA] per week) in 45 African American adults (mean age 48.7 years, SD 12.9 years; 33/45, 73% women) enrolled in the FAITH! (Fostering African American Improvement in Total Health) app pilot study. The intervention is a 10-week, behavioral theory-informed, community-based mHealth lifestyle intervention delivered through a mobile app platform. Participants engaged with 3 core FAITH! app features: multimedia education modules focused on CVH with self-assessments of CVH knowledge, self-monitoring of daily fruit and vegetable intake and PA, and a sharing board for social networking. Changes in self-reported diet and PA-related self-regulation, social support, perceived barriers, and CVH behaviors were assessed by electronic surveys collected at baseline and 28 weeks postintervention. Changes in diet and PA-related psychosocial factors from pre- to postintervention were assessed using paired 2-tailed t tests. The association of changes in diet and PA-related psychosocial variables with daily fruit and vegetable intake and MPA per week was assessed using Spearman correlation. Associations between baseline and 28-week postintervention changes in diet and PA-related psychosocial measures and CVH behaviors with covariates were assessed by multivariable linear regression.

RESULTS

Participants reported improvements in 2 subscales of diet self-regulation (decrease fat and calorie intake, P=.01 and nutrition tracking, P<.001), one subscale of social support for healthy diet (friend discouragement, P=.001), perceived barriers to healthy diet (P<.001), and daily fruit and vegetable intake (P<.001). Improvements in diet self-regulation (increase fruit, vegetable, and grain intake, and nutrition tracking) and social support for healthy diet (friend encouragement) had moderate positive correlations with daily fruit and vegetable intake (r=0.46, r=0.34, and r=0.43, respectively). A moderate negative correlation was observed between perceived barriers to healthy diet and daily fruit and vegetable intake (r=-0.25). Participants reported increases in PA self-regulation (P<.001). Increase in social support subscales for PA (family and friend participation) had a moderate positive correlation with MPA per week (r=0.51 and r=0.61, respectively).

CONCLUSIONS

Our findings highlight key diet and PA-related psychosocial factors to target in future mHealth lifestyle interventions aimed at promoting CVH in African Americans.

A Review of Disparities in Cardiac Rehabilitation: EVIDENCE, DRIVERS, AND SOLUTIONS

PURPOSE

Cardiac rehabilitation (CR) has been shown to improve functional status, quality of life, and recurrent cardiovascular disease (CVD) events. Despite its demonstrated compelling benefits and guideline recommendation, CR is underutilized, and there are significant disparities in CR utilization particularly by race, ethnicity, sex, and socioeconomic status. The purpose of this review is to summarize the evidence and drivers of these disparities and recommend potential solutions.

METHODS

In this review, key studies documenting disparities in CR referrals, enrollment, and completion are discussed. Additionally, potential mechanisms for these disparities are summarized and strategies are reviewed for addressing them.

SUMMARY

There is a wealth of literature demonstrating disparities among racial and ethnic minorities, women, those with lower income and education attainment, and those living in rural and dense urban areas. However, there was minimal focus on how the social determinants of health contribute to the observed disparities in CR utilization in many of the studies reviewed. Interventions such as automatic referrals, inpatient liaisons, mitigation of economic barriers, novel delivery mechanisms, community partnerships, and health equity metrics to incentivize health care organizations to reduce care disparities are potential solutions.

Association of body image dissatisfaction, behavioral responses for healthy eating, and cardiovascular health in African-American women with overweight or obesity: A preliminary study

BACKGROUND

African-American (AA) women have the lowest prevalence of ideal categorizations of diet and body mass index (BMI), as defined by the American Heart Association (AHA) Life's Simple 7 (LS7) cardiovascular health (CVH) components compared to other racial/ethnic groups, regardless of sex/gender. There is limited research exploring the interplay of unique psychosocial influences on CVH such as body image dissatisfaction (BID) and behavioral responses for healthy eating among AA women with overweight or obesity.

OBJECTIVE

This study aimed to assess the association of BID with behavioral responses for healthy eating and LS7 components.

METHODS

A cross-sectional analysis of baseline data was conducted among 32 AA women with overweight or obesity from a larger, community-based participatory research study. Self-reported measures were used to assess BID and behavioral responses to healthy eating (diet self-regulation to reduce fat or caloric intake and motivation for healthy eating [intrinsic motivation and integrated regulation]) using previously validated instruments. The LS7 components (e.g., BMI, diet, etc.) and composite score were evaluated using the AHA LS7 metrics rubric.

RESULTS

Women with no or lower BID had greater diet self-regulation to reduce fat or caloric intake (mean, 3.5 vs 3.0; P=.05), intrinsic motivation for healthy eating (mean, 5.3 vs 4.2; P=.01), and integrated regulation for healthy eating (mean, 5.3 vs 3.7; P=.002) than those with higher BID. These significant differences remained after adjustment for BMI. Women with higher BID had a higher proportion of BMI within the obesity range compared with those with no or lower BID (94.4% vs 57.1%, P=.03). BID was not significantly associated with other LS7 components or composite score.

CONCLUSION

BID and other psychosocial influences for healthy eating are potential targets for culturally tailored lifestyle interventions among AA women.

Health Care Delivery Interventions for Hypertension Management in Underserved Populations in the United States: A Systematic Review

[Figure: see text].

Recommendations for Health Equity and Virtual Care Arising From the COVID-19 Pandemic: Narrative Review

BACKGROUND

The COVID-19 health crisis has disproportionately impacted populations who have been historically marginalized in health care and public health, including low-income and racial and ethnic minority groups. Members of marginalized communities experience undue barriers to accessing health care through virtual care technologies, which have become the primary mode of ambulatory health care delivery during the COVID-19 pandemic. Insights generated during the COVID-19 pandemic can inform strategies to promote health equity in virtual care now and in the future.

OBJECTIVE

The aim of this study is to generate insights arising from literature that was published in direct response to the widespread use of virtual care during the COVID-19 pandemic, and had a primary focus on providing recommendations for promoting health equity in the delivery of virtual care.

METHODS

We conducted a narrative review of literature on health equity and virtual care during the COVID-19 pandemic published in 2020, describing strategies that have been proposed in the literature at three levels: (1) policy and government, (2) organizations and health systems, and (3) communities and patients.

RESULTS

We highlight three strategies for promoting health equity through virtual care that have been underaddressed in this literature: (1) simplifying complex interfaces and workflows, (2) using supportive intermediaries, and (3) creating mechanisms through which marginalized community members can provide immediate input into the planning and delivery of virtual care.

CONCLUSIONS

We conclude by outlining three areas of work that are required to ensure that virtual care is employed in ways that are equity enhancing in a post-COVID-19 reality.

Establishing a SARS-CoV-2 (COVID-19) Drive-Through Collection Site: A Community-Based Participatory Research Partnership With a Federally Qualified Health Center

The COVID-19 pandemic has disproportionately affected underserved and minority populations in the United States. This is partially attributable to limited access to diagnostic testing from deeply rooted structural inequities precipitating higher infection and mortality rates. We describe the process of establishing a drive-through collection site by leveraging an academic-community partnership between a medical institution and a federally qualified health center in Minnesota. Over 10 weeks, 2006 COVID-19 tests were provided to a socioeconomically disadvantaged population of racial/ethnic minorities and low-income essential workers.

Emergency Preparedness and Risk Communication Among African American Churches: Leveraging a Community-Based Participatory Research Partnership COVID-19 Initiative

The coronavirus disease 2019 (COVID-19) crisis has disproportionately affected the African American population. To mitigate the disparities, we deployed an emergency preparedness strategy within an existing community-based participatory research (CBPR) partnership among African American churches to disseminate accurate COVID-19 information. We used the Centers for Disease Control and Prevention Crisis and Emergency Risk Communication framework to conduct a needs assessment, distribute emergency preparedness manuals, and deliver COVID-19–related messaging among African American churches via electronic communication platforms. A needs assessment showed that the top 3 church emergency resource needs were financial support, food and utilities, and COVID-19 health information. During an 8-week period (April 3–May 31, 2020), we equipped 120 churches with emergency preparedness manuals and delivered 230 messages via social media (Facebook) and email. For reach, we estimated that 6,539 unique persons viewed content on the Facebook page, and for engagement, we found 1,260 interactions (eg, likes, loves, comments, shares, video views, post clicks). Emails from community communication leaders reached an estimated 12,000 church members. CBPR partnerships can be effectively leveraged to promote emergency preparedness and communicate risk among under-resourced communities during a pandemic.

A Cardiovascular Health and Wellness Mobile Health Intervention Among Church-Going African Americans: Formative Evaluation of the FAITH! App

BACKGROUND

In light of the scarcity of culturally tailored mobile health (mHealth) lifestyle interventions for African Americans, we designed and pilot tested the Fostering African-American Improvement in Total Health (FAITH!) App in a community-based participatory research partnership with African American churches to promote cardiovascular health and wellness in this population.

OBJECTIVE

This report presents the results of a formative evaluation of the FAITH! App from participants in an intervention pilot study.

METHODS

We included 2 semistructured focus groups (n=4 and n=5) to explore participants' views on app functionality, utility, and satisfaction as well as its impact on healthy lifestyle change. Sessions were audio-recorded and transcribed verbatim, and qualitative data were analyzed by using general inductive analysis to generate themes.

RESULTS

In total, 6 overarching themes emerged among the 9 participants: overall impression, content usefulness, formatting, implementation, impact, and suggestions for improvement. Underpinning the themes was a high level of agreement that the intervention facilitated healthy behavioral change through cultural tailoring, multimedia education modules, and social networking. Suggestions for improvement were streamlining the app self-monitoring features, prompts to encourage app use, and personalization based on individuals' cardiovascular risk.

CONCLUSIONS

This formative evaluation found that the FAITH! App had high reported satisfaction and impact on the health-promoting behaviors of African Americans, thereby improving their overall cardiovascular health. Further development and testing of the app among African Americans is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03084822; https://clinicaltrials.gov/ct2/show/NCT03084822.