WASHINGTON -- It's possible to get people in economically disadvantaged areas to make lifestyle changes that reduce their risk of heart disease -- if they're given a voice in the process as well as the right tools to make a difference, a speaker said here.
"Lifestyle change can reduce CVD [cardiovascular disease] risk by 44%," said Debra Moser, PhD, RN, chair of nursing at the University of Kentucky College of Nursing in Lexington. "But it's most effective when people are given the tools to engage in self-care ... When people have the opportunities, the skills, the knowledge, and the reduction in barriers to engage in self-care, it's the perfect solution to CVD reduction."
Moser and colleagues set out to improve the health of residents in medically underserved rural Kentucky. This part of the state, in the Appalachian Mountains, "has the county with the worst life expectancy in the U.S.; it's worse than many Third World countries," Moser said. "Appalachian Kentucky is in the top 1% of the nation in CVD morbidity and mortality."
And there were additional challenges. The residents had been burned by research teams before; "researchers would go there, do research, get their findings and leave, and never come back," Moser said. To regain their trust, "we spent a lot of time with focus groups, community members, including people in the target population, care providers, and community leaders ... to help us design the study to be most appropriate. It was not the study I originally designed, so I am so happy we did this." They also organized an advisory board made up of members of those same groups of stakeholders; the group attended monthly research meetings and talked about the study's successes, problems, and barriers.
To recruit patients for the study, the researchers advertised in newspapers as well as in beauty shops, convenience stores, gas stations, senior centers, courthouses, and on local radio and TV stations. "When you're from such a small community, everybody knows everybody" and word gets around very quickly, said Wayne Noble, who underwent 3 days of training to become a community health worker on the project.
The goal of the study was to compare 4-month and 1-year impacts of the study intervention on CVD risk factors selected by the patients, which included tobacco use, lipid profile, blood pressure, HbA1c levels in diabetes patients, BMI, depressive symptoms, and physical activity level.
A total of 352 people were enrolled in the study. At baseline, patients randomized to the control and intervention groups had similar demographic characteristics: mean age in the control group was 43.2 versus 42.6 in the intervention group; 75% of control group patients were female compared with 79.3% in the intervention group; and the control group had a mean 13.5 years of formal education compared with 13.6 for the intervention group. Nearly 100% of participants in both groups were white.
In terms of health characteristics, 45.2% of control group participants were smokers (as measured by urinary cotinine) compared with 38.6% of intervention group participants; the average BMI was 31 in the control group and 32 in the intervention group; and the mean Framingham risk score was 9.4 in the control group and 9.3 in the intervention group. Total cholesterol was 185.7 in the control group and 191.3 in the intervention group.
During the study, 168 were randomized to usual care, while the other 184 patients received usual care plus six interactive modules on topics such as nutrition, physical activity, depression control and stress reduction, smoking cessation, and medication adherence. The modules were delivered during in-person sessions with community health workers over a 12-week period; sessions were designed to be culturally sensitive, individualized, and to incorporate specific behavior change principles. A total of 290 patients completed the study, 138 in the control group and 152 in the intervention group.
"As an illustration of some of the power of these interventions that seem simple ... At one session, everybody in the group had never tasted anything made out of whole wheat, and they didn't want to taste anything made out of whole wheat because it tastes crappy, but Wayne made a soup that had whole-wheat pasta, and they were all shocked and amazed at how good it was and really wanted to get the recipe," said Moser. "We did a bigger engagement at all of these levels to get people to become interested in lifestyle change." In one group of patients, a man took charge and had everyone exercise with him -- "they would go walk up the hill at City Hall -- this big killer hill -- and walk back down ... All of the people in this area are really interested in their health and the health of their family members if given the opportunity."
At 1 year, a greater proportion of patients in the intervention group met the CVD risk reduction goals in most categories compared with patients receiving usual care, Moser said. For example, 36% of intervention group participants met their body weight goals compared with 9% of usual care group members; 65% of intervention participants met physical activity goals compared with 35% of the control group; and 88% of intervention patients met blood pressure goals compared with 18% of control group patients.
Also at 1 year, the average Framingham risk score among intervention group participants dropped from 9.4 to 7.7, while the score among those in the control group rose, from 9.8 to 10.8, a difference that was statistically significant. Similarly, systolic blood pressure among control group members dropped from a mean of 137.5 to 128.4, while the mean in the control group fell from 138.3 to 136.9.
"We think interventions that really focus on CVD risk reduction and self-care, and that are derived from collaboration with the community of interest, are really effective in medically underserved and socioeconomically distressed areas," Moser concluded.