Residents of rural America are dying at a higher rate from cardiovascular disease and stroke than their counterparts in urban areas, a gap that has widened in the past decade. It is one reason why life expectancy among rural residents, on average, is three years less than among urban populations.
In February, the American Heart Association (AHA) issued a call to action, published in the medical journal Circulation. “Addressing the unique health needs of people in rural America is critical to the American Heart Association’s mission to create a world of longer, healthier lives,” said Dr. Robert Califf, a lead author of the policy statement and a former Food and Drug Administration commissioner.
The AHA grouped the underlying causes of poor cardiovascular health in rural America into three categories:
- Individual factors, such as higher rates of diabetes, obesity, hypertension, and smoking;
- Social determinants of health, such as lower incomes, lower educational attainment, poor quality housing, limited access to fresh food, and challenges affording or finding transportation; and
- Healthcare delivery factors, including distant hospitals, physician shortages, and lack of medical insurance.
The AHA is calling on “healthcare and other stakeholders at the local, state, and national levels to collaborate in efforts to address the needs of rural populations.” The association itself has several actions it can take, such as ensuring its advocacy and programs are attuned to rural concerns, says Dr. Karen Joynt Maddox, a cardiologist and co-director of the Center for Health Economics and Policy at Washington University’s Institute for Public Health. Maddox served on the committee that wrote the AHA’s call to action.
For example, the AHA partners with many organizations to provide or enhance cardiopulmonary resuscitation (CPR) training and other kinds of heart health training. “It is easy to partner with a big urban academic center but partnering with someone in rural Appalachia may be just as important,” says Maddox.
The AHA is also calling for more scientific research to identify innovative approaches to bolster rural health. One example of such research occurred in Appalachian Kentucky, where researchers from the University of Kentucky tested a novel intervention to reduce the risk of cardiovascular disease. They published the results in 2019.
“The thing that I particularly liked about that study is that it tried to capitalize on the unique strength of rural areas: the community,” says Maddox.
The researchers hired community health workers (CHWs) to recruit study participants from eastern Appalachian Kentucky, a 54-county region with extreme health disparities. The counties “have the highest rates of multiple cardiovascular disease risk factors in the country,” says Debra Moser, professor of cardiovascular nursing at the University of Kentucky, College of Nursing and director of its RICH Heart Program. The CHWs recruited at health fairs, agricultural extension offices, community and senior centers, local businesses, and churches. Advertisements were placed on radio, TV, and in local newspapers.
The study was open to people who lacked a primary care physician and were at risk for cardiovascular disease. A total of 355 individuals were enrolled, and 82 percent stuck with the study through the end.
Participants completed baseline questionnaires and physical assessments and then were randomly assigned one of two options: a referral to free or low cost primary care for management of heart disease risk or to the intervention called Heart Health. The aim of Heart Health, designed with input from a community advisory board that included CHWs, local business people, a senior center director, a local physician, and laypeople from the area, was to help participants make lifestyle changes that research has shown can dramatically reduce risk for cardiovascular disease.
Participants in the intervention arm of the study met with a community health worker in groups of fewer than 10 people every two weeks for 12 weeks. Each two-hour meeting focused on a different aspect of self-care, such as nutrition, physical activity, stress reduction and depression management, and smoking cessation, if appropriate.
“We thought offering people an intervention that engages them in self-care and that is delivered by people in their community would be really well accepted and would be effective,” says Moser.
Community health workers live in the communities they serve. They go to church there, they shop there, and they have developed a level of trust with residents, says Wayne Noble, one of the CHWs involved in the study and a clinical research protocol manager at the University of Kentucky’s Center of Excellence in Rural Health. “They have built these relationships through time,” he said.
The study results supported Moser’s hypothesis. At the four-month mark, the researchers found that blood pressure, total cholesterol, high-density lipoprotein, body mass index, depressive symptoms, and the number of steps walked per day showed significant improvements in Heart Health participants compared to the group referred to a primary care physician. At twelve months, the improvements were still holding.
“Increasing activity levels to at least 30 minutes a day has a huge impact on decreasing cardiovascular risk. Improving blood pressure does, too, as does decreasing depression,” says Moser. “So these were not just statistically significant. They were clinically important.”
But Moser says programs like Heart Health are all too rare in rural America. She states the program could be replicated in other communities and at low cost and that her team would be happy to share the Heart Health protocol with other rural areas in the country, which could adapt it to local concerns and conditions.
“If you teach people how to better manage their own health using methods that are engaging instead of just telling them and if you start off working with the community, then you will have success,” says Moser.
For example, some Heart Health participants said they did not like whole wheat, says Noble. So the group made homemade low-sodium chicken soup with whole wheat pasta, and none was left, says Noble. “They realized that using healthy ingredients could actually taste good.” Cooking together or demonstrating exercises works much better than simply handing out healthy recipes or telling people to increase their activity level, he says.
In addition, meeting in groups was vitally important, says Moser. “We actually had groups that would go out and walk together after we were done teaching,” she says. “Groups are a great source of support and also social pressure.”
In a second study, Moser and her colleagues are testing the Heart Health intervention in caregivers of family members with chronic illness. Caregivers have a much higher incidence of cardiovascular disease than people who are not caregivers, she says.
In addition, HomePlace—which delivers health care to the uninsured and underinsured in Hazard, Kentucky and whose community health workers participated in the original study—has adopted the Heart Health intervention and is delivering it to people in the community. A senior center in Appalachian Kentucky is also using it.
“It didn’t die with the end of our study,” says Moser. “And we are wanting to work with the community there to leave it in other places in the future.”