Improving Health, Changing Lives: Communities Taking Action

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Originally published by the National Heart, Lung, and Blood Institute (NIH Publication No. 56-079N). U.S. government work, public domain. Reproduced as archived reference, not current guidance.

National Heart, Lung, and Blood Institute

Improving Health Changing Lives

Communities Taking Action

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

National Institutes of Health

Improving Health Changing Lives Communities Taking Action cov3

National Heart, Lung, and Blood Institute

Table of Contents

5 Making Hearts Healthy in Appalachia

11 America’s Public Health Challenges

15 From the Inside Out Improving Health and Changing Lives in American Communities

25 Communities in Cooperation Sharing and Synergy

37 Hearts n’ Parks Promoting Physical Activity and Heart Healthy Eating in America’s Parks and Recreation Centers

43 A Breath of Fresh Air The NHLBI Asthma Coalitions

Written by Richard Currey.

cov4 Improving Health Changing Lives Communities Taking Action

National Heart, Lung, and Blood Institute

Improving Health Changing Lives

Communities Taking Action

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health National Heart, Lung, and Blood Institute

Administrative Use Only May 2003

A Message From the Director

The National Institutes of Health (NIH)—the Nation’s leading biomedical research institution—is dedicated to innovation and discovery in the medical sciences. From its inception as a single laboratory housed in one building to the present 27 Institutes and Centers, the NIH has never changed its fundamental mission to support and further medical science with the goal of improving health.

In meeting today’s health challenges, NIH makes delivery of the news of its research results a critical part of its efforts to inform the American people who supported the work and stand to gain from the benefits.

Improving Health, Changing Lives: Communities Taking Action offers stories of communities touched and transformed by the results of NIH research. In innovative community-based initiatives that embrace outreach, education, motivation, and mobilization, these stories show how the best tools of medical science bring new hope to diverse communities.

Bringing research results to people in the most effective way remains a vital task. The vigorous community-based programs described here help make the benefits of research a reality for every American community. At the local and regional level, powerful partnerships for health are created and sustained, enabling scientific discovery to improve health, reduce burdens of disease, empower Americans—and better quality of life for more Americans.

Elias A. Zerhouni, M.D.

Director National Institutes of Health

Foreword

For more than a half century, The National Heart, Lung, and Blood Institute (NHLBI) has led the way in the fight against diseases of the heart, lungs, and blood, and sleep disorders. But as understandings of disease deepened, another critical issue emerged: the need to take the fruits of research to the people—to translate medical science into real health benefits for every American.

Many Americans do not enjoy the health improvements that science-based information can offer. We know a great deal about how to prevent and treat these diseases and every American could benefit from this information. The problem is that this information is not being fully utilized.

Improving Health, Changing Lives: Communities Taking Action offers portraits of high-risk communities throughout the country, which are committed to better utilization of NHLBI science-based information to eliminate health disparities and increase the quality and years of healthy life. From school-based outreach and faith-based initiatives, to the work of health care providers in small and large clinics and hospitals, partnerships are emerging and thriving. Whether the promotores of Texas or community health representatives at Laguna Pueblo in New Mexico or the lay health workers of the Mississippi River Delta, these individuals stand at the center of some of the most effective health campaigns now at work in America.

NHLBI’s logo, “People – Science – Health,” exemplifies this effort, characterizing a broad range of community-based programs designed to reduce risk, improve health and quality of life, and limit the costly economic and personal burdens of disease.

Claude Lenfant, M.D.

Director National Heart, Lung, and Blood Institute National Institutes of Health

HeartsHealthy

in Appalachia

In the coalfields of southern West Virginia health risks abound.

The local population tends to smoke (with smoking and other tobacco use often starting in early adolescence), tends to be overweight or obese, and currently endures unacceptable rates of high blood pressure, heart disease, and diabetes. In the only State lying fully within Appalachia (where cardiovascular mortality stands second highest in the United States), unemployment hovers well above the national average and access to physicians and other health care professionals is frequently difficult, if not impossible.

In a place like southern West Virginia, children are often the first victims of the problems their region faces. For example, 5th graders in the rural counties surrounding the cities of Huntington and Charleston have elevated cholesterol and blood pressure levels compared with their peers from other parts of the country. And more than one-quarter of school-age children in West Virginia are overweight or obese—a key risk factor for the development of cardiovascular disease (CVD) and diabetes.

Although ample research confirms that the risks of CVD and other chronic illnesses can now be limited

• or even prevented entirely—the people of West Virginia have often been deprived of this knowledge and its benefits by geographical isolation, poverty, and limited educational

resources. Like Americans in similar situations, including American Indians and Alaska Natives, African Americans, and Hispanics, the need for the good news from our nation’s research laboratories is pressing. But getting health messages to Americans is no simple matter: information with the potential to improve thousands of lives must be “translated” from research and scientific publications into clear and understandable messages. And, after that, those messages must be effectively disseminated, in culturally sensitive ways, using a wide array of media in order to reach the greatest number possible.

Is there a way to get the word out in a place like rural West Virginia? Definitely, says Pat White, M.P.A., M.P.H., administrator of West Virginia Health Right, the oldest

Improving Health

free clinic system in the State and the site of a National Heart, Lung, and Blood Institute (NHLBI) supported effort, The Healthy

found help in making those changes in The Healthy Heart Project with its group sessions devoted to weight loss, diabetes, high blood pressure, Heart Project. An NHLBI Enhanced and physical activity—even line

Dissemination and Utilization Center, or EDUC, The Healthy Heart Project is one of 12 such innovative programs nationwide. Funded by NHLBI to conduct outreach and education in promoting

dancing and heart healthy cooking. All of this is an effort to compare outcomes between patients receiving education and medical treatment versus those who receive medical treatment alone. Participants in the heart healthy behavior, The Healthy education group learn about risk

Heart Project is “a different kind of animal from what NHLBI has funded in the past,” according to

factors and the personal behaviors that will make a difference. “We’ve had patients successfully quit

Is there a way to get the word out in a place like rural West Virginia?

Ms. White. “We’re not an academic smoking, get their blood sugar levels center or a tertiary care center—and under control, and lose weight,” our patients are the impoverished says Ms. White. “And our cooking and the uninsured. We were already classes show folks that preparing bringing health education into the low-fat, low-calorie meals at home center of our work, so the opportu- is not as time-consuming or expen-

nity to become an NHLBI EDUC fits nicely with our programs. But NHLBI’s support has enabled us to

sive as they might have thought— and they are surprised to learn that the food tastes good, too.” move to another level, to expand services, and to establish specific Ms. White hopes The Healthy Heart support and training groups.” Project will support the roles of outreach and education as valid Retired coal miner Charlie Riddle, methods for reducing cardiovascular a Healthy Heart Project participant, risk. “It’s very exciting,” she says, knew his health was in trouble. “I “because we’re seeing evidence that had picked up quite a bit of weight, we can reduce risk as we limit

my cholesterol was at dangerous levels, my triglycerides were out of whack—I was a wreck. I knew I had to make changes.” Mr. Riddle

people’s dependencies on the health care system. And, of course, this is not just an effort that looks at individual patients. It’s all about the

6 Improving Health Changing Lives Communities Taking Action

larger system of care for the uninsured and underinsured poor who have no other resources. And, so far, the outlook for change is excellent.”

As The Healthy Heart Project makes progress with West Virginia adults, another NHLBI EDUC targets the State’s children. Shari Wiley, R.N., F.N.P., a nurse practitioner based at St. Mary’s Hospital in Huntington, West Virginia, heads HEART (Helping Educators Attack Cardiovascular Risk Factors Together). A schoolbased program that launched in April 2001, HEART targets more than 8,000 children in the 3rd, 4th, and 5th grades in 40 public schools in three counties along West Virginia's southern border with Kentucky. HEART is all about bringing the news of CVD risk to children and their families—along with, most importantly, ways to fix the problem.

Ms. Wiley and her colleagues distributed an NHLBI pamphlet called Eating With Your Heart In Mind during HEART’s first school-based screenings in 2001. Recalling a moment with a boy during a cholesterol screening, Ms. Wiley said he talked about sharing Eating With Your Heart In Mind with his mother, asking her to try some of the pamphlet’s heart healthy tips and recipes. “These kids have become very serious about their cholesterol,”

A Healthy Heart Project group session on diabetes.

Ms. Wiley says. “We’re seeing that bringing the health message into schools really excites and motivates children. And long before many of the other influences in their lives begin to weigh against healthy choices.”

Ms. Wiley described a new HEART- YMCA partnership in Huntington, West Virginia. “We’re piloting this intervention in five elementary schools that are in walking distance of the Y, with around 25 kids involved in the pilot. One mother told us how much trouble she’d had motivating her daughter to exercise. Her daughter was part of our YMCA partnership—and she’s now

a regular exerciser, she pushes her family to take walks together, she signed up for swimming lessons at

the West Virginia Rural Health Education Partnerships, but targeted only 5th graders in two counties the Y, and went out for basketball— of the southern border area. and made the team! And the won- HEART’s catchment area, with its derful thing is that we’re seeing this broad-based NHLBI mandate, kind of change in many children, included three border counties and not just rare individuals.” spanned 3rd through 5th grades.

In an example of community-based

Another HEART partnership includes a collaboration with the West Virginia CARDIAC Project (Coronary Artery Risk Detection

synergy at work, HEART and The CARDIAC Project linked forces. Dr. Neal continues to perform screenings in those counties where in Appalachian Communities), led he has established relationships by William Neal, M.D., a West with schools and teachers—but Virginia University-based pediatric thanks to HEART’s role as an cardiologist. The CARDIAC NHLBI EDUC the screenings now Project had been operating in the include three grade levels. And State since 1998 with support from children, teachers, and parents

Improving Health Changing Lives Communities Taking Action 7

Footprints painted on the walking course at Spring Hill Elementary School, Huntington, West Virginia.

can avail themselves of HEART’s expanded program offerings, materials, activities, in-service trainings, and exercise sessions.

In the 2001 school year HEART screened nearly 800 children (and 1,400 in the 2002 school year), revealing a startling fact: more than half of the children screened had either borderline elevated or elevated cholesterol, and were at risk for overweight and obesity. “In addressing these issues,” Ms. Wiley says, “part of our initiative is an exercise program called the Feelin’ Good Mileage Club. We’ve got children and their parents walking for health in a voluntary program. Through outreach efforts and information shared by our health care providers and classroom teachers, children learn not simply that exercise is Twhygood for us but it is.”

he results so far? More than 2,000 of Appalachia’s at-risk children have collectively walked more than 10,000 miles. Some schools have actually built outdoor tracks to support this effort. “25 Mile Clubs” have been created which give children awards and prizes for every 25 miles walked. Teachers have been transformed into health

8 Improving Health Changing Lives Communities Taking Action

ambassadors. Families are finding that health-promoting change is not

Teachers have been transformed into health

only possible, but also fun. And

ambassadors. Families are finding that West Virginia University is now health-promoting change is not only possible, considering support that will bring

the program to every county in

but also fun.

the State.

Other HEART strategies include grade-appropriate classroom curricula on heart disease, nutrition, exercise, and the risks of tobacco use. Outreach to parents promotes the same information and attitudes, and teachers receive regular inservice programs to expand their skills in teaching health and healthy lifestyles.

And as HEART makes headway with the children of West Virginia, The Healthy Heart Project points the way for the State’s at-risk adults in its group sessions devoted to exercise, blood sugar control, diet, and blood pressure. The word about cardiovascular risk is reaching West Virginians, young and old, as community-based partnerships work together to encourage people to make life changes. As people demonstrate through weight loss, increased activity, and reduction of risk factors that science can be effectively translated into authentic health benefits—and that education motivates change—The Healthy Heart Project and HEART are working examples of risk reduction and health improvement in the real world, at a time when many Americans need it most. 

Improving Health Changing Lives Communities Taking Action 9

America’s

Public Health

Challenges

The health of Americans has never been better. Although many factors have contributed to this—including new understandings of the biology of human health—much of the credit goes to public health and its longstanding emphasis on disease prevention. Improvements in housing, nutrition, and sanitation, particularly since 1900, helped

Americans become more resistant to disease and to live longer, healthier, more productive lives. Life expectancy, itself a key indicator of general health improvement, has seen a greater increase over the last 100 years than at any point in recorded history.

Screening for high blood pressure in an Arkansas Delta church.

But the revolution in Indeed, chronic illness is the critical

public health—while standing among our most enduring and significant social

health challenge of this new century. As heart disease and stroke remain the first and third leading causes of death in the U.S., control of key achievements—brought unexpected risk factors like blood pressure or challenges. As American life spans cholesterol levels, particularly grew longer, new patterns in disease among older Americans, is less than and mortality have emerged. Where optimal. Teenage smoking is on the hunger and malnutrition ravaged increase. Overweight and obesity our populations in 1903, epidemics along with high levels of physical

of overweight and obesity now plague us in 2003. Acute medical conditions were the primary cause of illness and death in 1903, but

inactivity is on the rise. And there are striking geographic variations in heart disease and stroke death rates, as certain racial and ethnic minority chronic ailments are now responsible groups continue to be disproporfor our most serious health concerns. tionately affected.

Improving Health Changing Lives Communities Taking Action 11

And while chronic illnesses are the

FACTS

most prevalent and costly of the

Fact: Heart disease is the number one killer of Americans, and the leading cause of death in women over the age of 40. Yet science tells us that preventive activities—

nation’s health burdens, these illnesses are also the most preventable —sounding a clarion call to action for America’s health institutions and agencies. cost-effective personal behaviors— will sharply reduce the risk of heart The NHLBI brings an investment in disease. research that now spans more than 50 years. With science-based data confirming that risk factors for car- Fact: Asthma is the most diovascular and respiratory diseases common cause of school absences can be addressed at the individual as well as the most common cause level, the job now is to take that of pediatric hospital admissions message to Americans. People can nationwide. Yet research has demonstop smoking, get more exercise, strated that much of the burden of improve their diets, and lose weight, asthma can be mitigated through but they need to know about these personal behaviors. strategies. And, with knowing, that enacting these strategies will make Fact: Obesity is epidemic in the positive differences in their lives. United States, with approximately 122 million overweight and obese One of the 27 Institutes and Centers adults and almost 9 million overwithin the National Institutes of weight children and adolescents. Health (NIH), NHLBI is a key

Most surveyed Americans are aware of this national problem—but are less clear on what to do about it.

Federal agency charged in the national campaign to address the major chronic diseases facing

Americans today. Responsible for

Fact: 60% of American adults do not get enough physical activity and more than 25% are not active at all. Again, a majority of surveyed Americans recognize the problem, but not how to address it.

research into diseases of the heart, blood vessels, lungs, and blood as well as sleep disorders, NHLBI also provides leadership and resources for a number of programs that educate the American public about these diseases.

NHLBI seeks solutions—and an end—to the geographic, racial, cultural, and ethnic disparities

12 Improving Health Changing Lives Communities Taking Action

in CVD in the United States. By partnering with concerned community members and groups that deal with these health challenges on a daily basis, a broad-based and far-reaching program of NHLBIsponsored community-based initiatives has come into being.

Taking the Message to Americans

On June 20, 2002, President Bush unveiled his administration’s HealthierUS Initiative. As he emphasized that “every little bit counts,” the President encouraged Americans to do what they can to be more active in their daily lives.

The President offered a four-point challenge to the nation:

 Be physically active every single day. The evidence is clear and abundant: regular physical activity at virtually any level is critically important throughout life. Active lifestyles help to avoid the changes traditionally associated with aging and reduce the impact that high blood pressure, heart disease, and diabetes can have in much younger individuals.

 Eat a nutritious diet. Only 25 percent of American adults and less than 20 percent of younger people eat the recommended servings of

fruits and vegetables each day— and well over half of the nation’s children and teens consume excess saturated fat.

 Participate in preventive health screenings. Periodic screenings help to detect health problems early, often when treatment is most effective.

 Make healthy choices by avoiding risky behavior. Tobacco, alcohol, and illicit drug use increase the chances of illness, disability, and premature death.

Secretary of Health and Human Services, Tommy G. Thompson, says, “Focusing on prevention is one of our major goals at HHS,” and is implementing Steps to a HealthierUS to advance the President’s initiative.

Healthy People 2010

Active lifestyles help to avoid the changes traditionally associated with aging and reduce the impact that high blood pressure, heart disease, and diabetes can have in much younger individuals.

Echoing the messages and principles programs, and health communicasounded by the President and the tions) that serve as specific points of Secretary, Healthy People 2010, the departure for NHLBI’s communitycornerstone for planning efforts, based initiatives. serves as the national roadmap to

creating better health. Utilizing 28 focus areas around which outreach campaigns can be implemented, Healthy People 2010 offers several areas (including heart disease and stroke, respiratory diseases, nutrition, overweight, physical activity, access to services and care, education and community-based

NHLBI’s community-based programs are committed to bringing the results of medical research to the public. These efforts span heart disease and stroke, obesity, and asthma, and employ an array of techniques that create and bridge community partnerships in promoting greater knowledge of preventive health and health-enhancing behaviors. Among these are schoolbased initiatives that carry the health message to young people; faith-based projects using churches is intended to achieve two overarching goals: to help people of any age as centers for advancing health and increase life expectancy and improve their quality of life, and to eliminate reducing risk factors; coalitions health disparities among different segments of the population. action networks within towns, offers specific objectives within each focus area, creating a cities, and States, and collaborations template for both implementation and tracking of outcomes, with clearly between communities with medical schools, hospitals, and clinics.  identified targets for improvement in all areas.

Improving Health Changing Lives Communities Taking Action 13

From the

Inside Out

Improving Health and Changing Lives in American Communities

The NHLBI is taking aggressive steps to enhance dissemination and outreach activities, with programs to improve the distribution, reach, and impact of health-enhancing messages. A key opportunity for accomplishing this is through the resources found in communities. Danville, Virginia middle Americans have always held their communities close as source points

school students take a

breather from jumping of their best energies and closest ties, and this tradition is critical to

rope.

the success of NHLBI’s community-based initiatives.

But much remains to be everywhere by activating and done. Many Americans, informing their own voices. In

observed NHLBI Director Claude Lenfant, M.D., do not

helping to transform community members into health advocates, and incorporating culture, lifestyles, enjoy the health improvements that language, and community-based science-based information can offer. values in science-based messages,

“We know a great deal about how to prevent and treat cardiovascular disease and every American could

NHLBI programs empower communities to find and develop health advocates. As new health messengers benefit from this information,” says are discovered—and new partners

Dr. Lenfant. “The problem is that this information is not utilized effectively.”

are identified within communities— heart healthy programs are made and sustained by the communities themselves. The nation’s minority communities have not shared equally in the bene- Meeting Heart Disease fits of America’s investment in scien- Where It Starts tific discovery. NHLBI is meeting these challenges through a dynamic Reaching out to people in at-risk, investment in community resources, low-income, and minority communibringing health messages to people ties, the NHLBI mission is to send

Improving Health Changing Lives Communities Taking Action 15

science-based information about CVD to people who need it most, in forms they can understand and immediately apply in their lives. The NHLBI’s CVD outreach efforts are realized through several initiatives, including the Enhanced Dissemination and Utilization Centers (EDUCs), Hearts N’ Parks, and several programs tailored for minority populations that specifically target the burdens imposed by heart disease and stroke on their communities.

The EDUCs effort is represented by NHLBI partnerships with 12 community-based coalitions. They are synopsized on pages 20-23. The EDUCs target communities where heart disease and stroke death rates stand well in excess of national averages, and are a key element in NHLBI’s response to the Healthy People 2010 objectives, including the elimination of racial and ethnic disparities in disease, and the overall improvement of health care for all Americans. As seen in the dynamic EDUCs of West Virginia, this effort carries unique potential for communicating health messages that make critical differences in reducing the burdens of care and disability on communities, States, and the nation.

Hearts N’ Parks is another potent NHLBI initiative that links the power of community with the fresh energies of exercise programs, new

The Cardiovascular Community Case Manager

I handle case management for individuals who have been in the hospital due to congestive heart failure (CHF). I have a patient who was an emergency department repeater and was frequently admitted to the hospital. With case management he has started weighing himself daily, watching his salt intake, and exercising more. Since then, he’s been admitted to the hospital only once for CHF, his weight is maintained, and he says he’s feeling much better since the program was implemented for him. He lives alone, and always tells me he is so glad that someone is watching out for him who cares about his health.

Another patient of mine weighed 353 pounds when I took her case. I followed her at home and began CHF teaching, stressing the importance of weight loss, limiting salt intake, and so on. She was very interested in trying to make a change, but she had a problem: she couldn’t afford a bathroom scale to monitor her progress. I was able to find a discounted scale for her through a program at Dan River Medical Center. When I took the scale to her, she discovered she’d lost 15 pounds! She says she’s beginning to feel much better with a few dietary changes and the addition of walking to her life. She has started with a short, slow walk—but it’s daily. Hopefully she’ll be walking 1/2 to 1 mile soon. That’s the goal.

Another CHF patient on the case management program lives in an adult home. He suffers with mental retardation and has trouble understanding the need to avoid salty foods. He’s able to walk to a nearby grocery store where he “pigs out” on chips, soda—all the salty stuff. Thanks to the resources of DRchip, we’ve prevented two emergency department visits by having the home health nurse go to the group home, make an assessment, and administer diuretics. The added benefit is that the staff at the home have started heart healthy cooking, watching food labels, and now everyone who works there is eating in a healthier manner!

information about health and diet, and the benefits of maintaining a healthy weight. One of NHLBI’s most innovative and far-reaching efforts, Hearts N’ Parks is a

reaching out not just to adults at risk for disease, but children— before their risk magnifies through years of inactivity and unhealthy eating.

partnership with the National Recreation and Park Association

Communities Taking Action

Heart Healthy Lifestyles

School Program

During our school-based blood pressure screenings in 2001/2002, we found several children with consistent elevations. We’ve educated all of them on the dangers of high blood pressure—particularly if unattended over a lifetime—and because of our intervention program many parents are taking their children for medical care and encouraging the children to work on heart healthy lifestyle and behaviors.

A 6th grade boy, after participating in our HeartSmart program, told the class about talking to his mother about her smoking and lack of exercise. He realized that his mom’s sedentary lifestyle and smoking increased her chances of heart disease. His mother is now walking the school track with him each night, but she’s not yet willing to quit smoking. Still, our student plans to keep working on his mom.

DRchip middle school students use hula hoops for fun physical activities.

Another girl reported that after doing her Family Tree Project she realized she has a strong history for hypertension and heart disease. She also recognized that she is overweight for her age and height, and said she would begin to change her diet and try to eat healthier foods.

We followed an 8th grader for persistently elevated blood pressure readings. Her blood pressures had been elevated and there’d been no response from her parents to either of our two notification letters. Later, the student’s father was seen at a high school band concert. When asked how his daughter was doing he reported that they had indeed taken her to a doctor about her blood pressure, and she was under treatment. He said there was a strong family history for hypertension, but neither he nor his wife had thought to have the children checked.

Several families have sent letters to us after our blood pressure screening letters went out. They said they would watch their children's blood pressure periodically. And some of the 6th grade teachers have launched a weight control program because of discussions they’ve heard in the HeartSmart nutrition classes. Several more of the teachers have asked specific questions in regards to healthy diet planning.

Improving Health Changing Lives Communities Taking Action 17

Hearts and Souls in Southern Virginia

NOTES and the Arkansas Delta

The Community Outreach Cardiovascular dis- Case Manager/Cardiovascular ease—heart disease Health Educator and stroke—is a significant burden

We screened a 64 year-old woman at

the YMCA who had a history of high for African American

blood pressure and is on medication. Even with medication, her blood pressure remained borderline, but after

communities. Two NHLBI EDUCs are based in communities with distinctive African American popu-

the DRchip screening and a discussion

lations, and both are making

of her risks she reports losing 15

headway against CVD with

pounds. And her blood pressure is

inventive agendas that educate,

now within normal range. She’s stick-

inspire, and empower.

ing with a low-sodium, low-saturated fat, low-cholesterol diet and intends

to lose more weight. Her mother died at age 48 of a massive heart attack, and she’s now aware of the significance of this family history. She is

The Dan River Region Cardiovascular Health Initiative Program (DRchip) in Danville, Virginia is located in a designated aware of her increased risk of heart

Medically Underserved Area. The

disease and is following recommend-

incidence of coronary heart disease

ed lifestyle modifications as a result

(CHD) in southern Virginia is in

of her DRchip screening and education.

the nation’s top 15 percent, and

A hypertensive, diabetic woman at the DRchip blood pressure class at Tarpley’s Chapel spoke about failing to follow her doctor's recommenda-

the stroke death rate is twice the national rate. To address this situation, DRchip was created, a partnership between the

tions in regard to lifestyle modifica-

Danville Medical Center and the

tions. As a result she is on dialysis

Danville/Pittsylvania Public Health

for kidney failure and has had a heart

Department—an effort designated a

attack. After taking the blood pressure

Cardiovascular Center of Excellence

training class, she realized that she

by the Consortium for Southeastern

could offer herself as an example to

witness to others about the impor- Hypertension Control in 1999.

tance of lifestyle modifications.

As an NHLBI EDUC, DRchip has And First State Bank created and post- expanded its focus to provide com-

ed flyers on stress reduction in the

prehensive education for the public

work place after a DRchip representa-

(including risk factor identification)

tive spoke at the bank on stress and

as well as for health professionals.

its relationship with CVD!

Various strategies include community cardiovascular risk factor

18 Improving Health Changing Lives Communities Taking Action

screenings and referrals; collaboration with locally based hypertension and lipid specialty clinics, a hospital-based case management program, and education activities with schools (DRchip’s Heart Healthy Lifestyles School Program), the YMCA, churches, as well as local businesses and banking institutions.

The Delta Health Education Center (DHEC), in the Arkansas Delta, is a program of the University of Arkansas for Medical Sciences in Little Rock that implements professional education and church-based health education programs to improve cardiovascular health in St. Francis and Lee Counties. For the last 5 years, Arkansas has ranked as the least healthy State in

The DHEC Heart and Soul project distributes NHLBI educational materials through the participating churches.

the U.S., and that burden is sharply felt in these two counties in the Mississippi River Delta, both of which are largely rural, impoverished, and in the top 15 percent of national rates for CHD and stroke mortality.

A unique faith-based initiative, DHEC unites the counties’ churches in reaching people at risk for CVD with the local health care network to reduce risk. With input from county advisory boards, DHEC works with approximately eight churches in each county. “Most people are very loyal to their church,” says Becky Hall, Ed.D., DHEC principal investigator and program director. “Most people feel a sense of family and community in their churches. So it seemed a very natural fit for our churches to tell their parishioners: we care about you, heart and soul.”

Half of the churches in each county participate in either a Lay Health Minister program or a Witness Role Models program. In the Lay Health Minister programs, health professionals from participating congregations conduct health evaluations of community members and followup with information, advice, and referral services for those found to have CVD risk factors.

In the Witness Role Models program, survivors of stroke or heart disease from each congregation

James Coleman, summed it up when he told his fellow parishioners that

A Heart and

the symptoms of a heart attack

Soul Scrapbook “will warn you. If you heed the

warning and get to a doctor, I We screened a woman at the guarantee you will not regret it.” Methodist Church who had extremely

high blood pressure, but she was not feeling bad. We impressed on her that high blood pressure often had no symptoms, and she must go and see about it. She had an appointment to see her doctor in 2 weeks— but we told her that her pressure was so high the problem couldn’t

All participating churches are offered opportunities to provide educational activities for congregation members in a wide range of health areas, including tobacco cessation, nutritional counseling, and exercise classes. Cooking demonstrations and youth group presentations aimed at discouraging wait. That was on Saturday. She tobacco use and encouraging heart went to the doctor on Monday. She healthy eating and physical activity later told us that the doctor said that are also available. In addition, if she had not come in when she DHEC, in conjunction with the had, she might not have been alive University of Arkansas for Medical by the end of the week. Needless to Sciences regional programs, say she was very happy our DHEC provides training programs and team came to the church—and so continuing medical education courses was her church family. for physicians, physician assistants, nurse practitioners, nurses, and At the Atkins Boulevard Church of office staff in the two counties. Christ we found a man who had high blood pressure in need of attention. “The NHLBI EDUC philosophy He was supposed to be on medication seemed so closely aligned with ours but had quit taking it. We helped to it was a perfect match,” Dr. Hall

get him back to his doctor for care, and he’s now taking his medicine again.

says. “And now we’re feeling that the future of health in the Arkansas Delta is bright.” 

work with a health educator to present information to the congregation about CVD risk factors— and their personal experiences with CVD. One Witness,

Improving Health Changing Lives Communities Taking Action 19

National Heart, Lung, and Blood Institute

CVD Enhanced Dissemination and Utilization Centers

NHLBI awarded the first six CVD EDUCs in April 2001. The results of those projects will be reported in 2004. A second wave of six CVD EDUCs was awarded in late September 2002, and those results will be reported in 2006. The 2002 EDUCs will be featured more fully in subsequent publications.

Each EDUC meets the requirement that the health service area where the project is being implemented falls within the top 15th percentile for coronary heart disease and/or stroke mortality, either overall or within one or more of the race-gender groups. A synopsis of each of the 12 current EDUCs appears below.

2001 EDUCS

Little Rock AR University of Arkansas for Medical Sciences, Delta Health Education Center

St. Francis and Lee Counties, AR

Partners AR Association for Medical Access; AR State Minority Health Council; AHA; hospitals and clinics; faith-based alliance; county family resource center and Cooperative Extension Service

Target Population African American and white members of 16 churches, their families and friends; MDs, RNs, LPNs, and office staff

Strategies/Activities Faith-based approach conducted in churches: monthly blood pressure monitoring and counseling with high-risk patients referred for treatment; heart and stroke “witnesses” provide models of behavior change; and conduct smoking cessation, CPR, exercise/ physical activity, and nutrition classes

Desired Outcomes Increased understanding of CVD risk-reduction strategies and confidence to make behavior changes; increased physical activity and controlled hypertension; decreased tobacco use

Winston-Salem NC Wake Forest University

Columbus and Robeson Counties, NC

Partners S and NW Area Health Education Centers; State health department; Lumberton Chamber of Commerce; Food Lion Supermarkets; NC AHA; UNC-Pembroke; Duke University School of Medicine

Target Population African Americans and Native Americans; 15,000 patients served annually; of 166 individuals screened at 1 event 47% referred for followup care; 44% SBP > 140 mmHg; 11% DBP > 90 mmHg; 34% HDL > 40 mg/dL

Strategies/Activities Community-based organization training program to enhance advocacy skills for environmental policy changes; screening and referrals for HBP, cholesterol, blood glucose; primary care physicians and emergency service providers’ professional education

Desired Outcomes Increased communities’ awareness of CVD risk factors and MI early warning signs; increased awareness of CVD prevention resources; improved knowledge of state-of-theart emergency care practice by providers

20 Improving Health Changing Lives Communities Taking Action

Fort Worth- Metroplex Area TX

Partners

Target Population

Strategies/Activities

Desired Outcomes

Danville VA

Partners

Target Population

Strategies/Activities

Desired Outcomes

Charleston WV

Partners

Target Population

Strategies/Activities

Desired Outcomes

University of North Texas Tarrant and Dallas Counties, TX

City and county health departments; community health centers and clinics; hospitals; HRSA; senior centers; faith-based organizations

Low-income Spanish- and English-speaking Latino families; conducted 344 community lifestyle behavior assessments; trained 18 lay health educators; conducted readiness assessment with 31 partners

Train lay health educators (promotores) to conduct family health screenings, education and referrals for BP, cholesterol, BMI, tobacco use, physical activity, and glucose

Increased heart health knowledge and practice of heart healthy behaviors; increased scores on core competencies and performance skills of promotores; decreased prevalence of risk factors; increased dissemination efforts

Dan River Regional Medical Center Pittsylvania, Henry, and Halifax Counties, VA and Caswell County, NC

Danville Regional Medical Center; middle schools; faith-based organizations; businesses

1,000 low-income African American and white children in 3 middle schools and their families; community at large; 3 churches; 6 businesses; YMCA; 50 community physicians; 79% of 6th, 7th, and 8th graders with high-normal or HBP also overweight; large proportion of children are African American

Screening and referrals for BP, cholesterol, BMI; case management of high-risk patients; family education; professional education

Decreased prevalence of CVD risk factors; improve cardiovascular health knowledge in students; increased provider use of appropriate treatment guidelines; reduced emergency department visits

West Virginia Health Right, Inc. Kanawha, Mason, Clay, Jackson, Boone, Putnam, Logan, Mercer, and Fayette Counties, WV

Senior centers; Cooperative Extension Service; Manna Meal local soup kitchen

Uninsured and underinsured poor adults and children who receive services from the Health Right clinic

Cholesterol, HBP, diabetes, tobacco use, and BMI detection; education and counseling on cardiovascular health, physical activity, nutrition/healthy cooking, weight loss, tobacco cessation, diabetes education/healthy cooking, early warning signs and symptoms of heart attack and stroke; medication treatment; women’s heart health education program

Increased BP and cholesterol control; reduced prevalence of HBP, cholesterol, smoking, and overweight; reduced medication due to behavior change; increased 911 access; increased knowledge of actions to take to prevent heart disease and stroke by women with CVD risk factors

Improving Health Changing Lives Communities Taking Action 21

Huntington WV

Partners

Target Population

Strategies/Activities

Desired Outcomes

2002 EDUCS

Colorado Springs CO

Partners

Target Population

Strategies/Activities

Desired Outcomes

Baltimore MD

Partners

Target Population

Strategies/Activities

Desired Outcomes

St. Mary’s Hospital Cabell, Lincoln, and Wayne Counties, WV

St. Mary’s Hospital; school system; WV Dept of Education; WV Bureau of Public Health; WV AHA; WV University; Marshall University Medical School; YMCA

8,000 3rd, 4th, and 5th graders, their families, and school staff including food service in 45 public schools in Appalachia; 40% of 5th graders overweight; 15% hypertensive; 11% elevated cholesterol levels

Screening and referrals for HBP, cholesterol, BMI; walking program for students and parents; healthy lifestyles school curricula; school breakfast and lunch program modification; teacher CVH training; and family education

Decreased prevalence of CVD risk factors; increased knowledge of risk factor prevention; increased physical activity; improved school food with more heart healthy choices

The Penrose-St. Francis Health Services Health Learning Center El Paso County, CO

Senior Health Center; Community Network of Caring; local AHA; media; faith-based organizations; El Paso County Department of Health; health care providers; local businesses

Women

Community awareness raising; screening and referral for HBP control; heart healthy diet and exercise lifestyle interventions; control of obesity and other CVD risk factors for HBP; collaboration with health care providers; case management.

Increased awareness of stroke risk factors; increased HBP control; increased control of BP to reduce stroke events

The Housing Authority of Baltimore City Baltimore, MD

US DHUD Baltimore office; Morgan State University; Baltimore City Department of Parks and Recreation; local public housing residents

40,000 African American public housing residents

CVD risk factor screenings; train-the-trainer community health worker programs; work with neighborhood grocers, fast food restaurants, and schools to encourage adults and children to choose heart healthy foods; establish safe places to engage in physical activity; develop community partnerships and coalitions to increase policymakers’ awareness of CVD issues

Increased awareness and adoption of appropriate lifestyle behaviors for cardiovascular health; increased number of residents both adults and children who choose heart healthy foods and safe places for physical activity; increased number of local partners advocating for improved community heart health

Communities Taking Action

Omaha NE

Partners

Target Population

Strategies/Activities

Desired Outcomes

Winston-Salem NC

Partners

Target Population

Strategies/Activities

Desired Outcomes

Dayton OH

Partners

Target Population

Strategies/Activities

Desired Outcomes

Toledo OH

Partners

Target Population

Strategies/Activities

Desired Outcomes

The Creighton Heart Education Center Omaha Metropolitan Area; Douglas County, NE

Creighton University Schools of Medicine, Nursing, and Pharmacy; The Charles Drew Clinic; Douglas County Health Department; Catholic Charities

African Americans

Media and public education campaigns; town hall meetings; community CVD risk factor screening, referral, and followup using mobile screening unit and health fairs; nutrition (shopping, cooking, and healthy eating), blood pressure, and exercise courses; train community heath advocates to conduct comprehensive heart health awareness activities; professional education training

Increased awareness of and action to control CVD risk factors; increased adoption of heart healthy lifestyle behaviors; increased physicians’ awareness and application of latest NHLBI CVD “best practice” interventions

Wake Forest University School of Medicine Forsyth, NC

Forsyth County Health Department; Consortium for Southeast Hypertension Control; Tri-State Stroke Network

African Americans

Community-based CVD risk factor screening, referral, and followup; personalized health action plans; training of community health advisors to implement education activities; community events to increase awareness; worksite wellness programs

Increased awareness of and community education about stroke risk factors; increased control of stroke risk factors; reduced incidence of stroke among African Americans

The Wright State University Division of Health Systems Management Montgomery County, OH

Local health care providers; primary care organizations; insurers; public health officials; media; local employers; Premier LDL Reduction Project; Consortium for Southeast Hypertension Control

Appalachian and African American patients and their physicians

Know your numbers campaign; BP and cholesterol management through systems changes

• chart audits, case-based interactive education/training, utilizing “best practices” from NHLBI clinical practice guidelines to detect, treat, and control HBP and high blood cholesterol

Increased community awareness/knowledge of CVD risk factors; improved physician practice behavior related to controlling HBP and high blood cholesterol; increased number of people treated for HBP and high cholesterol; improved patient outcomes and satisfaction

Toledo Hospital Lucas County, OH

Ottawa Coalition neighborhood; Owens State Community College health and hospitality studies students; local PBS station WGTE

30,000 minority and low SES residents, mostly African Americans

Walking clubs; BP, cholesterol and exercise train-the-trainer programs; culturally tailored nutrition, smoking cessation, and heart attack warning signs courses; community education forums

Increased awareness of BP and cholesterol numbers; increased heart healthy behaviors; increased knowledge of heart attack warning signs and actions to take

Improving Health Changing Lives Communities Taking Action 23

CommunitiesinCooperation

Sharing and Synergy

Healthy Hearts in Hispanic Communities

As the largest minority group in the U.S., 35 million Latinos constitute

13 percent of the population. And as one of the youngest U.S. population groups, there is a unique opportunity for Latinos to encounter health messages at younger ages, along with the chance to maintain healthy behaviors throughout their lives. As early as 1994 the NHLBI

Teaching the promotores

started to develop strategies and tools to help accomplish this goal.

about high blood cholesterol and its effect on

Salud para su Corazón (SPSC), a comprehensive health promotion,

arteries.

education, and outreach initiative, was launched to increase awareness and knowledge about CVD prevention and promote heart healthy lifestyles among Latinos. One NHLBI CVD EDUC located in north

Texas is now using the materials and tools to implement outreach and education activities in a local Latino community characterized by poverty, unemployment, poor education, and limited access to health care and preventive health services. Based at the University of North

Texas Health Science Center at Fort Worth, the North Texas EDUC operates in partnership with a community-based clinic, Harris Methodist

Fort Worth Hospital, and two community-based coalitions in the

Dallas/Forth Worth area.

Heart disease is the We needed to bring programs that leading cause of would really make an impact, and

“

death in Latino our collaboration with NHLBI is communities,” precisely that sort of partnership.” observes Hector G.

Balcazar, Ph.D., M.S., program director of the North Texas SPSC EDUC. “Our community here in

A major focus for SPSC is the use of lay health educators, called Promotores de Salud, to help identify north Texas is certainly no different. individuals with CVD risk factors

Improving Health Changing Lives Communities Taking Action 25

and guide them through treatment an idea-generator and focal point and followup, providing individual- for community feedback and sup-

ized risk reduction education and promoting adherence to prescribed regimens. The program has also

port. The cuéntamelo evaluation tools use a variety of culturally specific methods that integrate launched a variety of neighborhood planning, continuous feedback, and community-wide awareness and and program accountability, with education activities, such as guided methods that track, guide, and group discussions, or charlas, com- assess project performance at three munity health fairs, cooking demon- levels: promotores, families, and strations, and mass media activities community-based organizations. to reach community residents with

heart health and family wellness messages. “Cuéntamelo” (tell me about it)

Salad para su Corazón: Promoting Health from Within The Community The same SPSC frame-

helps measure the impact and effectiveness of SPSC programs, shares those results with the community and other programs, and serves as

work that provides both foundation and impetus for the University of North

Texas EDUC has connected with Latino communities across the United States. The promotora concept has taken science-based health messages where they have rarely gone before. As one of many NHLBI health promotion programs targeting ethnic, racial, and cultural minorities, SPSC reflects the Institute’s goal to change the way people think about their health, part of the wider aim to reach every American with life-saving information.

The idea that the most persuasive health educators in minority communities will come from within those communities has proven its worth from an initial pilot project in Washington, D.C., to seven

The D.C. Community Alliance for Heart Health carries the SPSC banner in the Hispanic Heritage Month parade.

26 Improving Health Changing Lives Communities Taking Action

initiatives in New Mexico, Texas, California, and Illinois. When Mary Luna Hollen R.D., Ph.D., of the University of North Texas EDUC described a promotora as “a caring person who lives in the community and retains the culture and the language,” she observed that “this is the reputation of these individuals, the way they’re seen by the community—as somebody you can trust, somebody you love to be around.” This trust and confidence is earned and carried by the Salud promotores, and stands at the heart of one of the country’s most powerful minority health outreach efforts.

In 2001, the SPSC expanded into the lower Rio Grande Valley in southwestern Texas, through a new partnership with the Health Resources and Services Administration and others. Known as SPSC-Las Colonias, this project incorporates SPSC information, skills, and activities into existing activities in the border area of south Texas. Interventions will be based in schools, clinics, and the distinct communities arrayed along the border known as “colonias,” rural, low-income neighborhoods facing a number of challenges in education, social services, and public infrastructure, as well as health care services.

Another collaboration partners the National Council of La Raza (NCLR), the nation’s largest Hispanic community organization,

Promotora de Salud

Teresa Andrews, a promotores coordinator in Escondido,

California, changed not only her own life but is now helping to improve the health of others in her Latino California community. Her story illustrates the power of SPSC to not simply provide a health outreach benefit, but to change lives, enhance self-esteem, and bring more Americans into the circle of the nation’s promise.

With Ms. Andrews’ move to the United States, she left behind not only her support group of friends and family, but also an entire lifestyle. Although she had walked everywhere in her native country, she found nothing near enough to walk to in her new adopted home in suburban southern California. She did not speak English, her husband needed the family car each day to get to his job, and Ms. Andrews found herself isolated and limited to only the simplest duties of a homemaker and mother. With grocery shopping difficult, Ms. Andrews’ native cooking traditions using fresh vegetables and fruits fell away as she found herself turning to fast food for most of her family’s meals. Her frustration grew with a lifestyle she seemed helpless to change, and she became depressed, gaining weight along with her sense of disconnection and isolation.

But when Ms. Andrews discovered SPSC and became a promotora, she was part of a group of Spanish-speaking people who shared many of her experiences and had found innovative ways to cope. “The training I received as a promotora helped me learn how to protect my own and my family’s heart health by modifying the new lifestyle I picked up after moving to the U.S.,” Ms. Andrews says. Her spirits rose and her weight fell; partly thanks to the Spanish-language aerobics class she attended—and which she now has led for 4 years.

Improving Health Changing Lives Communities Taking Action 27

Dr. Hector Balcazar instructing promotores on SPSC.

with Salud’s promotores. “We are Center, Escondido, California; working together toward a common Hands Across Culture Corporation, goal—improving health outcomes in Espanola, New Mexico; Centro San the Latino community,” said NCLR Vicente, El Paso, Texas; Council for

President Raul Yzaguirre. The NHLBI-NCLR partnership has, since 1999, expanded the SPSC effort by implementing culturally

Spanish Speaking, Stockton, California; and Center for Hispanic Policy and Advocacy, Providence, Rhode Island. appropriate prevention strategies to address health disparities in Latino “For the promotores to develop as communities. With funding from the community educators, they need

Metropolitan Life Foundation, and with the University of North Texas Health Science Center School of Public Health in an advisory role,

adequate tools,” says Odelinda Hughes, promotora de salud at Centro San Vicente, El Paso, Texas. “With Salud para su Corazón, the there are now six community-based heart health tools are simple, bilin-

service agencies implementing the SPSC-NCLR program: Centro San Bonifacio, Chicago, Illinois;

gual, and practical. This makes our work in the community easy and effective.” Escondido Community Health

28 Improving Health Changing Lives Communities Taking Action

There are many stories from The North Texas SPSC EDUC, stories of hope, of possibility, of lives touched and changed. As the promotores continue to make a difference, their value is measured by evaluation results that have shown significant increases in awareness, knowledge, and practices related to heart disease risk factors, along with a high level of satisfaction with the educational materials as well as how the information is presented. Latino families and communities take pride and exhibit confidence in their informed heart health choices.

Heart Health for American Indians and Alaska Natives

Although American Indians and Alaska Natives (AI/AN) are the smallest self-identified racial-ethnic group in the United States, this group is represented by 547 tribes spread among the 50 states. A spectrum of cultures distinguishes these communities enriched by beliefs, distinct heritages, and the vast and various geographies that so define the lives and histories of the nation’s Native Americans.

Within this diversity, however, a pattern of parallels and shared values distinguish AI/AN values, including family and tribal-centered cultures, a sense that communities and individuals should strive to live in harmony with the natural

Tribal community members receive training in Santa Fe, New Mexico.

“Our people want to get out there and teach and do something about our problems, because virtually everybody here has been touched in some direct way by heart disease and its complications.”

environment, and an abiding respect AI/AN communities are experiencfor a traditional world view handed ing the burden of CVD as never down through hundreds of years. before. As such, AI/AN communities offer unique points of departure for locally Understanding both the uniqueness based health outreach programs. and commonality in AI/AN cultures is key to mounting programs that CVD is responsible for more deaths resonate within the AI/AN tribally among AI/AN men and women over rooted communities. And targeting the age of 45 than any other cause. these needs has brought into focus

The rise of CVD and related problems like obesity, high blood pressure, and diabetes can be charted with the gradual adoption of Western lifestyles by AI/AN people over the 19th and 20th centuries.

the strengths and resources of NHLBI’s community initiatives— notably an ability to create new synergies with and among each other, from program to program and person to person. As we embark on a new century,

Ideas and tools developed among any one minority community “benefits us all,” notes Natalie Thomas, program manager for healthy heart efforts at Laguna-Acoma, an AI community in New Mexico. “With our large population of people with diabetes—a key risk factor for heart attack and stroke—there’s a great deal of interest in health here at Laguna-Acoma. Our people want to get out there and teach and do something about our problems, because virtually everybody here has been touched in some direct way by heart disease and its complications. So we’re happy to have help and advice from our friends in other communities who face so many of the same concerns.”

NHLBI researchers had worked to identify the burdens of CVD among AI/AN communities with the Strong Heart Study, which estimated cardiovascular morbidity and mortality along with the prevalence of risk factors, and received overwhelming support from individuals and tribes at study sites in central Arizona, southwestern Oklahoma, and in North and South Dakota. A subsequent program called Pathways was a multisite school-based obesity prevention effort designed to assess the ability of outreach and education to reduce prevalence of obesity in school-aged children by promoting healthful eating and physical activity. With the data from the Strong Heart Study in hand, and encouraging results from Pathways,

Improving Health

NHLBI moved ahead to translate science into action for American Indians and Alaska Natives.

A turning point came in May 2001 with an NHLBI-sponsored workshop, Mobilizing American Indian and Alaska Native Communities for Improving Cardiovascular Health. Sixteen tribal representatives from three disparate AI/AN communities (Laguna-Acoma, Ponca, and the AN villages at Bristol Bay, Alaska) came together for a 2-day workshop. After returning home and reviewing strategies, the communities realized they still needed greater skills for delivering the heart health message to their people.

As the AI/AN pilot communities requested more training, the Indian Health Service (IHS) encountered the NHLBI Latino outreach manual Your Heart, Your Life. Interested in the possibility of adopting the manual for AI/AN use, IHS sought input from NHLBI who in turn asked their AI/AN partners to consult on the manual development. This activity—adapting the Latino manual for use in AI/AN communities—led to a pivotal training conference.

That conference, held in Santa Fe, New Mexico, turned new ground when the lay health educators from Latino communities—the promotoras—brought their insights, skills, and passion to the event. Serving as

Proud graduates of the week-long Sante Fe training conference.

The Elders not only bring endorsement of Laguna’s healthy heart initiative, but their own advocacy “carries enormous weight in our community.”

trainers to their colleagues from Bristol Bay, the Ponca Tribe, and Laguna Pueblo, the conference created a unique transcultural blend.

Another wonderful aspect of this is the network of friends that’s been created—I keep in touch with Teresa on a regular basis, for exam-

Since that time the promotoras have ple. We’re constantly trading ideas.” participated in followup conference calls with AI/AN project managers, Ms. Thomas notes that each of and have served as both friends to Laguna’s six villages has an assigned the cause and mentors in the work. community health representative, or CHR. “They do screenings for

Ms. Thomas of Laguna-Acoma recalls the promotoras as “truly inspirational. One of the Latina trainers in particular, Teresa Andrews, was so powerful and effective that we saw, first hand, right there in front of us, what could be accomplished in bringing the health message forward.

blood sugar, blood cholesterol and check body mass index—and they teach,” she says. “We connect with people wherever we can: when they make a clinic visit, or just walking down the street. And we also have the very important support of our Elders.” The Elders, Ms. Thomas explained, not only bring endorse-

Communities Taking Action

ment of Laguna’s healthy heart initiative, but their own advocacy “carries enormous weight in our community.”

Other events at Laguna-Acoma include Healthy Heart Bingo, for both school children and adults. “We give prizes focused on health, and hand out healthy snacks along with heart health fact sheets. I can’t say enough about the marvelous support of NHLBI in encouraging us to take charge and engineer our own materials, and just take hold of our own destiny.”

Asian Americans and Pacific Islanders: New Vistas for Health

Among the fastest growing of American populations, Asian Americans and Pacific Islanders (AAPIs) present an array of specific health information needs, as well as needs for improved access to health services. Frequently immigrants or refugees, AAPIs migrate within the United States to settle in their own communities—centers of family, language, religion, and culture nestled around employment opportunities. These communities include some 30 different Asian and Pacific Island groups, but as the cultural imprints of these communities are diverse, their health concerns mirror those of many other populations. CVD, in particular, is the leading cause of death across all AAPI groups. Asian

West Bay Pilipino Multi-Service Center joins NHLBI in making a commitment to improving the heart health of Filipinos in San Francisco.

American men in general have significant burden among AAPI higher stroke mortality rates than communities, but these communities do white men. There are significant are also underserved in health care rates of hypertension among funding, outreach, and services. Filipinos, Japanese, and Southeast Asians. Obesity and diabetes, two With research findings confirming key risk factors for CVD, are preva- unacceptable levels of CVD among

lent among Pacific Islanders— and the CVD death rate among Native Hawaiians is the highest in the nation.

AAPIs, the NHLBI partnered with several health and community organizations in mounting two major meetings in the late 1990s. Fifteen different AAPI groups were Community-based health programs involved and a national consensus targeting various AAPI populations was reached to focus initial efforts have been underway around the toward specific groups with pressing country for more than two decades. needs for interventions, including

These pioneering programs have established precedents and opened doors, using a variety of outreach techniques from posters and billboards to small group classes and

culturally sensitive (and languageappropriate) printed materials, and outreach strategies designed to reach communities and individuals in effective ways. With efforts coaphysician education. Along the way, lescing and growing in pilot coma number of studies and surveys munities throughout the United established that not only is CVD a States, the NHLBI’s powerful brand

Improving Health Changing Lives Communities Taking Action 31

Staff of the Ka’Ili Community Center on Moloka’i, Hawaii.

of community empowerment in the a low percentage of people and service of health is on convincing families taking advantage of display among Native Hawaiians, available health care services. on the island of Moloka’i, often referred to as the “last Hawaiian Recommendations from a workshop island.” With a population of nearly cosponsored by NHLBI and Moloka’i

7,000—more than half of who are Native Hawaiian—Molaka’i has the largest proportion of Native Hawaiians throughout the islands that make up the State of Hawaii.

General Hospital reflected the community’s belief that solutions lay in two related directions: community mobilization and community outreach. Local leaders wanted both outreach and mobilization geared

Still largely rural and relatively untouched by urban development, the residents of Moloka’i have worked to retain Native Hawaiian customs and language. But

toward prevention rather than, in the words of Judy Mikami, R.N., NHLBI project director on Moloka’i, “trying to address problems after the damage is done.” Moloka’i also has one of the highest

unemployment rates in the State, accompanied by both a lack of access to health care services and

The NHLBI is partnering with Lamalama Ka’Ili Community Health Center to develop a healthy heart

32 Improving Health Changing Lives Communities Taking Action

curriculum to be used by kupuna in elementary schools. Kupuna are the elders of Native Hawaiian culture, respected sources of knowledge and wisdom, leaders and spiritual guides who serve—by long tradition—as facilitators, counselors, and advocates. “A big piece of all this,” according to Ms. Mikami, “is the cultural aspect, which hinges on the vital endorsement of the kupuna.” “We want to bring the kupuna into the schools as heart health educators, teaching our elementary kids. The influence of the kupuna will interweave values and localize this program in such a way as to substantially increase its relevance for the children and the families they carry the message home to.”

Ms. Mikami enlisted a local graphics designer to create materials for the elementary children who are the project’s primary target audience. These materials feature Hawaiian children, words from the Hawaiian language, and pictures of locally produced foods. “Our designer is already one of our success stories,” says Ms. Mikami. “She had no health background before working with us, but after designing these materials she reported watching her food labels very carefully for fat and caloric content!” Another partner is a cultural specialist that Ms. Mikami has asked to name the Moloka’i project—in Hawaiian. “Soon we’ll be rechristening our project with a name or title in the Hawaiian language.”

The Moloka’i heart health curriculum includes an instructional section, which is a “script” for the kupuna to use in bringing the message to the classrooms of Moloka’i, as well as colorful activity sheets for the children to use that review the heart health message. A version of the kupuna-led heart health program will be offered entirely in the Hawaiian language, in the Hawaiian immersion program in one of the Moloka’i elementary schools.

Preliminary discussions have been held with the kupuna leadership, according to Ms. Mikami, and draft materials have been reviewed. Initial responses from the kupuna were quite positive and supportive, and Ms. Mikami has been asked to present the project to the entire Moloka’i kupuna group. “The kupuna will be our community health advocates in this process,” says Ms. Mikami. “They are respected by everybody, throughout the community. Their involvement, and enthusiasm, will bring great legitimacy to this effort, and we can utilize this powerful link between old and young, between wisdom earned and those who are learning new things every day. The heart health message has never had such powerful friends as the kupuna of Moloka’i.”

An Indianapolis student demonstrates the use of a digital blood pressure monitor.

Putting the Squeeze on High Blood Indianapolis, Indiana, and Akron, Pressure Ohio, the school-based curriculum is aimed at middle school children On Molaka’i the path (ages 11-13). Promoting prevention

of education, involvement, and inspiration moves from seniors to

and control of hypertension through increased awareness of the problem and its contributing risk factors, the curriculum’s outreach component

school-aged children. Another new NHLBI collaboration also uses an intergenerational approach by educating middle schoolers to become

sends children home to interview parents and grandparents about risk factors and family histories for high blood pressure. Children will also heart health advocates for their par- measure blood pressures within ents and grandparents. their families and help parents and grandparents design family hyper- “Putting the Squeeze on High Blood tension plans. Pressure” is an NHLBI partnership with the SPRY (Setting Priorities for With children serving as the emis-

Retirement Years) Foundation and the OASIS Institute, a nonprofit organization that manages senior centers throughout the nation. Pilot tested in St. Louis, Missouri,

saries of the heart health message in the “Putting the Squeeze on High Blood Pressure” program, older adults are the recipients of the message’s benefits, encouraging lifestyle

Improving Health Changing Lives Communities Taking Action 33

changes along with better adherence same basic manual, Your Heart, to already existing diet, activity, and Your Life, as a point of departure.

medication regimens. The program also performs a critical task: bringing awareness of heart health concerns into the center of American

Aspects of all these innovative tactics are coming to the fore in an extraordinary new partnership emerging in Baltimore, Maryland. lives by involving all ages. Carol Payne, M.S.N., enjoys the In a related program that also uses term “community-specific” in “Squeeze” materials, a hypertension describing the Baltimore collaboramodule will be offered to seniors as tion. As an operations specialist

part of the OASIS “HealthStages” program. Presented in senior centers, the module moves seniors from an awareness stage to a self-management stage. OASIS has established partnerships with local clinics, hospitals, and health care centers (with staff from these part-

with the Baltimore Field Office of the U.S. Department of Housing and Urban Development (HUD), a role she assumed after 23 years as a nurse at Johns Hopkins, she knows well that the most successful educational and outreach programs are community-specific: designed for ner organizations routinely involved and targeted to the unique needs of in “HealthStages” implementation). specific communities. The OASIS presentations will focus on intergenerational workshops in “Among low-income families any which children and older adults health disparity is going to be exacerteam to learn more about risks and bated due to reduced access to prevention of high blood pressure. resources, both knowledge and services,” Ms. Payne says. “In public Converging at the Point of Health: housing here in Baltimore City we African Americans in Baltimore work with a very discrete community, mostly African American, mostly Seniors are using their low-income, mostly under-educated. inherent experience and Thinking about it, I realized that so legitimacy for intergenera- many barriers and burdens in this tional heart health educa- community tend to converge around tion in rural Hawaii. the point of health. A health promo-

Children are serving a similar role in the SPRY and OASIS efforts in the Midwest. Hispanic and

tion program that is truly community-specific—made for this place and engaging all residents at all ages—can American Indian and Alaska Native achieve something truly meaningful.” communities have tailored the concept of lay health workers to Knowing that the African American respond to local needs, sharing the communities of Baltimore suffer

34 Improving Health Changing Lives Communities Taking Action

Among the core partners, Morgan

State University’s Public Health

Program is unique as a public health training program housed in a historically black university with a mission to train public health professionals for work in urban communities, and to specifically address minority health disparities. The Baltimore City

Department of Recreation and Parks provides low or no-cost opportunities for Baltimore community members to become physically active, addressing another major factor in the community’s cardiovascular health.

exceptionally high CVD mortality rates, Ms. Payne discussed heart health outreach in public housing with both her own supervisors at HUD as well as the Housing Authority of Baltimore City (HABC). This “was a chance to bring resources directly to public housing residents that are otherwise unavailable,” Ms. Payne says. “Both my boss and the people at HABC agreed. Thus, the Baltimore City Cardiovascular Health Partnership (BCCHP), with core partners including HUD’s Baltimore Field Office, HABC, the Public Health Program at Morgan State University, and the Baltimore City Department of Recreation and Parks was formed.

To increase the network of partners and create effective strategies for use among public housing residents, the BCCHP held a workshop in Baltimore in September 2001 with more than 70 representatives from health and social service organizations, the clergy, and public housing residents and resident leaders attending. Participants provided their knowledge, experience, and ideas on public education and media, the public housing community, involving public health students in health outreach activities, and sustaining broad collaborative partnerships on behalf of the larger effort.

The players and part-

“ ners got solid infor-

mation at the workshop,” says Ms. Payne. “We heard the hard facts on CVD and the extent of the problem in the African American community. By the end of the day a roadmap was coming into focus to help us understand how we could move forward.” To garner further insights into the health and information needs of the public housing community, 12 discussion sessions were conducted with participants who spanned age and gender segments of the public housing population, including youth/adolescents (15-18 years), adult men and women (19-54 years), and senior men and women (55 years and above). The discussions focused on current health

(and subsequently adapted by AI/AN communities), is being used as a curriculum model in Baltimore. An assessment of the major components of Your Heart, Your Life evaluated its relevance to African Americans, and helped create a new training manual for use by the CHWs of the Baltimore EDUC.

NHLBI believes the public housing

Housing Authority of Baltimore City residents and

staff leaders. outreach and education model being implemented in Baltimore has great

status, lifestyles, heart health knowledge, barriers to heart healthy lifestyles, and optimum ways to deliver and receive health information messages.

potential for replication in public housing communities nationwide. With the outreach and education lessons learned from the Baltimore EDUC project, similar activities can be implemented in other public In 2002 the BCCHP’s “Healthy housing communities throughout Hearts in Housing” project was the United States. selected as one of the new NHLBI

CVD EDUCs. Healthy Hearts in Housing is a 3-year project that creates a learning environment for community residents, offering pro-

Ms. Payne agrees. “There’s so much potential here,” she says. “In creating this project we also build sustainability for the entire initiative— grams that increase knowledge and an effort that will not only last 3

skills, encouraging healthy food choices in grocery stores and fast food restaurants in public housing neighborhoods, and promoting improved nutrition and physical

years, but long past that time. This idea of heart health outreach in public housing marries two major goals, one being NHLBI’s goal to address health disparities in minoriactivity in schools. A major compo- ty communities. The other is HUD’s

nent of the project is selecting and training a cadre of public housing residents who are respected formal or informal community leaders to become cardiovascular community health workers (CHWs). Your Heart, Your Life, the NHLBI lay

goal toward family self-sufficiency and removal of barriers that impede that process. And the closer we can get to the community, the more we will involve them in every part of the process, and the more likely we are to see wonderful outcomes.”  health advisor training product developed for Latino communities

Improving Health Changing Lives Communities Taking Action 35

Hearts n’Parks

Promoting Physical Activity and Heart Healthy Eating in America’s Parks and Recreation Centers

If the driving premise of NHLBI’s community-based initiatives pivots on engaging and inspiring communities at the local level, this theme resounds through an innovative partnership with the National

Recreation and Park Association designed to reach Americans where they play—in our nation’s parks and recreation centers.

Seventy-five percent of or almost 9 million youth. And,

Americans live within a 2-mile walk of a public park. These facilities are widely accessible to indi-

the problem is beginning earlier in a child’s life. Over 10 percent of younger preschool-aged children between ages 2 and 5 are overviduals from culturally and socioe- weight, up from 7 percent in 1994. conomically diverse populations, as In adults, nearly 65 percent or 122 well as individuals with disabilities. million are considered overweight With this in mind, Hearts N’ Parks or obese. During the late 1990s obecarries messages rooted in rigorous sity continued to increase dramatiscientific research: exercise need not cally for Americans of all ages and

be either drudgery or dangerous to be effective, healthy eating need not be boring or unappealing, and good health can be achieved with an investment of as little as 30 minutes a day.

currently is at an all time high. Overweight and obesity acquired during childhood or adolescence often persists into adulthood, increasing the risk for chronic diseases later in life, including heart disease and stroke, diabetes, certain An Obesity Epidemic cancers, gallbladder disease, sleep disorders and osteoarthritis. Over the past two decades, the numbers of overweight children and Hearts N’ Parks is all about bringadolescents has tripled to 15 percent ing science-based messages about

Improving Health Changing Lives Communities Taking Action 37

A Hearts N’ Parks participant works out.

lifestyle choices to people—to help develop productive partnerships to them achieve a healthy weight and further enrich their activities. reduce their risk for heart disease. In Hearts N’ Parks programs, skills Pilot Testing the Program for incorporating healthy eating

plans and regular physical activity into everyday life are taught as part of the programs offered by park and recreation departments. Programs may deal with nutrition and fitness, stress reduction or

Hearts N’ Parks was pilot tested in the summer of 1999 at 33 sites in 12 North Carolina communities involving more than 2,000 participants. Followup evaluation showed that participants retained informafamily life programs, walking clubs, tion about heart healthy behaviors. cooking classes, and aerobic and Children reported learning new swimming classes. And activities physical activities and improving can be adapted for children, youth, their performance in others; seniors adults, and seniors. Hearts N’ Parks reported feeling healthier and expeprovides opportunities for commu- riencing less pain in their daily lives nity organizations to gain recogni- as a result of participation. tion for their commitment to healthy behaviors, as well as to

38 Improving Health Changing Lives Communities Taking Action

Two examples of the pilot program include the Albemarle Park and Recreation Department that teamed up with the local hospital, Stanley Memorial, to develop the “Walk About” program for adults in the community. Walks around the county were combined with health education, blood pressure and blood glucose screenings, stress management seminars, and strength training. And, the seniors “Walk for Life” program of the Mecklenburg County Park and Recreation Department teamed up with Presbyterian Hospital to offer a variety of health screenings. For the 2,000 youths involved in the Mecklenburg summer day camp programs, the department focused

on the health benefits of participating in lifelong sports like tennis and presentations on heart healthy eating. As a result of this program’s overall success, nutrition classes are now being provided in local after-school programs.

Up to the Moment in the Nation’s Recreation and Park Centers

Hearts N’ Parks is now a fixture with magnet centers in 13 States and more than 50 communities nationwide. Through the work of recreation professionals as well as dedicated community volunteers, Hearts N’ Parks is making a difference at a level where its critical health messages can be heard. In 2002, over 60 Hearts N’ Parks programs were conducted and assessed; 32 programs were conducted for children, 8 for adolescents, and 26 for adults. The sites conducted an assessment of the participant’s knowledge, behavior and intention for heart healthy eating and physical activity both before and after the programs. Children’s scores increased significantly from pretest to post-test for heart healthy eating knowledge, behavior, and intention. For physical activity, the children “learned” or “got better at” at least five activities by the end of the program. Adolescents showed the most significant improvements in heart healthy eating behavior followed by intention. And, adults finished their programs with more knowledge about proper nutrition,

“...physical activity should be a regular part of your life, no matter who you are or what your age...”

overweight/obesity, physical activity, that physical activity should be a

causes of high blood pressure, and how to control high cholesterol, than they had when they started.

regular part of your life, no matter who you are or what your age is. We certainly know that kids with They were significantly more active asthma, for example, do not exer-

and, on average, spent 8 fewer hours doing inactive things such as watching TV.

cise like they should, and Hearts N’ Parks is one way to reach out, to offer programs, and to generally get the word out. My work “I’ve been working with Hearts N’ involves recruiting dietitians to Parks as a registered dietitian,” says work with one of the four Indiana Catherine Parker, M.S., R.D., Hearts N’ Parks magnet centers Hearts N’ Parks coordinator for in Bloomington, Gary, Lafayette, Indiana. “We’re promoting the idea or South Bend.

A Hearts N’ Parks event in Savannah, Georgia.

Improving Health Changing Lives Communities Taking Action 39

Baltimore participants warming up for National Senior Health and Fitness Day activities.

Hearts N’ Parks activities in activities that included supervised Lafayette, Indiana work to highlight games and other physical activity

the connection between a healthier lifestyle and all 17 of the city’s parks. The Hearts N’ Parks Recreation Day Camp launched in

for a minimum of 30 minutes each day, and went on field trips oriented around physical fitness. Campers also attended guest lectures that the summer of 2002 with a kick-off stressed the importance of heart program featuring Lafayette’s healthy eating and making physical Mayor Dave Heath and Purdue activity an everyday activity. University’s women’s basketball coach Kristy Curry, an event that Meanwhile, on the Gulf Coast of brought focused media attention in Florida, children are being treated newspapers and on television. With to other kinds of organized activities

the support of partners like the local dairy council, Subway, and the Western Indiana Dietetic Association, children between the ages of 6 and 12 enjoyed camp

that underscore the importance of physical activity and healthy diets. According to Joan Byrne, M.A., C.P.R.P., recreation program manager for the City of Largo’s

40 Improving Health Changing Lives Communities Taking Action

Recreation, Parks, and Art Department, this summer’s new Hearts N’ Parks sports and wellness camp for kids “will really focus on diet and fitness.” A related event offering a number of activities and events for children is the annual “Heart of Largo” festival. “We divide the city’s main park into areas that represent different geographical parts of the United States,” Ms. Byrne says. “This year the centerpiece of the festival is Hearts N’ Parks—so for each part of the country that’s represented we’ll offer a signature physical activity.” “For example,” Ms. Byrne says, “the Northeast’s signature

These Hearts N’ Parks programs, and others like them in towns and cities across the nation, are changing the way Americans learn about physical activity and heart healthy lifestyles.

event is the Boston Marathon, so Indiana their kick-off last summer, we’ll have treadmills in place. Kids, called “Hooray for Gray,” included along with their parents or their a panoply of activities and entergrandparents, can do a certain num- tainments to draw attention to ber of minutes on a treadmill and Hearts N’ Parks. The program went become an ‘official’ Boston on to garner such popularity among Marathoner. The Pacific Northwest South Bend’s seniors that the city’s

will be represented by a climbing wall, and a certain number of minutes on the wall will qualify a youngster as an ‘official’ rock climber.”

Memorial Hospital partnered with the effort—committing 3 years’ worth of financial support devoted to Hearts N’ Parks activities. And members of Memorial’s professional staff have given their time and

Community health organizations have been enlisted for health fair activities, with booths for blood

expertise as blood pressure and blood sugar screeners as well as nutrition educators. cholesterol and blood sugar screen-

ing, as well as printed information and direct advice from health professionals and nutritionists. “We’re also preparing signs that will let people know how many calories they use in an hour of activity in that sport,” Ms. Byrne says. The signs will be posted at tennis and

Meanwhile, some 700 miles south of South Bend in the moss-draped city of Savannah, Georgia, seniors are targeted in two “Golden Ager” programs. “We sponsor two programs for seniors,” says Barry Baker, C.P.R.P., recreation services director for the City of Savannah’s basketball courts and at the head of Leisure Services Bureau. “One walking trails, and will carry both group operates around a fitness the Hearts N’ Parks logo along with schedule, working out on exercise

the logo of the City of Largo. “All of this will tell the community,” Ms. Byrne says, “that Largo, Florida is a Hearts N’ Parks city.” Hearts N’ Parks opportunities also abound for seniors. In South Bend,

machines, treadmills, and stationary bikes, and then they gather to walk around a lake in one of our parks. The other group combines movement and stretching, like Tai Chi and yoga, with walking. Partners

include a local hospital and the city health department that provide educational materials. Our biggest Hearts N’ Parks success, though, was our community fun walk. We convened at a larger park last spring, and offered free T-shirts and water bottles to the first 100 registrants. We opened up with a short program to warm everybody up— and, of course, that gave us a chance to introduce Hearts N’ Parks and the campaign for healthier people. It was very successful. In fact, nothing we’d done drew as much media attention to either Hearts N’ Parks or the heart healthy message as the fun walk. We plan to do two this year—in the spring and fall.”

These Hearts N’ Parks programs, and others like them in towns and cities across the nation, are changing the way Americans learn about physical activity and heart healthy lifestyles. Hearts N’ Parks programs are framed in the context of leisure and fun, fueled by community spirit, and reach out to all citizens, no matter their age, ethnicity, race, age, gender, or level of ability. And Hearts N’ Parks participants, be they recreation professionals, volunteers, or participants, are proving to be passionate advocates on behalf of heart health—demonstrating once again that empowering communities with knowledge and awareness offers untold potential for positive change. 

Improving Health

A Breath of

Fresh Air

The NHLBI Asthma Coalitions

Only a few years ago asthma was a relatively rare reason for individuals to see their doctor. Not so in 2003, as asthma has joined the nation’s major health problems, affecting some 20 million people— nearly 6 million of whom are under the age of 18. By the mid-1990s, the U.S. had witnessed a 75 percent increase in asthma prevalence across the previous 15 years—startling rates that give cause for national concern. For children between the ages of 5 and 14 the prevalence of asthma rose by 74 percent, and it is currently estimated that

In Arkansas, a school

nearly 9 percent of America’s children now suffer with asthma.

nurse answers students' questions about asthma.

Asthma is now respon- among health professionals and

sible for some 500,000 hospital admissions annually,

the public that asthma is a chronic disease with a growing impact on all corners of American life. with a total cost burden estimated at $12 billion. People Related NAEPP goals included with asthma experience in excess of acquainting health professionals, 100 million days of restricted activi- families, and the public with the ty every year—and the disease now symptoms of asthma. In realizing accounts for 5,000 deaths annually, these goals through treatment and with mortality rates clustered among education programs, asthma con- African Americans and the elderly. trol—and a reduction in morbidity and mortality—is encouraged

NHLBI’s National Asthma Education and Prevention Program (NAEPP) was initiated in March 1989 to address the growing prob-

through partnerships among individuals with asthma and their families, physicians, and other health professionals. lem of asthma in the United States. The goals of the NAEPP include, NAEPP works with a number of first and foremost, raising awareness partners including major medical

Improving Health Changing Lives Communities Taking Action 43

Students "graduate" from an asthma education program on how to manage their asthma.

associations, universities, hospitals, of individuals with asthma and voluntary health organizations, and their families, health care providers, other community programs to community leaders and elected educate patients, health professionals, officials—each coalition aims at a and the public, including the pivotal community commitment to give

strategy of locally based asthma coalitions. Creating a Coalition

long-term focus to the management of asthma. To assess program progress and impact, each coalition must also Each local asthma coali- look to a set of measurable pertion is a broad-based, formance points, such as reduction multiple-organization in hospital admissions or in emerpartnership that links a gency department visits for asthma number of stakeholders, over designated time periods. Other

such as public health departments, hospitals, volunteer organizations, professional or business associa-

concrete measures might include a reduction in missed school or workdays due to asthma flare-ups. tions, clinics and managed care organizations, schools, churches, Seven such coalitions are now locatlocal businesses, and recreational ed throughout the United States, organizations. With the involvement from the deep South to the Midwest

44 Improving Health Changing Lives Communities Taking Action

to central California and the Pacific Northwest, in high-risk communities where asthma mortality falls in the top 15 percent of the nation. These initiatives use culturally specific, community-centered tactics such as local advisory boards, educational efforts, outreach and public awareness campaigns, media relations, and support to health care professionals, all tailored for optimum impact in the communities the coalitions serve.

Southeastern United States

George Rust, M.D., M.P.H., recalls the origins of what would become the Morehouse Safety- Net Practice Based Asthma Research

COMMUNITIES

Engaging a community’s strengths reflects the NAEPP belief that coalitions are powerfully effective tools for change at the local level— bringing a sensitivity to community needs along with an understanding of how those needs must be met. In order to invest in the capacity of communities to be their own best helpers, the coalition concept pivots on education, targeting all levels of the involved community. From professional sessions for health care providers to school-based programs for children and teachers, to informational events for the general public, the organizing principles in implementing coalitions are rooted in education and communications.

Network, now centered at the Morehouse School of Medicine in Atlanta, Georgia. It was 9 years ago that a group of medical directors representing community health centers in the South approached him with an interest in new ways to improve quality and outcomes for their patients. “They wanted an academic partner to assist in this quest for change,” Dr. Rust says, “but also to help with the tools of research that would verify and validate their efforts.” Dr. Rust, deputy director of the National Center for Primary Care at the Morehouse School of Medicine and now a project

investigator with the Morehouse “At the outset,” says Dr. Rust, “it Safety-Net project, was initially was clear that community health involved as a facilitator. “Our early centers in the Southeast could not

conversations were all about what this partnership could do that would bring meaning to their com-

implement national asthma guidelines due to an inability to provide basic tools of asthma care like peak munities,” Dr. Rust says. “We began flow meters and spacer devices. to talk about a focus area, and And the reasons these devices were asthma kept coming to the surface.” unavailable wasn’t just budgetary. There were administrative confu- Asthma, Dr. Rust points out, met a sions and slow-downs, and many number of single-condition criteria providers were simply overwhelmed around which very specific evalua- by the numbers of patients presenttions and targeted improvements in ing to their clinics. We documented

care could be made. “Asthma is a high-volume condition,” Dr. Rust says. “It’s the most common chronic disease in childhood, and it’s a high-disparity condition with

all this, by way of creating a clinically focused strategy to bring health care providers appropriate training and resources, along with redesigned processes to impact dramatically different outcomes for health disparities and overall minority, low income, and underin- asthma morbidity in the region.” sured populations. It’s also a highvariance condition in that there is a Virgil Murray is the Safety-Net significant gap between usual care research coordinator, overseeing and optimal care. We just knew we implementation of asthma guidecould do a better job.” lines and resources in clinics participating as study sites in the program. The target population for this effort “This coalition” he says, “has not included community health center only allowed very strong individual clinicians and asthma patients within and cumulative evaluation and the Southeast Regional Clinicians’ followup, but also enables our Network (SERCN), more than a participating clinic sites to monitor hundred Federally funded communi- their successes as they happen.” ty and migrant health centers in eight southern states (Alabama, Florida, In launching the Safety-Net

Georgia, Kentucky, Mississippi, North Carolina, South Carolina and Tennessee). More than half of the SERCN patient population falls

program, an initial sample of 32 potential clinic sites was selected. These were locations and communities Safety-Net below the poverty level and 56 directors and coordinators felt percent are represented by African would not only offer an informative American and Hispanic populations. cross-section of clinic styles and

Improving Health Changing Lives Communities Taking Action 45

“An important point about our effort is that we’re not just trying to push knowledge out of academia. We want to be a conduit for wis- dom and experience coming back from the communities. And we want our health profes- sionals and clinic staffs that are working out there on a daily basis to know their messages for us will be treated with integrity. We want to do our best to bring the word from the front lines of health care to the people who create guidelines and write national policy.”

George Rust, M.D., M.P.H. Project Investigator, Morehouse Safety-Net Practice Based Asthma Research Network

communities served, but also repre- financial, social, or cultural— sented sites where the need was are impacting implementation of great. During the recruiting process, asthma protocols. And as we go Safety-Net representatives in Atlanta forward we’re learning how to made many phone calls to discuss address and surmount obstacles that the study and the benefits of devel- are unique to specific communities.” oping broad-based coalitions in the

interest of better health. “This was not prescriptive, though,” says Mr. Murray. “We were not recruiting sites and then insisting their providers adhere to an ideal standard of care. The entire point was to learn more about how national guidelines might be tailored to fit specific communities. One of the benefits of the Safety-Net program has been incoming data on what

The Safety-Net coalition enlisted 9 intervention sites and 12 control sites. “These are facilities that already do a lot with a little,” Mr. Murray says. “We prepared a kind of digest of the asthma guidelines, and worked to tailor them to different clinics in different locations. And we told our partners that this entire effort was a collaboration— in other words, if they needed to kinds of influences—be they clinical, vary how they achieved guideline

46 Improving Health Changing Lives Communities Taking Action

compliance based on local needs or issues, they should do so.”

The Safety-Net intervention provided not only tailored guidelines, but resources like spacer devices used in administering asthma medications, and peak flow meters that are not only diagnostic tools but encourage self-monitoring and self-management of asthma. The overall strategy focuses on two NAEPP goals: the diagnosis and management of asthma, and the prevention of recurrent exacerbations.

“Every study of asthma care clearly shows there’s way too much onetime point-of-care intervention and not nearly enough education and preventive care that will substantially reduce morbidity and reduce both burdens of illness and cost,” says Dr. Rust. “It’s one thing to talk about translating research to clinical practice, but when you consider the next step, translating from academic-centered clinical care into real world clinics that are underresourced and care for low-income populations—it’s at this level where our great challenges and opportunities lie. Translating what research has taught us into practical, everyday applications is how we’re going to make a difference and eliminate disparities in our health care system. And this, in a nutshell, is what the Morehouse Safety-Net project is all about.”

Arkansas

Iattended a seminar sponsored

“ by the Arkansas Asthma

Coalition,” says Kristy Summerhill, R.N., of Little Rock Children’s Clinic, “and I learned how to perform a pulmonary function test (PFT) for the first time. Not only that—I learned how to interpret a PFT. And, believe me, this one fact alone has changed the way we work.”

The lack of adequate medical care combined with poor access to medical services critically affect asthma morbidity in Arkansas, key factors that led to the initiation of an asthma coalition for the State, administered from the Arkansas Children’s Hospital Research Institute in Little Rock. The program targets primary care providers and their staff, along with school nurses, particularly those serving rural and Medicaid populations. By raising awareness and promoting behavioral change in primary care providers, the ultimate target population—low-income, rural children—will benefit.

“I attended a second seminar put on by the asthma coalition,” says Ms. Summerhill. “I’ve learned what to look for in identifying mild, moderate, or severe asthma. Here at the clinic I work with a nurse practitioner and we do the screenings and evaluate our findings. The seminars really brought me up to speed: they taught me about forced

A clinic physician counsels her young patient about asthma.

expiratory volumes and lung residu- implementation among primary care als and what significance these providers, improving the health things have for our patients. Before care for patients with asthma in the this we referred every patient with high-risk, rural areas that surround even possible asthma to allergists. Little Rock. But after the seminars we’ve been able to bring these services back to Primary care providers, and nurses the clinic. It’s better for our patients like Ms. Summerhill, are exposed to in every way: better care, cheaper multifaceted asthma educational care, smarter care.” interventions that improve the diagnosis and management of asthma.

Capitalizing on earlier work of the Arkansas Asthma Coalition, this stage of the effort evaluates the

Health care providers in high-risk communities were invited to attend continuing medical education magnitude of asthma morbidity and (CME) sessions focusing on the mortality in Arkansas in developing assessment and treatment of asthstrategies to promote best practices ma, as well as on skill-building

The lack of adequate medical care combined with poor access to medical services critically affect asthma morbidity in Arkansas...

Improving Health Changing Lives Communities Taking Action 47

techniques in managing, educating, and communicating with asthma patients. Clinic support staff

patient referrals, Ms. Summerhill says that “our patients are much happier, too.” received training on techniques for educating and managing patients “It’s interesting to note,” Ms. with asthma. School nurses received Summerhill adds, “that one of the training on establishing links with allergists in town is now sending primary care providers, and how to pediatric patients to us to get pre-

identify and refer children with undiagnosed asthma to medical care.

liminary PFTs done! The assistance of the Arkansas Asthma Coalition has made a world of difference for this clinic.” All of this speaks to the first three goals of the NAEPP program: Indianapolis, Indiana promoting asthma awareness, improving diagnosis and manage- About 600 miles north

ment of asthma, and reducing recurrence or worsening of asthma. Success is being measured using patient documentation in medical

of Little Rock, in Indianapolis, studies conducted in innercity middle schools

records and electronic databases. Investigators are looking for changes in practice patterns (e.g., documented management plans),

found a 20 percent prevalence rate of asthma. Preliminary research in those schools demonstrated the importance of targeting teachers prescription patterns (e.g., increased and school staff to facilitate asthmaanti-inflammatory medications), and friendly school environments for

improved patient self-management. Ms. Summerhill says the help of the Arkansas Asthma Coalition “changed my practice. I became

children with asthma, and to provide classroom workshops that increase student awareness about asthma. much more familiar with all the

asthma medications, how they’re used and why they’re used. But it’s more than just technical information. What I’ve learned—and been able to share with my colleagues— has made a very large difference in the services our clinic delivers.” And in noting that the Little Rock Children’s Clinic has been able to reduce paperwork, administrative

The Indianapolis coalition’s portfolio includes comprehensive school staff training and followup, and consultation to facilitate asthmafriendly school environments along with an infrastructure for ongoing student asthma education programs. Asthma screening is provided in 13 Head Start sites, as well as parent education and Head Start case time on the phone, and unnecessary manager training.

48 Improving Health Changing Lives Communities Taking Action

COMMUNITIES

Based on the startling asthma prevalence rate of 20 percent in Indianapolis inner-city middle schools, the Indianapolis Asthma Community Development Group has expanded efforts in elementary and middle schools, along with Head Start programs that serve as core sites for multidimensional education and screening. With the American Lung Association also involved in the partnership, the program is administered through the Marion County health department (Health and Hospital Corporation of Marion County, Inc.) in Indianapolis, with project manager Catherine Parker, M.S., R.D., providing direction and strategic planning.

“When we first initiated this program,” says Robin Costley, C.R.T., “we decided that kids are the best place to start with asthma education.” Ms. Costley is the Indianapolis coalition’s supervising asthma educator, coordinating Head Start activities, parent and staff education, and asthma screenings for all children participating in Head Start programs in Marion and surrounding counties. “We also do

“When we first initiated this program, we decided that kids are the best place to start with asthma education.”

school workshops for children, par- major NAEPP goals: promoting

ents, and teachers,” Ms. Costley says. “I coordinate those as well, making sure we have properly trained educators available for the events.”

asthma awareness, enhancing the diagnosis and management of asthma, and the implementation of community programs and policies that might contribute to a reduction in recurrences of asthma. Ms. Costley draws from a pool of

12 educators that include nurses and respiratory therapists from various hospitals and other local organizations, in support of the

Head Start programs require regular physician visits, and the Indianapolis coalition has used that aspect of policy to link asthma screening and coalition’s objectives that echo four care to the publicly supported pre-

school programs. “We’ve developed a form that alerts a doctor or other health care provider to children who have screened positively to a simple set of questions. Head Start also requires an Asthma Action Plan for all their children with asthma, so we’re getting 100 percent followup for our kids and a cooperative program we can feed into.”

With this multitiered educational approach in action, community understanding of asthma has improved, leading to public and medical policy changes that will improve the overall diagnosis and management of children with asthma. Along the way, Ms. Parker, Ms. Costley, and their colleagues,

Improving Health

are marking success by documenting the increase in asthma-friendly policies and programs in schools, decreased school absenteeism from asthma, and increased awareness about asthma among groups targeted for education and training.

New York City

Emily DiMango, M.D., of the Columbia University Asthma Coalition (CUAC) in New York City points out that asthma among Latino populations in New York has often received less than adequate clinical attention over the last few years. This has been remedied through CUAC asthma poster. the efforts of CUAC, based at the Columbia University College of

Physicians and Surgeons. “We’re among the first initiatives in the New York City area to focus on

rate among urban New York Latino communities, a rate similar to that of Harlem, where asthma abounds. and document the impact of asthma “From the start,” says Dr. DiMango,

in the Latino community,” says Dr. DiMango, whose program has brought new understandings of

“CUAC was specifically tailored to inner-city, low-income populations with a large portion of non-English asthma’s toll in lives and families to speaking individuals.” the predominantly Hispanic neighborhoods of Washington Heights, As an investigational project, CUAC at the northern tip of Manhattan. examined the use of a comprehensive, multidisciplinary approach to

“Through our various interventions,” Dr. DiMango says, “we’ve been able to demonstrate a 40 percent reduction in hospitalization rate in our catchment area.” This achievement alone is remarkable, in view of CUAC documentation

care in the clinic system of a major medical center in an urban area, along with culturally sensitive public awareness and community outreach campaigns. Emphasis was consistently placed on languagespecific community outreach and that showed a 15 percent prevalence public awareness campaigns to

50 Improving Health Changing Lives Communities Taking Action

reduce asthma morbidity and mortality in the target communities.

“We wanted to reach the high-risk individuals by any means necessary,” Dr. DiMango says. “We identified ‘high-risk’ as those individuals with frequent emergency department visits for asthma exacerbations, along with their families, primarily the mothers who often make decisions regarding health care or the need to seek help.” The overall strategy included CUAC’s link with two advisory boards and two major community partners that umbrella 75 smaller community groups, focusing on three major NAEPP goals, the promotion of asthma awareness along with improved diagnosis, management, and control of recurrence of asthma.

CUAC designed a community rollout that included enlisting high-risk patients into a culturally appropriate, multifaceted program for asthma management. The program incorporates appropriate medical care, asthma education, behavioral and social screening, environmental assessment, and referrals to appropriate social service agencies, built around bilingual asthma educators.

“Our asthma educators are individuals from within the community,” says Dr. DiMango. “They present workshops, seminars, and small group sessions at clinics. They’ve

“Through our various interventions, we've been able to demonstrate a 40 percent reduction in hospitalization rate in our catchment area.”

done over 50 workshops at WIC (Women, Infants, and Children) Clinics in the neighborhood. We

More and more people in our target group know what asthma is and that it’s a significant community

even did random street surveys over problem as well as a health concern. the last two summers, asking folks

about their awareness of asthma— and found that awareness is on the rise. We’ve demonstrated improvement in what I call ‘Asthma IQ.’

Dr. DiMango says the CUAC asthma educators make home visits, too, discussing common asthma triggers in the family environment. “And

we’ve partnered with the Columbia School of Nursing,” Dr. DiMango adds. “The school has a community outreach class that nursing students are required to take, and some of the students were interested in outreach and home visits. So our asthma educators now take student nurses along on their home visits, allowing us to extend our efforts to the education of new professionals. This benefit has proven to be typical of our work with asthma: there are unforeseen advantages, new opportunities, and new understandings. You can’t know how far you can go until you start.”

Improving Health

Fresno, California M.P.H., C.H.E.S. “Right out of the gate,” Mr. Clegg says, “we recog- The residents of the San nized the needs of this community Joaquin Valley in cen- were both various and quite specific. tral California reside Languages, cultures, beliefs...plus in a geographic area our people are spread over a lot of with some of the high- miles, from low-income farm workest asthma mortality rates in the ers living in camp settings, to our United States. Reaching a popula- Southeast Asian populations.” tion particularly vulnerable to

excess asthma morbidity due to large proportions of ethnic minorities—notably Hispanics and one of the nation’s largest concentrations of Hmong—is a dynamic asthma coalition led by Robert Clegg,

One of the most successful approaches to getting the word out on asthma in this environment was through the medium of video. “Our video was a huge success,” says Mr. Clegg, “and has been

San Joaquin Valley farm workers.

52 Improving Health Changing Lives Communities Taking Action

COMMUNITIES

Central California holds one of the nation’s largest concentrations of ethnic Hmong—Southeast Asians from Thailand and Laos—where they face many of the same challenges as do other ethnic groups adjusting to a new home. “We’ve developed a couple of very successful programs centered around educational materials that target the Valley’s Hmong residents,” says Mr. Clegg. “We have an ‘Asthma 101’ binder in

English, Spanish, and Hmong, which is a book of transparencies that can serve as a guide for workshop leaders, but also serves health care providers in educating their patients one-on-one or in small groups.

Family members can use the binder equally well, as can self-care givers.” ‘Asthma 101’ covers basic anatomy and function of the human lung, and illustrated steps to take if either you or a family member is experiencing an asthma attack.

“We also developed a four-color poster providing five simple steps on what you need to do in the event of an asthma attack,” says Mr. Clegg, “and this has been adopted by the California School Nurses Association for use in the State’s schools.” A front-back design, the poster features English/Spanish on one side and English/Hmong on the reverse. In tandem with these materials, the coalition created laminated asthma medication posters that include all major asthma drugs now in routine use. “These posters are ideal for clinics and hospitals,” according to Mr. Clegg. “They’re available in both an 11- by 17-inch wall version and an 81/2- by 11-inch hand-held

Hmong–language asthma poster.

edition. We’ve given out more than 3,000 of the medication posters. We have an order form that we leave at

broadcast in North Carolina, Minnesota, and Alaska, as well as many times over right here at

conferences, medical education events, and town meetings, and orders are brisk—approaching home.” Premiering on public televi- 10,000 orders filled so far.” sion in the greater Fresno area on July 20, 2002, the video is an hour- A community needs assessment long program featuring Long Thao, identified the primary need for this

M.D., the only Hmong-speaking physician in the Valley. “Dr. Thao served as our on-air medical con-

community to be a long-term, coordinated commitment to asthma control. The San Joaquin Valley Health sultant, fielding questions from both Consortium asthma coalition has

a live audience and call-ins, speaking in both English and Hmong.” Also aired on radio, the program was broadcast once a week for a month.

addressed that need by employing a multitiered community approach of mass media, health care provider training, and outreach to schools and other community organizations.

Mr. Clegg reports an array of specific activities, including a multicultural, multilingual mass media campaign of TV, radio, print and billboard in rural areas and farm labor camps; a media rally on World Asthma Day; ongoing asthma education and training for professionals and the public alike; representatives from schools, churches, and child care centers trained to implement asthma-friendly programs and policies.

“We’ve documented, right now, outreach to more than 33,000 people in the Valley,” reports Mr. Clegg. “Our CME programs have reached over 500 health care professionals. We’ve educated over 4,000 parents of kids with asthma. Our schoolbased outreach now exceeds 8,000 children. And we get calls every day to offer presentations in the community—a sure sign we’re having an impact.”

The coalition’s goal, according to Mr. Clegg, “is straightforward: we want to create partnerships that are self-sustaining and institutionalized within this community. Through implementation of the awareness strategies, media messages, and an increase in the number of community organizations actively involved in the coalition, we are making real headway against asthma-related morbidity and mortality.”

Improving Health

Tacoma, Washington

Our program is

“ called Clean Air

For Kids, and it’s operated by the Tacoma-Pierce County Asthma Partnership,” says Leanne Noren, program director. “One of the most outstanding aspects of this program is the partnerships we’ve forged throughout the county, with local academic and medical organizations. These partnerships have helped us sustain interest and bring validity to what we wanted to do—which is offer outreach to families—in their homes—where children with asthma live. In the low-income communities of Pierce County, even a health outreach worker at the door can be viewed as suspicious, so citing our partners and endorsers has helped a lot.”

The Clean Air for Kids Coalition uses outreach workers and volunteers to implement a variety of services, including identifying high-risk individuals through documented visits to area hospitals and clinics and making outreach workers an integral part of the primary care team in the role of client advocates. The Coalition also encourages development of a school asthma management plan, and conducts a Home Environmental Assessment List (HEAL) to identify indoor air

Industry in Tacoma, Washington.

“These partnerships have helped us sustain intertest and bring validity to what we wanted to do—which is to offer outreach to families—in their homes—where children with asthma live.”

pollutants and then develop an action plan to alleviate the problems.

lines. “When we launched we anticipated that we would interact with 60 families over the 3-year course

of the project,” says Ms. Noren. Additional activities include com- “But we found that families only munity asthma education programs need us for about 4 or 5 months, for children and families, and con- and then they’ve got what they tinuing education and other oppor- need—our followup evaluations tunities for health care providers found that families and kids do based on national asthma guide- much better with that level of

Communities Taking Action

COMMUNITIES

Clean Air for Kids

Clean Air for Kids is reaching children and adults of multicultural populations, many non-English speaking, who reside in four high-risk communities in Pierce County where there is significant poverty, unemployment, substandard housing, and general distress. Leaky roofs, poor ventilation, mold and mildew, and increased exposure to secondhand smoke place an already demographically high-risk population at even greater risk for development or exacerbation of asthma. The project draws upon outreach workers and volunteers to deliver an intervention that integrates environmental education strategies with access to proper medical care as a means of strengthening medical management of asthma.

outreach and support. The upshot is that we’ve been able to serve more than twice the number of families as we originally projected— we’ve hit 158. We have been much more successful than we ever imagined.”

Chicago, Illinois asthma mortality rate four-fold higher than African American com- Jura Scharf, executive director munities in other major cities.”

of the Chicago Asthma Consortium, remembers the year 1995. This was when

Responding to this challenge brought the formation of an ALA- ACCP action partnership, which members of the Chicago-area became the nucleus of what was to chapter of the American Lung become the Chicago Asthma Association (ALA), in discussion Consortium (CAC). with the leadership of the American College of Chest Physicians (ACCP), Employing the Community

registered alarm at the precipitous rise of asthma in the Chicago metropolitan area. “That alarm was quite particularly noted on behalf

Organization Theory, the program utilizes the “community activation” approach, which emphasizes the involvement and coordination of of our African American communi- major community institutions to ties,” Ms. Scharf says. “Those mobilize community leadership and communities were experiencing an resources for health promotion and

Ultimately, the CAC was integral in pushing through a law that now extends asthma medication privileges to all students in all schools, public and private, throughout the state of Illinois.

Improving Health Changing Lives Communities Taking Action 55

COMMUNITIES to improve public awareness of

health issues. It also employs the

From the beginning, the CAC hoped to create a legacy—the possibility that a defined period of grant support would build a capacity for continua-

Social Marketing Theory, which guides the design and distribution of the asthma awareness message, whether presented in print, electronic, or face-to-face formats. Communities tion, for sustaining asthma outreach have participated in public asthma efforts across the many years needed awareness events, self-assessed to effect lasting change in public asthma risks and knowledge, and health. Ms. Scharf says that a “very identified community asthma

large benefit of the CAC is in teaching all of us about the value of coalition and collaboration. The CAC

leaders whose influence endorsed and promoted the development of local asthma networks. brought people together and helped them see things in new ways. As a “An achievement we look on with particular pride is our work with result of these relationships, people the Chicago public schools,” Ms. have been very successful in bringing Scharf says, “where the CAC has more and new grants and contracts led an effort to change school medto the city in support of various ication policy. Children are now aspects of asthma intervention. At allowed to carry their emergency

this point we can look at new referral systems, coalitions down to the neighborhood level, partnerships that involve schools, churches, and businesses, all in the service of outreach

asthma medications with them— rather than the older system where medications were locked in the nurse’s office.” Designed to reduce uncontrolled asthma exacerbations when children do not receive medactivities that echo Chicago’s long ication in a timely manner, the politradition of community-based activity. cy change was in no way a simple We now have an entire network that or straightforward undertaking. continues to build and connect.” Ms. Scharf describes the enlisting of partners and allies, advocating with school and community leaders, and making numerous presentations about the rising prevalence of asthma. Ultimately, the CAC was integral in pushing through a law that now extends asthma medication privileges to all students in all schools, public and private, throughout the State of Illinois.

56 Improving Health Changing Lives Communities Taking Action

In focusing on two NAEPP goals— promoting asthma awareness and implementing community asthma programs and policies—formative evaluation preceded and directed CAC program efforts. Along the way, the CAC developed its message on many fronts, including issues of medication adherence, clinical care and professional education, and referral networks.

“When we discovered that the rate of refill on asthma medications was quite poor, we went to both Medicare and private pharmaceutical distributors,” says Ms. Scharf. “In creating partnerships with these agencies, the CAC was able to review and track asthma medication prescribing and dispensing patterns, and see where in the city efforts needed to be emphasized or redoubled. We can now happily report a statistically significant improvement in medication refills in metropolitan Chicago over the rest of the State. Hand in hand with compliance improvement, the CAC has also created model collaborations of hospital emergency departments and outpatient clinics to improve processes of care and reduce asthma recurrence and clinic visits.” 

DISCRIMINATION PROHIBITED: Under provisions of applicable public laws enacted by Congress since 1964, no person in the United States shall, on the grounds of race, color, national origin, handicap, or age, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity (or, on the basis of sex, with respect to any education program or activity) receiving Federal financial assistance. In addition, Executive Order 11141 prohibits discrimination on the basis of age by contractors and subcontractors in the performance of Federal contracts, and Executive Order 11246 states that no federally funded contractor may discriminate against any employee or applicant for employment because of race, color, religion, sex, or national origin. Therefore, the National Heart, Lung, and Blood Institute must be operated in compliance with these laws and Executive Orders.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health National Heart, Lung, and Blood Institute

May 2003