For vulnerable patients, community intervention can boost cardiovascular health

Offering health education to individual patients aimed at lowering blood pressure is the most common community-based intervention used among vulnerable populations to improve their cardiovascular health. And for about half of these patients, combining health education with one other community-based intervention such as counseling is commonplace, according to a systematic review of the literature of community-based cardiovascular health interventions of vulnerable populations.

Benita Walton-Moss, PhD, a clinical associate professor at the  University of Southern California’s Suzanne Dworak-Peck School of Social Work in Los Angeles described the results of the literature review during her presentation entitled “Community-Based Cardiovascular Health Interventions in Vulnerable Populations: A Systematic Review, delivered during the American Heart Association (AHA) Scientific Sessions in New Orleans.

Although cardiovascular health has improved for most Americans, cardiovascular disease remains prevalent among vulnerable populations. Walton-Moss conducted the literature review to fill in the gaps of what is currently known about the use of community-based interventions to improve cardiovascular health in vulnerable populations. She used a broader definition of vulnerability to include populations beyond racial/ethnic minority populations to include in the study.

Defining vulnerability as “the susceptibility to harm,” she included studies that looked at a wide range of vulnerable populations. These included racial and ethnic minorities, persons of low socioeconomic static status or low literacy, or persons who reside in geographic isolation or poverty. Populations were not included if their sole vulnerability was due to physical health characteristics, such as age or health status.

The review included 32 studies, 16 of which were randomized clinical trials. Of the other studies, nine were quasi-experimental studies and seven were single-group pretest/post-test investigations. Most of were conducted in the United States, and included sample sizes that varied from 15 to >110,000 patients. Most of the studies looked at adult populations, with two studies looking at adolescents.

The pooled data showed that education was the most frequently employed intervention, comprising about 38% of the studies. This was followed by counseling or support (28%). Overall, seven (22%) of the studies included both education combined with counseling or support. Exercise classes were used in 19% of the studies, either as a single or combined intervention. The least employed interventions included community improvements, meditation, healthcare provider training, food provision (monitored eating in a study) or storytelling.

Next: Challenges

Of the people providing the intervention, the data show that most are healthcare providers followed by public health or community professionals. Most intervention is delivered in clinics, homes and various community sites, and typically lasts between two months and one year.

When looking at specific cardiovascular health outcomes, the data showed that interventions for blood pressure were the most promising, said Walton-Moss. A total of 20 studies, 13 of which were randomized controlled trials, tested blood pressure as an outcome measure. In many of these studies, participants were not required to have a baseline blood pressure of at least 140/90 or be on blood pressure medication. The data showed significant reductions in both systolic and diastolic blood pressure, regardless of the category of vulnerability (i.e., race, economic, geographic).

Most challenging, according to Walton-Moss, are interventions aimed at changing behavior. Of the 21 studies that focused on weight management, five found significant reductions in body mass index (BMI), 11 reported on dietary outcomes with inconsistent findings and one study found a significant effect of smoking intervention among men living in a rural area.

Unlike interventions for blood pressure that did not appear to be more effective for one group over another, “intervention effects on BMI and physical activity appeared more efficacious for low-income or individuals living in socially disadvantaged communities,” said Walton-Moss.

In addition, data appeared to show that studies on physical activity as an intervention may be more effective in women than men whereas studies on interventions to reduce BMI may be more effective in men, she said.

Based on these results, Walton-Moss said that “when cardiovascular interventions are considered, providers should consider a community focused intervention with community health workers if appropriate.” She suggested that primary care physicians consider combining health education with another intervention, such as counseling, and tailor the approach to each patient.