Cardiovascular disease (CVD) is especially prevalent among vulnerable populations. This health disparity is true across all vulnerable populations—from ethnic minority,1 to low-income,2–4 to income-poor5,6 neighborhoods and high-risk geographic regions in the United States.7,8 Corresponding disparities also exist for CVD risk factors, such as obesity, hypertension, smoking, and sedentary lifestyles.1–3 Furthermore, despite US prioritization of addressing the health needs of these vulnerable populations,1,9 cardiovascular disparities in the United States have generally worsened over the past 3 decades.4,10 Reasons for this disparity in CVD include, but are not limited to, fewer socioeconomic resources,11 limited English proficiency,12 and differences in quality of care for vulnerable populations13–17 even when health access is accounted for.12,13,17
Davis and colleagues18 conducted a systematic review of healthcare interventions from 1995 to 2006, focusing specifically on cardiovascular health in racial/ethnic minority populations. They concluded that high-quality research specifically addressing reduction of cardiovascular racial and ethnic disparities is virtually nonexistent. Their review, however, did not include interventions that were exclusively community focused, such as faith- and school-based programs, which have increasingly been shown to produce positive effects in improving physical activity, weight loss, and blood pressure (BP) control. Furthermore, the review focused only on racial/ethnic minority populations, 1 segment of the population who may be disproportionately vulnerable to CVD. Therefore, the purpose of this article was to conduct a systematic review of community-based cardiovascular health interventions in vulnerable populations.
Reviewing the existing literature is especially important with the Affordable Health Care Act providing access to individuals from more vulnerable populations. Improving access however, is not sufficient to reduce cardiovascular disparities as it is critical to determine what approaches work well for specific populations. This review adds to the analysis by Davis and colleagues18 by analyzing interventions with a community-based component. Further, this review includes research with vulnerable low-income populations irrespective of race or ethnicity.
Vulnerable populations are defined in various ways. Vulnerability can be broadly defined as “the susceptibility to harm.”19(p 1220) The literature is often defined by the way vulnerability is identified, most often as people who are from rural, poor, racial, or ethnic minority or special groups such as veterans, those uninsured without health insurance, disabled persons, homeless people, or elderly individuals with numerous coexisting chronic illnesses.19 In addition, vulnerability is often measured using broad dichotomies, that is, a population of vulnerable/nonvulnerable people. However, evolving conceptualizations of vulnerability view it as a multidimensional construct, resulting from numerous individual as well as community-level factors,20 and this is the viewpoint guiding the inclusion of studies in this article.
Health outcomes observed as a result of this approach to defining vulnerability would need to consider both individual- and community-level factors to identify health disparity patterns. Consequently, interventions that extend beyond a single risk factor to target multiple risk factors would likely be more efficacious.20 In 2010, the American Heart Association (AHA), the leading voluntary health organization in CVDs and stroke, changed its focus from reducing the burden of CVD to promoting cardiovascular health.21 It defined ideal cardiovascular health as the simultaneous presence of ideal health behaviors (nonsmoking, body mass index [BMI] <25 kg/m2, physical activity at goal levels, and a diet consistent with current guideline recommendations) and ideal health factors (untreated total cholesterol <200 mg/dL, untreated BP <120/80 mm Hg, and fasting blood glucose <100 mg/dL). These 7 metrics, selected by the AHA, will assist in determining the changing prevalence of cardiovascular health status and define achievement of the impact goal. In this article, we used the AHA’s 7 metrics to provide a critical review of the effect of community-based CVD interventions on improving cardiovascular health behaviors and factors of vulnerable populations in community settings.
We conducted a systematic literature search with librarian consultation in PubMed, PsychInfo, CINAHL, and Scopus. These included terms such as vulnerable populations OR healthcare disparities AND cardiovascular disease AND clinical trials OR public health practice AND English. See Appendix 1 for all search terms used. This search strategy resulted in the retrieval of 7120 abstracts. Each abstract was reviewed by at least 2 authors (BW-M, SLS, THN, YC-M, LS), and eligibility for the systematic review was confirmed after reading the full article (Figure). At least 1 author read each article in full before determining eligibility and justified the exclusion of articles to the group. Articles were included in the systematic review if the title and abstract described a community-focused intervention targeting a vulnerable population and described a CVD or at least 1 of the following AHA-defined cardiovascular metrics: BP, smoking, physical activity, BMI, diet, cholesterol, and fasting blood glucose. To be included, the article had to be published between January 2006 and March 2011 and describe statistical testing on at least 1 of the AHA metrics. Vulnerable populations include racial and ethnic minorities, those of low socioeconomic status or low literacy, and individuals who reside in geographic isolation or poverty. Studies were excluded if they were not in English or were published before 2006 or if individuals were described as vulnerable due solely to physical health characteristics, such as age or health status.
Thirty-two studies met eligibility criteria, including 16 randomized controlled trials (RCTs),22–37 9 quasi-experimental studies,38–46 and 7 single-group pretest/posttest investigations.47–53 All but 7 studies23–25,29,30,38,43 represented unique study samples. Vulnerable (ie, susceptible to harm) populations studied included Asian/Asian American,25,30,38–40,41,43,50 African/African American,26,29,32,34,42,47,50–52 Latino/Hispanic American,23,24,31,36,48 as well as low-income or populations from socially disadvantaged neighborhoods,27,28,33,35,37,41,44–46 rural settings,37 or neighborhoods with elevated mortality rates.46 Two investigations25,29 were conducted with adolescents, and the remainder, with adult populations. Most studies were conducted in the United States, with the remainder completed in South Africa,26 Guatemala,34 China,39 Norway,41 Pakistan,44 Sweden,45 the Netherlands,28,46 or Australia.27 Sample sizes varied widely from as few as 16 participants52 to more than 110 000.39
Education was the most common intervention,23,24,34,35,37–39,43,44,47,49,50 comprising about 38% of the studies reviewed, followed by counseling or support,35,38,39,41–43,46,47,53 constituting 28% of the reviewed studies. Seven (22%) of the investigations included both education and counseling or support.34,35,38,43,47,48,51 Nine (28%) of the education investigations were RCTs.23,24,27,29,30,33–35,37 Exercise classes were also included as the main strategy or in combination with others in approximately 19% of the investigations39,41,45–47,52 in this sample. None of the exercise studies were RCTs. Less frequently used interventions included community improvements,41,44,46,50 meditation,25,29 healthcare provider training,34,39 food provision,26,36 or storytelling.32,42 Five of the studies with less frequently used interventions were RCTs.25,26,29,32,36 About 31% of the investigations included more than 1 component.38,39,41–46,50,51
Healthcare providers were the most frequent interventionists,26,28,30,33–35,38,43,45,46,51,52 followed by public health or community professionals,25,27,29,41,44,50,51 community health workers,23,24,31,36,47 or prelicensure health students or research staff.37,40,42 The interventionist was the patient for 1 study.32 One investigation did not report who implemented the intervention.39
Duration of follow-up was most often 2 to 12 months, but there were investigations in which the intervention and assessment occurred on a single day42,49 as well as those with a duration beyond 12 months.36,39,41,44,46,47 Community settings were also variable but most frequently included clinics23,24,28,31–33,37,42,45 or homes25–29,32,34,38,43 as well as various other community sites.25,29,35,36,39,41,42,44,46,49
The following sections describe the 32 selected articles based on their focus on 1 or more of the following AHA measures: BP, smoking, physical activity, BMI, diet, fasting blood glucose, or cholesterol. Statistical significance was determined using a level of significance of α = .05.
Twenty investigations tested BP as an outcome measure22–26,28,29,31–36,38–43,51; 13 of these were RCTs.22–26,28,29,31–36 Thirteen of these investigations did not require eligible participants to have baseline BPs of at least 140/90 mm Hg or be on BP medications.22,24,25,28,29,31,33,35,36,39,41,42,51
Studies With a Blood Pressure of at Least 140/90 mm Hg Not Required
These studies had a range of foci, from adolescents,25,29 to African American men,42 to CVD prevention or risk reduction trials,31,36,39 to physical activity/diet,33,35,41 to diabetes mellitus.22,51 The remaining investigations required a cardiovascular risk factor that could include 1 of several such as diabetes or high cholesterol, as well as hypertension.24,28 Significant reductions were observed in systolic BP (SBP) in 62% of the BP studies in this group.25,29,31,35,36,39,41,51 Significant diastolic BP (DBP) reductions were observed25,29,35,39,51 in 38% of the studies. Five investigations were RCTs25,29,31,35,36 and 2 were non-RCTs,39,41 in which significant BP differences were observed between groups. One investigation did not include a comparison group.51 Interventions, interventionists, and duration of follow-up were varied across studies.
Reductions in BP in 2 investigations39,41 were significant only if sex was accounted for in the analyses. Jenum and colleagues41 had nearly equivalent numbers of men (43%) and women (57%) in their 3-year community risk reduction trial in Norway. Although both sexes significantly reduced their SBP, effects for men were moderated by age; that is, these reductions were present only among men older than 50 years. Significant reductions were consistent for women of all ages, although of greater magnitude for those older than 50 years. In contrast, Chen and colleagues39 observed in their 9-year CVD risk reduction trial among Chinese factory workers that significant BP reductions depended upon whether participants were urban or rural residents. Among all urban residents, DBP reductions were greater in the treatment group relative to the control group, a finding observed in men and women. Significant SBP reductions were also observed, but only among urban participants who were normotensive at baseline. Among rural participants, however, greater BP reductions were limited to SBP and noted only for women.
Studies With a Blood Pressure of 140/90 mm Hg Required
Seven investigations required study participants to have a diagnosis of hypertension to be eligible.23,26,32,34,38,40,43 Half of these were RCTs.23,26,32,34 No study in this group had a follow-up duration of 12 months or longer. In 3 investigations, participants in the treatment groups were more likely to have significant SBP26,32,34 or DBP32 reductions. Reductions in BP for 2 studies32,34 were limited to participants with uncontrolled BP (treated or untreated) at baseline.
Houston and colleagues32 used a storytelling intervention with African Americans, achieving significant SBP and DBP reductions for participants with uncontrolled BP (stage 2 hypertension defined by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [JNC 7]) at baseline. Pezzin et al34 investigated 2 home-based interventions that differed in intensity with African Americans from a home health agency. Blood pressure control was achieved for participants with JNC stage 2 hypertension at baseline but not the overall group. These reductions were limited to SBP and observed for the augmented intervention relative to usual care.
In summary, 20 investigations included BP as an outcome measure (Tables 1–3). In more than half of these studies, BP greater than 140/90 mm Hg (treated or untreated) was not required for study participation. Significant BP reductions were more frequently noted in this group compared with the group requiring a hypertension diagnosis. In some studies, statistically significant BP reductions were dependent on residence, sex, or BP severity (see Tables 1–3).
Other Cardiovascular Risk Factors (Body Mass Index, Physical Activity, Diet, Fasting Blood Glucose, Cholesterol, and Smoking)
Twenty-one studies measured aspects of weight management behaviors, including changes in BMI, physical activity, and/or diet.15,16,18–20,22,23,25,27,29,31–33,38,40,44–48,50 Interventions included education,15,16,19,25,27,29,31,32,38,40,44–48,50 counseling,15,16,19,23,25,27,32,38,46–48 exercise classes,25,33,40,44–47 improved community-based primary care services,31,20 the provision of healthful food,18 and structural improvements in the community.33,45 Most included interventions targeted at minorities, but several targeted low-income and underserved communities that did not have a predominance of minority residents.19,25,27,31,33,38
As can be seen in Tables 1 through 3, 12 studies reported BMI data; 5 studies found a statistically significant reduction in BMI, and no differences in BMI were found in the RCTs between groups. Similarly, 4 of 13 studies found statistically significant improvements in physical activity, including 1 that found increased physical activity at 6 but not 12 weeks after intervention.41 Among the 6 investigations including fasting blood glucose as an outcome, only Stein and colleagues36 observed significant between-group results among children in Guatemala. Children who were fed azole, a nutritional supplement, between 36 and 72 months of age had significantly lower fasting blood glucose levels, an effect noted in both sexes. Of the 7 studies that included total cholesterol as an outcome measure, only Steinhardt et al52 observed significant reductions. Eleven studies reported dietary outcomes, with inconsistent findings, with all but 1 study33 relying on self-report. Tables 1 through 3 present dietary results relevant to the AHA dietary score, including consumption of sodium, fruits and vegetables, and fiber. Studies also found reduced consumption of fats and cholesterol23,24,27,51; increased intake of potassium, calcium, and magnesium23; and improved overall dietary patterns.23,24,31
Six investigations included smoking status as an outcome.24,30,31,39,47,50 Five studies followed participants for 1 year or more to see if smoking rates decreased30,31,39,47,50 and another followed participants for 4 months.24 Only Chen and colleagues39 found a significant decrease in smoking prevalence after intervention, and this finding was limited to rural-residing men only.
Intervention effects on BP did not appear to be more effective for one group over another. All racial and ethnic minorities as well as low-income groups were represented. Overall, these interventions seem to be more effective for reducing SBP versus DBP; however, there is more potential variability for SBP. Notably, more than half of these interventions were tested in RCTs. Research that examined intervention effects on BMI and physical activity seemed to be more efficacious for low-income individuals or individuals living in socially disadvantaged communities again, regardless of race or ethnicity. We found that studies including BMI as an outcome measure may be more effective for men, whereas studies including physical activity may be more effective for women. There were no studies for which BMI or physical activity improved more for women or men, respectively. In contrast, dietary interventions were effective across vulnerable populations studied.
Because of the heterogeneity of the interventions, it is difficult to state which interventions are more effective. Similarly, no one vulnerable group appeared to benefit more from one type of intervention over another with regard to the AHA measures reviewed. Even so, there was a pattern for successful education and support interventions in that there was often initially a more intensive phase that was either individual or group based followed by a less intensive phase that often included individual telephone support or support groups. Again, this approach appeared to be no more effective for one vulnerable group over another but effective for each.
We conducted a systematic review of community-focused cardiovascular interventions targeting vulnerable populations. Blood pressure interventions were the most promising, whereas behavior change interventions (such as those targeting increased physical activity or decreased smoking) were the most challenging. Education interventions were the most common type of intervention, although almost half of interventions were multicomponent. Almost all of the interventions were at the individual level. Finally, differential effects of interventions were observed with some results that were moderated by age, sex, education, or residence.
Because behavior change is so difficult, many have suggested the need to intervene at the community or even societal levels,20,54,55 such as increased neighborhood walkability56 or decreased access to sodas for children.57 This review found only sparse data addressing data that focused on integration into current healthcare practice or social policy, and all of the studies were proof-of-concept or efficacy trials. For those that were successful, it remains to be seen whether they can be translated into a larger clinical or societal population.
Strengths of the review include a systematic search of comprehensive databases with a standard extraction tool and multiple authors. Focus on the 7 areas targeted for ideal cardiovascular health was another advantage. However, our search did not yield enough studies that included fasting blood glucose, 1 of the target areas, as an outcome measure. Our review was also limited by the selection of studies published in English as well as possible publication bias. Furthermore, the heterogeneity of the studies prevented us from conducting a meta-analysis.
Future research should target other vulnerable groups such as the homeless or military veterans. Whenever possible, study duration should extend beyond 12 months. When considering physical activity and exercise, research designs should be RCTs, a design absent from physical activity studies in this review. Finally, it is important to consider carefully whether the comprehensive assessments themselves may lead to improved results. The attention given for these assessments may have more of an impact among vulnerable groups that may lack even minimal attention in “usual care” groups.
Because there are entrenched health disparities in CVD among vulnerable populations, it is essential to understand what can improve them. This analysis is a step toward this understanding as it synthesizes the current literature. The next step should be integrating the identified successful interventions into larger health systems and/or social policies.
What’s New and Important
Among all the community-based cardiovascular interventions reviewed in this article:
- Education interventions were the most common type of intervention, although almost half of interventions were multicomponent.
- Blood pressure interventions were the most promising, whereas behavior change interventions (such as those targeting increased physical activity or decreased smoking) were the most challenging.
- Almost all of the interventions were at the individual level and were proof-of-concept or efficacy trials.
The authors thank the directors of the P30 Center of Excellence for Cardiovascular Research of Vulnerable Populations for their support, mentorship, and encouragement in writing this article. They include Drs Martha Hill, Miyong Kim, Haera Han, Jerilyn Allen, Deborah Gross, and Cheryl Dennison-Himmelfarb.
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Appendix 1. Search Strategy