Performing Department
Public Health Sciences
Non Technical Summary
Need for project. Heart disease is 1.34 more prevalent and cerebrovascular disease is 1.45 times higher in rural residents as compared to urban residents. Both hypertension (HTN) and ischemic heart disease are higher in rural counties than urban areas (Zuniga, Anderson, & Alexander, 2003). Rural citizens are concerned about these health threats, as 41% of respondents to the Rural Healthy People 2010 survey chose heart disease and stroke as their highest priority. The District of Columbia, Mississippi, Alabama, Louisiana, Texas, Georgia, and South Carolina have the worst uncontrolled HTN rates in the United States. These seven states had the highest number of people (all age groups) diagnosed with HTN in 2007 (BRFSS 2007). HTN is a major cause of stroke and heart attacks, the leading causes of death in South Carolina and Oconee County. In South Carolina, the overall prevalence of HTN increased from 1997 to 2008, from 26.8 percent in 1997 to 33.2 percent in 2008 which was higher than the nationwide median of 27.8 percent (2007 data) and significantly greater than the Healthy People 2010 objective of 16 percent (SCDHEC, 2009). Rates of HTN in Oconee County are even higher than the state average. Residents have higher rates of HTN risk factors than their national counterparts; they smoke more, drink more, are more obese and more often report having "poor or fair health" Project Aim: To improve hypertension control among program participants. Potential Benefits The Third National Health and Nutrition Examination Survey data revealed that even small changes in blood pressure - 2 to 3 mmHg - could result in a 25 percent to 50 percent decrease in the incidence of hypertension; specifically an annual reduction of stroke, coronary heart disease and all-cause mortality by 6 percent, 4 percent and 3 percent, respectively" (Halm, 2008). A 2006 study on quality improvement methods for hypertension management also found that even small reductions in high blood pressure have major impacts in clinical outcomes and health care spending. Specifically, a 2 mm Hg decrease in systolic blood pressure or diastolic blood pressure significantly reduces risk of stroke, coronary heart disease, and mortality from vascular causes (Walsh, JM., et al., 2006). Our current project, which we propose to expand, has demonstrated the ability to reduce mean systolic blood pressure by 2.28 mmHg indicating the potential to reduce stroke by 6 percent, coronary heart disease by 4 percent and all-cause mortality by 3 percent among the 19,000 Oconee County patients who have been diagnosed with HTN by the 49 physicians in the county (Oconee Physicians Practices, 2011).
Animal Health Component
(N/A)
Research Effort Categories
Basic
(N/A)
Applied
100%
Developmental
(N/A)
Goals / Objectives
The project, Expanded Health Coaches for Hypertension Control (EHCHC), will expand the reach of a current project, called: Health Coaches for Hypertension Control (HCHC), (which currently serves those diagnosed with hypertension over 60 years of age) by adding hypertensive participants 45-59 years of age in Oconee County, South Carolina. At the end of year one, we will develop plans for replication of activities in Abbeville and McCormick Counties in South Carolina. The project uses community health workers called Health Coaches (HCs) to deliver small group classes and support groups. Based upon promising results of work with those over age 60 years, we expect to see reduced systolic blood pressure, reduced BMI and waist circumference and reduced triglycerides accompanied by behavioral changes of increased physical activity, increased intake of fruits and vegetables, reduced sodium consumption, increased use of stress management strategies, and integration of daily blood pressure monitoring. We see our project as part of the HHS Million Hearts initiative which aims to prevent 1 million heart attacks and strokes over the next five years as we support the "B" of the "ABCS" goals by increasing blood pressure control through empowering rural residents to make healthy choices through mentoring by HCs (http://millionhearts.hhs.gov/). Project Aim: To improve hypertension control among program participants. Our project aim is directly aligned with two Healthy People 2020 objectives: HDS-5.1 Reduce the proportion of persons in the population with hypertension from 29.9% to 26.9% and, HDS-12 Increase the proportion of adults with hypertension who have it under control from 43.7% to 61.2%. (USHHS, 2011). Goal 1: Maintain and expand participation by consortium partners and stakeholders. Objective 1.1: Advisory Board will meet twice yearly with project team and Health Coaches to provide feedback on best strategies to grow and sustain program offerings. Goal 2: Recruit, train, and retain community volunteers as Health Coaches (HC's) Objective 2.1: Implement previously developed recruitment plan, training program, and retention program. Objective 2.2: Train and retain at least 10 community members to be HCs Goal 3: Enroll 250 Oconee County residents, age 45+, who have hypertension. Objective 3.1: Implement and refine referral protocol. Objective 3.2: Obtain informed consent from program participants Goal 4: Deliver and evaluate EHCHC program activities Objective 4.1: Deliver eight core modules, supplemental classes and support groups. Objective 4.2: Develop participant skills in creating Individualized Action Plans (IAP) and maintaining Personal Health Diary of behaviors and health status indicators. Objective 4.3: Collect evaluation data via Health Risk Appraisal, clinical measures and surveys. Goal 5: Develop sustainability plan for EHCHC and replication plan for McCormick and Abbeville Counties. Objective 5.1: Develop and disseminate business case for sustaining in order to obtain corporate support.
Project Methods
Methods. The project uses community health workers called Health Coaches (HCs) to deliver small group classes and support groups. Eight core educational sessions and supplemental sessions in nutrition and physical activity follow recommendations by the RWJ Foundation for essential elements of chronic disease self-management programs, Stanford Chronic Disease Self-management strategies, such as Individualized Action Plans, and motivation strategies from wellness coaching approaches. We also developed a Personal Health Diary customized to hypertension control behaviors which participants use to record their daily behaviors and blood pressure. Additionally, we integrated materials from the CDC Community Health Worker sourcebook: A Training Manual for Preventing Heart Disease and Stroke, the NIH "Your Heart, Your Life: A Lay Health educator's Manual and several materials from the National Heart, Lung and Blood Institute (NHLBI). Health Coaches teach participants to use blood pressure monitors, pedometers, cookbooks, and relaxation CDs. Each of the eight weekly core modules is approximately 1.5 hours in length and includes several experiential learning activities. Modules include: Basics of Hypertension Control, where participants are given overview of lifestyle behaviors including medication management required for HTN control and are provided with a blood pressure monitor they are taught to use; Nutrition (which includes weight control); Physical Activity (which includes weight control); Tobacco Use; Stress Management; and Medication Management. The final module focuses on the development of a long-term, personal action plan to continue hypertension control activities for the next eight weeks. Participants may also take an additional six weekly classes in nutrition and an additional two classes in physical activity. The additional nutrition sessions were created for the Expanded Food and Nutrition Education Program (EFNEP) provided by Clemson University Extension. We will use a quasi-experimental design with an intervention (Treatment) group and a wait-list (Control) group. In our previous projects, we used a one-group pre/post design. Now that we have refined intervention strategies and recruitment protocols, we will use a stronger research design to reduce threats to internal validity and rigorously assess efficacy of the intervention. Compared to a randomized experiment, this quasi-experimental wait-list control design allows us to overcome our community partners' concerns over denying participants the benefits of our program. Baselines measures will be collected through use of a Health Risk Appraisal (HRA) called Personal Wellness Profile by Wellsource, Inc, which includes questions about stage of readiness for change and health risk behaviors as well as biometric data collected by Wellness Center staff at our partner hospital. Blood pressure, cholesterol, glucose, and BMI are part of the HRA biometric data collection. We will also implement surveys that measure knowledge, self-efficacy and outcome efficacy of HTN management behaviors. These baselines measures are repeated at 16-weeks at the end of the intervention period.