Current Centers for Population Health and Health Disparities

University of North Carolina at Chapel Hill
Center To Reduce CVD Disparities: Genes, Clinics, and Communities

Contact Information
Beverly Garcia, MPH
1700 MLK Jr Blvd, CB #7426
Chapel Hill, NC 27599-7426
(919) 966-6088
Beverly_Garcia@unc.edu
www.hpdp.unc.edu

Alice Ammerman, DrPH – Contact Principal Investigator

Abstract: Risk factors for cardiovascular disease (CVD) disproportionately affect low-income and minority populations. Lenoir County, North Carolina, is among the poorest in the state and is situated in the "stroke belt," with significantly elevated heart disease, stroke, and obesity rates relative to state levels already well above the national average. At the same time, this county is home to many clinical and public health efforts on which to build. We propose an integrated set of three interdisciplinary studies in Lenoir County to: (1) determine genetic factors associated with CVD risk; (2) understand the multilevel determinants of poor health outcomes and the potential social and community capital that can support sustainable change; (3) work with community leaders, health professionals, and citizens to apply these understandings to improved practice-based management of hypertension and community-centered lifestyle management, and test the impact on improving outcomes and reducing disparities in cardiovascular health among 700 participants. We will partner with East Carolina University Brody School of Medicine, a leader in community-based primary care, to assist with local interventions. Our Center also will include an innovative partnership with a non-profit call center, Connect Inc., adding a lifestyle and medication adherence coaching component to their current focus on jobs, employment, and benefits counseling; (4) test the impact, reach, adoption, and sustainability of clinical, community-level, and policy interventions, including economic development potential; and (5) develop and implement strategies for translation and dissemination of the clinic-based and community-level interventions to other underserved regions. This work will be supported by an administrative core housed in the Center for Health Promotion and Disease Prevention (a Centers for Disease Control and Prevention-funded Prevention Research Center with a focus on community-based participatory research). Additional cores include: (1) a Genomic Bioinformatics Core available to this project and other P50 programs to analyze genetic/genomic data and other pathways of interest; and (2) a Social Determinants/Economic Development/Dissemination Core to understand the interface between poverty and health, and to explore strategies with the potential to create jobs while promoting health. Additional core support for data collection, community engagement, and economic development will be leveraged through the University of North Carolina (UNC) Clinical and Translational Science Awards (North Carolina Translational and Clinical Sciences [NC TraCS] Institute) and the Community-Campus Partnership for Tomorrow, which is the result of a statewide assessment led by the President of the UNC 16 campus system "to produce a more proactively responsive University focused on meeting the challenges of the state over the next 20 years."

Relevance: Comprehensive approaches are needed to create healthier environments and stronger health care delivery systems so that individuals of all backgrounds and life situations are able to achieve and maintain cardiovascular health.

Center Aims

• Conduct an extensive formative assessment in Lenoir County regarding: social determinants of health; community assets, including social and community capital; the culture of primary care practices and community organizations; community context, and preferred lifestyle intervention approaches by low-income participants;
• Test a carefully designed practice-based, sustainable blood pressure management program addressing individual and practice-level factors associated with racial disparities in blood pressure control with a goal of reducing racial disparities;
• Assess the impact of a community-based lifestyle intervention to improve diet and physical activity for cardiovascular risk reduction and weight control through individual and group level interventions as well as broad organizational and community-level change;
• Test the value added to both blood pressure management and lifestyle modification of an innovative partnership with a nonprofit call center, Connect Inc., adding a lifestyle and medication adherence coaching component to the current focus on jobs, employment, and benefits counseling;
• Determine the prevalence of genomic risk signatures in high-risk community populations using genome-wide association studies (GWAS); develop and evaluate novel genomic models incorporating high-risk features in this population to design patient and genomic-specific intervention; and determine whether genomic signatures can be used to predict responsiveness to interventions that address CVD disparities;
• Explore with economic development experts both at UNC and in Lenoir County, the potential for spinoff entrepreneurial activities that both create jobs and promote health in the county, including such possibilities as expansion of a local health coaching call center, a worksite wellness consulting company, and local food production/distribution systems as rural North Carolina transitions from a tobacco-dependent rural economy.

Project 1 is a three-phase study to reduce CVD risk and disparities in risk by improving lifestyle factors, which underlie CVD risk in Lenoir County, NC, a rural county with extremely high rates of CVD, especially among its large African American population.

Specific Aims
Phase I–Assessment and Preparation Phase

• Assess perceived barriers, facilitators, and values among community members who may benefit from lifestyle change;
• Evaluate existing community characteristics, resources, programs, and policies that may facilitate or impede lifestyle change to reduce CVD risk;
• Assess level of interest and concerns of the local business community (restaurants and grocery stores) relevant to offering more healthful menu and grocery options;
• Assess activity and interest related to local sustainable food systems that may increase access to healthy foods and facilitate economic opportunities among food producers and distributors;
• Assess level of interest and political will among local decision makers regarding policy change in support of healthier lifestyles;
• Develop protocol and intervention materials for Implementation Phase.

Phase II–Implementation and Experimental Phase

• Assess effect of intervention on diet quality at 6-month followup;
• Assess the following outcomes at 6-month followup: diet quality as measured by questionnaire, physical activity as measured by questionnaire and accelerometer, blood pressure, blood lipids, A1c, weight, and health-related quality of life;
• Assess use of community resources relevant to lifestyle change;
• Re-assess above outcomes at 12, 18, and 24 months to determine if changes at 6 months are maintained, enhanced, or attenuated overtime;
• Assess policy and environmental change (including levels of economic/entrepreneurial activity) using the RE-AIM Framework and soon-to-be released Centers for Disease Control and Prevention Common Community Measures for Obesity Prevention (COCOMO).

Phase III–Analysis, Report Writing, and Dissemination Phase

• Complete analysis and report writing of major findings;
• Prepare intervention components for dissemination.

Project 2 will use a community-based participatory research approach to carefully design and test a practice-based, sustainable hypertension intervention. The intervention will target medication and lifestyle management at both the patient and practice level, and is designed to narrow disparities in blood pressure (BP) control. Although it is expected that BP control will improve for everyone, the study focuses on narrowing the racial gap in BP between Whites and African Americans.

Specific Aims
Formative Phase

• Use community-based participatory research principles to understand sources of disparities and inadequate care in Lenoir County, refine a practice-based approach to improving hypertension care, and make community connections to support ongoing links between the practices and community to sustain optimal hypertension care.

Implementation Phase

• Evaluate the effect of the intervention on lowering blood pressure in a cohort of patients with hypertension;
• Evaluate the cost of implementing and sustaining a community supported practice-based intervention for improving blood pressure control from the health care system perspective.

Project 3 is a clinical research plan that targets CVDs that disproportionately afflict underserved and disadvantaged North Carolinians using a systems approach to develop models that will integrate clinical data with datasets derived from clinical genomics and other inductive, highly detailed methods. To this end, the Center has developed an approach, referred to as the SAMARA (Supporting A Multidisciplinary Approach to Research in Atherosclerosis) Project that applies recent, major advances in biomedical and computational sciences at UNC to develop deeper understanding of human CVD.

Specific Aims

• Determine the prevalence of genomic risk signatures in high-risk community populations using GWAS;
• Develop and evaluate novel genomic models incorporating high-risk features in this population to design patient- and genomic-specific interventions;
• Determine whether genomic signatures can be used to predict responsiveness to interventions that underlie CVD disparities.