Arkansas Leads the Way in Controlling Hypertension with Prevention Research Study

March 30, 2017|5:07 p.m.| Matthew Oglesby

Nate Smith

The partnership between practice and academia is critical for advancing public health science. The hypertension study is a great example of how the school of public health and the department of health can work together to make a difference for our communities in Arkansas and develop better approaches in the control of chronic diseases to share with others.” – Nate Smith, director and state health officer of the Arkansas Department of Health

Background

Hypertension is a major public health problem in the United States. Around 54 percent of U.S. adults suffer from hypertension, making it the leading cause of cardiovascular events such as coronary heart disease, congestive heart failure, stroke, and kidney disease.

In Arkansas, death rates related to hypertension are 33 percent higher than the rest of the country. In fact, data suggests that “about 50 percent of adults in Arkansas over the age of 18 are hypertensive,” according Jim Raczynski, who spoke with ASTHO about efforts to reduce hypertension in Arkansas through his work with the Arkansas Prevention Research Center (ARPRC).

The ARPRC was established in 2009 at the Fay W. Boozman College of Public Health at the University of Arkansas for Medical Sciences. As part of a national network of 26 CDC-funded prevention research centers (PRCs), it aims to promote health and disease prevention, as well as train and assist state and local public health practitioners. Raczynski is director of the ARPRC.

“In addition, a little over 30 percent—almost one in three—adults in Arkansas are not only hypertensive, but their hypertension is uncontrolled,” Raczynski says, echoing the consensus that many cardiovascular events associated with hypertension could be avoided if blood pressure was controlled.

The Challenge

With this in mind, the ARPRC partnered with the Arkansas Department of Health (ADH) to improve blood pressure control in hypertensive patients. The decision to focus on hypertension was a collaborative effort between the health department, the ARPRC, and community partners.

ARPRC is focusing its research on the southeastern region of the state, where rates of uncontrolled blood pressure are higher than in other regions of the state, where residents have higher educational attainment and better access to healthcare services.

“And not only that,” Raczynski elaborates, “in the southeastern region of the state, you encounter a lot of misconceptions. For instance, some believe that drinking vinegar helps lower blood pressure and that’s all you have to do to control it. These are the kinds of beliefs and attitudes we’re trying to change.”

Gathering participants for the study itself wasn’t challenging. “It’s a small, rural community, and word gets around,” Raczynski says. “We pass out fliers and do blood pressure screening and recruiting events. We go to churches, work sites, and even business locations. We let people know if they have hypertension and they’re interested in learning more about the project, they can call us and get screened. And, healthcare providers in the area have been great about referring people they think need help adhering to the changes they are being asked to make to control their blood pressure.”

The ongoing challenge, however, is making sure that participants adhere to their medication and treatment plans once enrolled.

Helping Raczynski lead the project is Martha Phillips, co-director of the ARPRC. Phillips echoed many of Raczynski’s sentiments. “In this hypertension program, we don’t have a lot of trouble getting people hooked into medical care. We don’t have a lot of trouble getting them insurance or access to medicine. But working with them to make sure they remain adherent, that’s hard.”

The Approach

To help address this issue, as a part of the study, ARPRC employs community health workers who make sure patients are taking their medication, following their treatment plan, and complying with doctor’s advice. “Community health workers are very good at working with neighbors and other community members to encourage patient adherence and lifestyle changes,” Phillips says.

To bolster this approach, ARPRC developed a series of short videos to help guide community health workers and participants through the treatment plan. The program involves:

  • A 5-minute video that introduces the day’s topic. A community health worker then uses this introductory content to facilitate discussion, set goals, provide education about blood pressure, help identify participant-specific barriers, and link participants to community services, such as insurance, treatment, and medication.
  • Three steps of support to help hypertensive patients control their blood pressure. Each step is designed to be more intensive than the previous step, if the previously completed step was not sufficient to help the participant gain control of his or her blood pressure.

To test its effectiveness, Raczynski and Phillips have randomly assigned participants to the intervention group and a minimal-assistance group to compare outcomes.

Sharing the Model

If the model turns out to be effective, it could be delivered in other settings. If a physician’s office is large enough and wants to explore this route, they might consider implementing the intervention within the office setting. Or, a hospital might implement the program and make it available to community physicians. A group of doctors might collaborate and share the model. It could even be provided through the health department, which would make the service available to physicians in the area.

A partner advisory committee has been organized, consisting of a diverse group of Arkansas healthcare and public health leaders, both to provide input into the project and assist with dissemination efforts. Nate Smith, director of the Arkansas Department of Health, and Dan Rahn, chancellor of the University of Arkansas for Medical Sciences, are co-chairs of the committee. Also serving on the committee is the director of Medicaid, the Arkansas Surgeon General, director of the Arkansas Center for Health Improvement (a policy think-tank), as well as representatives from the Arkansas Minority Health Commission and Arkansas Blue Cross and Blue Shield.

“A wide range of partners are involved,” Raczynski says. “The advisory committee really informed the conceptualization and development of this project. Health department staff were at the table when the program was developed and the intervention designed. And they are actively engaged to this day. When we meet, we usually meet for an hour-and-a-half, and we end up going on for much longer than that, discussing questions and ideas about how to apply the same model we’re using [for blood pressure control] to other healthcare problems in the state. Diverse stakeholders have been very willing to come to the table to help.”

Partnering with the PRC

“The partnership between practice and academia is critical for advancing public health science,” says Nate Smith. “The hypertension study is a great example of how the school of public health and the department of health can work together to make a difference for our communities in Arkansas and develop better approaches in the control of chronic diseases to share with others.”

In addition to Nate Smith, several other key members of the state health department serve on the partner advisory committee, including Appathurai Balamurugan, medical director of ADH’s chronic disease prevention and control program. In fact, Balamurugan serves on both the partner advisory committee and as a member of the research team that developed and oversees the project.

“We have a very good and long working relationship with the Arkansas Prevention Research Center,” Balamurugan says. “In fact, having seen their success, we thought, how can we address this same issue through the health department?”

Working with colleagues at ADH who develop community-based care programs, Balamurugan helped to develop a very similar program to the one being tested by Raczynski and Phillips and the research team working with them.

“The ARPRC and the health department are both addressing hypertension,” Balamurugan says, “but we are coming at it from a slightly different approach. In the project with Raczynski and Phillips, we are using a stepped-care approach with community health workers, whereas the health department is using nurses in local health units to partner with physicians in the community to do case management or team-based care.”

When asked for advice about what health departments should do if they wish to collaborate with PRCs in their state or region, Balamurugan says, “The primary thing is to have an ongoing, working relationship.”

Raczynski and Phillips were even more straightforward: “Make a phone call.”

For more information about this study or the work of the ARPRC, visit CDC’s Prevention Research Centers webpage.

Matthew Oglesby is associate editor, public relations at ASTHO.