Health Equity Approaches to Preventing Heart Disease and Strokes

ROBERT JOHNSON:
This is Public Health Review, I'm Robert Johnson.

On this episode: understanding why some people have higher rates of heart disease, hypertension, and stroke when their neighbors don't.

MICHAEL SELLS:
We have to be able to look at health not just in terms of the manifestation of disease. We have to be able to look at health as what people have or need in order to survive.

CHIP ALLEN:
The challenge is we know the data exists, but we have to be honest with our work and address where the data leads us.

ESTHER MUÑA:
When we go to funerals, we see the same people. We see the same people that have been in our community, in our lives, and we want to help that.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we discuss the most pressing public health issues facing our states and territories and explore what health departments are doing to improve the condition of our country's most vulnerable populations.

Today, we're tackling health equity, an issue that has gotten more attention in recent years as public health leaders uncover the root causes of conditions like heart disease, hypertension, and stroke.

Treating these diseases is one thing, but understanding why some communities or even some neighborhoods endure more than others is often more important, especially when it comes to solving the problem. As we've heard, many times the social determinants of health—things like access to healthy food, jobs, safe housing, clean water, and education—have as much to do with some people's health concerns as family history, for example.

Our guests this episode take the discussion a step further, addressing the difficult question of health equity and what happens when some suffer so much that it literally makes them sick. Chip Allen from the Ohio Department of Health will share his work to find those neighborhoods where the data collide. Then, we'll visit with Esther Muña in the Northern Mariana Islands about her efforts to improve the health of people living in paradise.

But first, we get a definition and an overview from Michael Sells, a senior project officer within the program development and services branch of the Division for Heart Disease and Stroke Prevention at the Centers for Disease Control and Prevention.

SELLS:
We look at health equity as the opportunity for everyone to obtain the highest level of their health potential. That means that people may come to the table with various social and environmental determinants that may place them at an advantage or disadvantage, and the goal is for them to achieve health equity across the board.

JOHNSON:
Where and when did this term or approach originate?

SELLS:
Couldn't really tell you where, because I know that the World Health Organization has been leading this effort, has really—I say that, a lot of what CDC gets comes from the World Health Organization, and from the experts here at CDC kind of working in conjunction with folks from the World Health Organization, and from local- and state-level experts as well. So, the term of health equity has been around I'd say for at least a decade, and it has been I think getting more and more popular, I'd say over the last three to five years.

JOHNSON:
Why do you think that it is?

SELLS:
I think that because there's now an ability to really get to the data and understand that, if we follow the data, we see that there are certain populations who have just disproportionately been impacted by diseases. So, when we honestly follow the data and we just see this trend over time, that particular subpopulation or subpopulations are constantly on the bottom of the tier when it comes to health outcomes, there's now a need to really do something about it.

JOHNSON:
Let's talk about that a little bit. What are the characteristics of a community challenged or impacted by a lack of health equity?

SELLS:
From the perspective of heart disease and stroke and hypertension, it may be an issue of access to clinical care, it may be an issue of having risk factors that are exacerbated by living in certain communities, and it may be just this whole issue of access and resources and the inability to have the resources to get the care and the preventive care and treatment that you need.

JOHNSON:
You mentioned heart disease, stroke, and hypertension. Are those the three big ones that you're looking for when you determine whether people are having a hard time getting healthcare in a particular area; or does it really affect everything, all kinds of illnesses and conditions?

SELLS:
It being health disparity, health equity?

JOHNSON:
Right.

SELLS:
Yeah, it is something that affects all conditions and diseases and health outcomes. So, if we're talking about nutrition, physical activity, there are health disparities and health inequities. If we're talking about cancer, there are specific health disparities that exist for that disease area. And for the area that I'm in—which is heart disease, stroke, hypertension—there are specific health risk factors and risks in terms of just being in a certain community, in terms of health systems and clinics, that some groups are being disproportionately impacted by.

JOHNSON:
Does that mean that they can't get access to a clinic that can identify their problem, or the care isn't as good—people aren't noticing when they come in that they've got these issues? What are those definitions or characteristics?

SELLS:
It ranges. So, we can have an issue where a subpopulation may not have access to some of the better clinics and health systems and hospitals that may exist in another community; or it can be an issue of they have access and don't have the health insurance, the coverage, or the resources to get access to a clinic or health system that may provide them with the care and treatment and all of the resources that they need to address the health concerns or disease that they may have.

What we see in terms of hypertension and cardiovascular disease is that, a lot of times, individuals can live with hypertension and not know they have it because of the lack of indicators—you know, you don't have any symptoms, you don't have the symptoms—and then they don't go and they don't have a regular provider to test their blood pressure. So, they can live with hypertension and eventually this can lead to a stroke or cardiovascular incident, and it could have been avoided had they had access to a provider.

JOHNSON:
So, a lot of times, then, it has to do with having insurance or just being tuned into the idea that you need to go see a physician every now and then, if for no other reason than to have a checkup?

SELLS:
Right, so, the need for increased awareness in certain populations, the need to focus on an intervention or interventions that can lead to preventive care so that you don't even get to that point—all of these things are oftentimes missing when you are looking at health outcomes of certain populations who are disproportionately impacted.

JOHNSON:
Is there any one thing or common thread that you see when you spot a community or population suffering from the health inequities? Is there anything that just sort of jumps out that you know automatically, well, this is an area that might have an issue? Is that its economic condition, or is it more than that?

SELLS:
That's a very good question. Because across the country, you have rural populations, you have urban and suburban populations, and there are these different races within a certain parts of these communities.

But education and income would be to the major indicators. So, what happens a lot is you go to a state and you do what we call a GIS map, where you find the hotspots for the disease and, in this case, you find where the most of the hypertensive patients are, you find where the most cardiovascular incidents have occurred, or strokes. It may in one state be in a rural area, maybe in another state in an urban area; but what they have in common oftentimes would be low income, or low education, or both.

JOHNSON:
So, how does the CDC go about trying to tackle that problem?

SELLS:
There are various ways of doing it. But from a national perspective, we have to think about how we target our resources. So, one way of doing that is to have a dual strategy, and that's where you target your resources and your activities on a national level to do universally available approaches that will reach everyone; but you also allocate resources that will specifically target those populations that are bearing the highest burden, so you have this sort of dual approach.

JOHNSON:
Now, the CDC deals with health, and some of the issues that you've identified have really no policy connection to healthcare, right? How do you deal with that? How do you deal with the income factor, or the education factor, the housing factor, all of these other things that are playing into this issue—the race factor? How does the CDC deal with that?

SELLS:
Again, as you stated, we're a public health institution, but the way we best approach that is by, first of all, ensuring that you are collaborating with organizations and agencies who do do that work. So, I may not work in housing, but that does not say that I cannot collaborate with someone from the housing department or someone from welfare department, and begin to kind of talk with them and collaborate with them and, you know, form maybe a learning collaborative. So, that's one way to do it from a big picture perspective.

Now, targeting a little more, we can target resources to more culturally tailored interventions that reach the disparate groups, so interventions that are designed to take into account sort of some of these factors that we are discussing. Now, we can't specifically help a person get a house, but we can target resources to hospitals, clinics, health departments, local health departments who do work with those subpopulations to ensure that they are becoming aware in terms of communications, in terms of interventions, that interventions are targeted to them. And then, we can go even further and say we promote cultural competence in clinical care so that the doctors, the providers, the pharmacists are aware that they must be culturally competent when addressing certain issues and dealing with certain subpopulations.

JOHNSON:
Can you identify areas where your efforts have shown success?

SELLS:
I'll just start with things that I'm recently kind of closely in involved with it, and that would be like ASTHO and CDC learning collaborative activities; so, ASTHO—the Association of State and Territorial Health Officials—collaborating with us here at CDC to support—we've been doing this for some years, supporting, I'd say about four to five years—where we identify some states to form some cohorts and we support their work within each state to form learning collaboratives. And then, they work together across states, learning from each other.

And so, we've seen some great outcomes in terms of our work with health systems and getting some blood pressures under control and seeing some more sustainable activities that look like, once we're gone, these activities will continue to flourish.

JOHNSON:
Can you give us an example of a state where you're pleased to see the results of this effort?

SELLS:
I would say Alabama is a good example of a state that basically formed the learning collaborative, did some work around getting health systems involved in the work, getting some hypertension activities going, and then aligning that work with electronic health records and how to better utilize the electronic health records to generate reports that inform the doctor's work and get patients' blood pressures under control.

JOHNSON:
Chip Allen is the director of health equity for the Ohio Department of Health. He's been working on a health opportunity index that matches local disease statistics with neighborhoods to find out whether social conditions play a role in community health, with the hope of giving policymakers the information they need to make informed decisions.

ALLEN:
We're looking for evidence that shows what is actually driving health opportunity. So, one of the things that we are working on in our department of health to get to that—and it was based on some help from our colleagues at the Virginia Department of Health—is we actually are working on a tool called the health opportunity index. And what that does, it is like a composite measure of various social determinants of health at the census track level that actually lets you know, based on the score and the other data that supports it, what is really driving health opportunity.

So, while we know, for example, that low educational attainment and poverty are key drivers to poor health, even though you might have those issues going on in a particular neighborhood, those in and of itself may not be what was driving poor health opportunity in that area. And so, with tools like the health opportunity index, allows you to look at about 14 different social determinants of health. While they may be present, it may be only a few of them actually really driving poor health opportunity.

And the reason why that is so important is because if we know what community factor is actually driving poor health opportunity, we can apply the best solutions to the problem with driving poor health opportunity as opposed to just looking at interventions that, while they may be evidence-based, they may not be getting at the problem in and of itself which is causing people to be unhealthy.

JOHNSON:
How does it work? Do your staff members put the information in the index, or does it go out to the community for people to fill out? Where does the information come from and how do you implement it?

ALLEN:
So the information that we have, much of it comes from data that's publicly available, like the census. We also were able to go into our biostatistics data and draw information for the index. And the health opportunity index, it relies on a statistical method called principal component analysis. And what it is, is a data reduction technique. And so, what it does is, for the social determinants of health that we examined, we actually had to have information available at the census track level. Many people consider this is a strength, to be neighborhood level of data.

And so, it took all this data that we had available at the census track level and it actually, using the principal component analysis method, it actually basically condenses it to those particular factors. Well, actually it looks at these components, so it takes all the data and brings them into four different components that actually looks at what it is impacting health in Ohio. And then, for a particular census track, it actually has a score; and based on this data, allows you to understand what specific social determinants of health are clustered around each other. And then once you know that, you can actually look at the scores and say in any given community what is driving poor health.

Additionally, our colleagues at the Virginia Department of Health, what they also did was calculate life expectancy for each census track. So, not only—so we may have, for example, a census track that has a very low life expectancy. And then right next to that census track, there can be another census track that actually have a very high life expectancy. And so basically, looking at those indicators, we can then go deeper through really understand what's going on.

JOHNSON:
And each community in Ohio gets a score?

ALLEN:
Each census track gets a score.

And I think it's very important, too, is that the health opportunity index is not like a health ranking—so it doesn't necessarily compare one community to the other and then rank them. What it does is allows us to understand for that particular area what's really driving health opportunity.

I should also mention that often times—and my colleagues and I have talked about this at length—is that when we actually have tools like the health opportunity index or other tools like, for example, the health rankings, there are not always met with a lot of favor. And the reason being is because oftentimes many leaders in local communities do not want data or any information that shows a particular blight or highlights certain types of problems. And that's understandable because, in some cases when data like that is available, sometimes blame was assigned or someone may be criticized for not doing all of the things that could, and that's really unfortunate.

We realize that many leaders in local communities, whether they be community-based or whether they are elected officials, are often trying to deal with a number of very difficult issues or issues that actually impact health that are happening simultaneously. Some of those problems that have existed for years and they're doing the best they can.

And so, the reason that I wanted to mention it is that any time that you actually have data and you want data to make data-driven decisions to really impact health but to really make some improvements, we have to do, I think, a better job of messaging what this data will tell and what it won't tell you so that those individuals who work at the local level—as well as those of us who work at the state or even at the federal government—can really come together in a way that doesn't assign blame or doesn't point fingers but to say that we have information that allows us to understand what is really driving the problems that impacts all of us. How can we use our collective wisdom to actually be able to use our resources appropriately to get to the root cause? And if we don't do that, I'm afraid that innovative tools, like the health opportunity index, will never get all of the attention that they should.

JOHNSON:
Now, the strategy in Ohio also talks about some other items here, and I thought it would be interesting for the audience to go through these. It says achieving health equity requires valuing everyone equally. Can you explain that challenge?

ALLEN:
The reality is, is that part of the reason why we have so many problems and poor health can be linked back to the fact that we have not valued the lives of individuals or communities that have been different, who have traditionally—and even to this present day—have been marginalized. And that marginalization, in some ways, manifests itself through poor health that we see or these disparate health outcomes. And if we don't recognize that, if we don't make that a part of our consciousness when we are designing interventions, we will—in a way—perpetuate these inequities which, at its root, is social injustice that actually manifests itself to poor health outcomes.

JOHNSON:
The strategy also notes avoidable inequalities. What are those?

ALLEN:
When we think about health equity, we recognize, for example, that there are problems in the inner cities or urbanized areas—but there's also problems in Appalachia. So, Appalachia is not predominantly populated by people of color, but they actually have some of the worst health outcomes that we see. And so, we have to realize that the health problems and the manifestations of these poor health problems that we see is really based on these -isms and poverty and lack of opportunity.

And the only way that I can also describe this to make this relevant for people who may not currently be experiencing health disparities or health inequities, is I can identify any affluent neighborhood in Ohio. And if we were to actually take away the wealth, if we would actually no give them access to clean housing or affordable and safe housing, if we would actually not give them a living wage, we were able to subject them to a number of -isms—sexism, racism, or, if the racism didn't apply, anything that would allow them from reaching their full potential—the good health that those individuals in those communities currently enjoy would soon diminish. And it just goes to the importance of understanding is that we have to provide environments and opportunities for people to thrive.

And the other complicated issue about health inequities is that the root causes of those issues, whether or not it's transportation, it's segregation, if they're living in what we look at as food deserts—all of those issues are very complex, but they all may be different as you go from one community to the other.

And while I don't want to sound like I'm rambling, but the reason I wanted to be able to just to mention this and spend time with this is that we have to be able to look at health not just in terms of the manifestation of disease. We have to be able to look at health as what people have or need in order to survive. And until we begin to do that, we will perpetuate these disparate outcomes that are largely distributed along racial and ethnic lines and people who are poor.

JOHNSON:
Allen recommends a website—communitycommons.org—that can help public health professionals understand where social and health conditions may be clashing in their own states and territories. A link can be found in the show notes.

Canned foods are convenient and their content seem to last forever, but that's what our next guest thinks lead to trouble in paradise for her friends, relatives, and neighbors living in the middle of the Pacific Ocean on the Northern Mariana islands. Esther Muña is the CEO of Commonwealth Healthcare, the government healthcare provider for people living there.

MUÑA:
We are the typical Pacific Islanders: we have high incidences of diabetes, hypertension; there's obviously a lot of cardiopulmonary diseases and all the diseases of the Pacific Islands basically; and we are surrounded by ocean. So there is—you know, the history of the islands is really a healthy population—however, what we've seen over the years is that the numbers have increased in, especially in regards to diabetes and hypertension.

JOHNSON:
Now, I have to admit it's a little hard to believe that anyone living on an island in the middle of the South Pacific could have high blood pressure, but you're telling me that they do—and that's not all.

MUÑA:
Correct. I have to say that, you know, myself growing up, I used to eat, you know—I mean, basically there's a lot of taro, there's a lot of the root vegetables that are available. Farming was something that my parents were doing, you know. But, unfortunately, there's SPAM introduction, and I think that's common throughout the Pacific, especially in the western Pacific and even Hawaii that's common.

So, they have the canned foods. And there's—I have to say that when you think about the history of the CNMI, or the Commonwealth of the Northern Mariana islands, you know, there's resiliency and there's resiliency in regards to responding to World War II, in response to typhoons—which is very common here in the islands, and maybe like once a year—and of course the last major one that hit us was back in 2015, which is Typhoon Soudelor. And when you don't have refrigeration, when you don't have the ability to basically, you know, you want to survive and you want to try to make sure that you have food on the table, canned goods seems to be the best option. And I think that's where it's become common in a diet of the Pacific Islanders.

JOHNSON:
And so that has just really, over time, caused people to take on the same sorts of diseases that we have here in the States.

MUÑA:
Correct, yes, unfortunately.

JOHNSON:
You've got a project that is aimed at trying to take a bite out of that hypertension issue, at least. Tell us what you're doing.

MUÑA:
So, through ASTHO, we knew that there was this hypertension problem, the diabetes problems. So, what we decided to do is try to make an impact in the community. We've been doing outreach for many, many years—you know, public health staff would take the mobile clinic and go to, let's say for example, the market or an event. And, you know, there's always that discovery of someone who has hypertension and sometimes they didn't even know about it.

So, you know, what we usually do in the past was we said, "You need to go see your primary care doctor. This project looks at the factors of why they don't follow up. And we see that, for example, there's financial reasons, there's the scheduling. So we try to, using this project, we were trying to address those factors and try to eliminate those barriers.

And so, what we decided to do was, you know, we have a collaboration with the college, with the community health center, and try to make sure that the primary care services are available after that outreach, after that discovery of the disease that they have.

JOHNSON:
And you go to village markets, right?

MUÑA:
Correct, yes, we go to the village markets and it's usually around after working time when people are actually out there in the community. One thing about the islands is that people, their life is really, you know, Monday through Friday, they got to work, they come home, they basically take care of their families. And this is an opportunity where we just basically go in there when they are actually out in the community, and so they are really available. So, we're trying to reach as many as possible.

JOHNSON:
Now, I saw a photo of one of the clinics set up, and it was a folding table with all of the equipment you needed out by the hair care products.

MUÑA:
(laughs) Yeah!

JOHNSON:
How's it going? How's that working?

MUÑA:
It was really working well. What we—well, we wish it was better, obviously. I mean, we saw that the participants were coming. There are times were there are still the challenges of actually making it to their appointment. So, even after we screened them and, you know, we can refer them to the clinic and their primary care provider, that even though we offer them vouchers—like, for example, a $5 voucher for their clinic visit—there are times when they basically don't show up. And a lot of times it's not in a bad way. Some of them have refused because they just change habits on their own.

The idea is really the fact that they found out about it, which they probably would not have found out about it if they really didn't do the outreach and we didn't do this project.

JOHNSON:
I can imagine the reaction some people might have when they're walking around the corner in the store, looking for the hairspray, and they find your team waiting for them with a blood pressure cuff.

Are there any moments that you have heard about from those interactions, good or otherwise?

MUÑA:
They're actually very grateful. They're very grateful. In fact, I did encounter one individual in the community and they said that they were actually very happy that they found out about that. And it's—especially because people think, individuals actually think that it costs money to screen.

And we, you know, in the community we always say—especially in the corporation, we are always out there in proclamations, you know, awareness proclamations—and we're saying that screening is free, please come, we would like to know how we can try to help you. I still see, you know, encounter individuals that bring that up and say, "I didn't know that I could just go up to you and get those services."

JOHNSON:
On this episode, we're talking about health equity. How does your program address that concern?

MUÑA:
Well, number one, we know that there's, you know, the financial is—obviously, it's a barrier in health equity. And our bringing this project really is, you know, making sure that people that aren't insured do have access to care. You know, we always say that services need to be accessible, affordable, and available, and being a health system that is, you know, the only health system really in the Northern Mariana Islands, it's about trying to ensure that the services that are available also are affordable and people can access it.

You know, there's always this challenge of culturally, I think in some ways, there's some cultural aspect of it, of, "Why, you know, how can I access services? I really don't feel like I need to." You know, obviously we're surrounded by a lot of ocean and people do tend to, you know, saying that, "I'd rather go to the beach or I'd rather go fishing."

But this is one way—we say this is a service, that we want you to be healthy, and breaking that barrier financially. And making, you know, the message out there, I think it brings back the opportunity for people to really come out and access these services and be able to be checked because if they aren't—you know, whatever reason, whatever factor they have, we're trying to make sure that it's available to everybody.

JOHNSON:
Did you mention earlier that you are from the Islands?

MUÑA:
Correct. I'm born and raised here.

JOHNSON:
How does that play into this cause that you've embarked on?

MUÑA:
Well, thank you for asking that question. You know, my father passed away—he did have high blood pressure, he died of stroke—and, you know, even my mother was diabetic. So, there is that history. So, I know that it's common, very common here and in the CNMI. And I, you know, I think about, you know, what can we do to make it better? I definitely want my children to be healthier and I want the community to.

So, the people here really, to be honest with you—I mean, it's not fake, I really feel for them, you know, when they struggle with their health. It really touches a lot of us because especially, you know, in the CNMI it's often—it's happening more often too, is that what we see is that we go to funerals. And when we go to funerals, we see the same people. We see the same people that have been in our community and in our lives. And, you know, we want to help with that.

And, you know, so we're very grateful, number one, with ASTHO and with any support from whether CDC or NIH programs that come in and really help us out to expand these services. We have a struggling health system, but we want to look beyond that and say, you know, how can we help our people? Because getting our people healthier is the only way our health system can be actually even—you know, we can resolve it too, we can solve the issues of it. So, this is something that really touches me a lot.

JOHNSON:
More information about health equity and the projects mentioned in this episode can be found in the show notes.

Thanks for listening to Public Health Review.

If you like the show, please share it with your colleagues.

And if you have comments or questions, we'd like to hear from you. Email us pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.