February is American Heart Month, so we sat down with Department of Global Health faculty members Dr. Chris Longenecker and Dr. Sarah Masyuko from the Global Cardiovascular Health Program to discuss their heart health research in rural communities and its connection to global health.
The University of Washington School of Medicine is the coordinating center for the Rural PRO-CARE HERN grant, and is managed by a team led by Dr. Longenecker. The center team supports collaborative efforts among the five project sites in developing and testing technology-based implementation strategies to promote uptake of evidence-based interventions within local rural practice in the U.S.
WHY IS UNDERSTANDING AND ADDRESSING ONE’S CARDIOVASCULAR HEALTH IMPORTANT?
CL: Cardiovascular disease remains a leading cause of death and disability across the United States, although rural-urban disparities and especially economic differences have led to some counties seeing much higher rates of cardiovascular disease than others. The stroke belt across the rural South is an example of where high rates of high blood pressure, obesity, and cardiometabolic disease track closely with poverty and race to create significant disparities in stroke and other cardiovascular outcomes.
Cardiovascular health promotion starts in childhood and social determinants of health are really critical in terms of cardiovascular disease that develops 5 or 6 decades later. Interrupting these social drivers of cardiovascular risk factors should be everyone’s business. The American Heart Association—who funds our Health Equity Research Network—likes to frame it in terms of Life’s Essential 8™. These are stop smoking, maintain healthy weight, eat better, get active, control cholesterol, manage blood pressure, reduce blood sugar, and get healthy sleep. All of us, no matter how fit or not fit, no matter our race or ethnicity, no matter our zipcode, should care about maintaining these 8 essential pieces of heart health. Furthermore, we all deserve access to the resources we need to help us do so. That’s fundamentally what cardiovascular health equity research is about.
SM: Heart health is important as heart disease is the number one killer in the United States and globally. The best part is that this can be largely prevented. In fact, the World Health Organization estimates that 80% of heart attacks and strokes are preventable. There is so much one can do to protect one’s heart. This begins by knowing your numbers. How much do I need to exercise to keep healthy? How many servings of fruits and vegetables am I eating? Is my weight, blood pressure and cholesterol level in the healthy range? How much am I smoking and drinking alcohol? This knowledge then allows an opportunity to discuss and make a realistic plan that can fit one’s lifestyle. Everyone can make small changes to a healthy heart. Small acts like increasing physical activity by walking, drinking more water, choosing heart healthy foods and replacing salt with herbs and spices, can have a big impact on keeping our hearts healthy.
HOW DOES RURAL HEALTH EQUITY FIT INTO A GLOBAL CARDIOVASCULAR HEALTH PROGRAM?
CL: Great question! There is a lot of reflection these days about how we do global health research. We’re moving away from a colonial model of researchers from high income countries travelling to low-income countries to fix their health problems. There is much more of an emphasis on mutual respect, resource sharing, and bi-directional priority setting. Quite frankly, there is a lot of innovation coming out of low-income countries that might be able fix some of our problems here in high-income countries. So with this new rural health equity research in the USA, our global cardiovascular health program aims to leverage relationships with our colleagues in low- and middle-income countries to think about how we might be able to adapt their models of health service delivery that may be particularly suited to rural areas of the USA. We call this reciprocal innovation.
In the spirit of bidirectional learning, there may be things that our colleagues from Uganda or Brazil may learn while conducting research with us in rural Montana that they could take back with them to try in their contexts. There is not just one way that innovation should flow—it can go both ways. I honestly think that doing more domestic research could reinvigorate the raison d’etre of global health researchers. We all benefit from breaking down siloed areas of research to learn from one another.
I’ll say there are multiple axis of reciprocal innovation—it’s not just global-to-local or local-to-global. It’s also rural-to-urban and urban-to-rural. It’s academia-to-practice and practice-to-academia.
SM: The mission of the Global Cardiovascular Health Program (GCHP) is to improve cardiovascular health globally through interdisciplinary research and education and equitable partnerships based on collaboration and mutual respect. Improving rural health equity is in line with our mission and therefore part of our focus on improving cardiovascular health outcomes. We are striving to build equitable partnerships by working with implementing partners such as American Indian tribal council and members, Indian Health Service and Tribal Health Boards, and National Organization of State Offices of Rural Health (NOSORH). Our projects are also strongly based on partnering with communities to identify barriers and solutions to overcome these barriers, co-design and implement programs that meet their needs. We have therefore adapted a community based participatory research approaches in our work including the Rural PROCARE grant. We are also using implementation science methods to better understand who is reached and missed with existing interventions and use these methods to design, test and scale up evidence based interventions with a focus on health equity. We also promote translation of research into policy and practice through work on policy analysis and reviews focused on rural health and capacity building of allied health professionals.
WHY IS FOCUSED OUTREACH TO RURAL POPULATIONS IMPORTANT?
SM: Having lived and worked in a low- and middle-income country, I saw how health disparities affect the most vulnerable or less resourced. Some of the challenges in rural areas in the US are shared with rural settings globally. These shared challenges include gaps in health access, funding and quality of services in rural populations including health workforce.
It is estimated that people who live in rural areas of the U.S. are 40% more likely to develop heart disease and 30% more likely to have a stroke than people who live in urban areas. Social determinants of health such as low income, low education, and health literacy are big issues in underrepresented populations that often result in decreased health access and demand which often manifest in heart disease.
To be able to develop culturally appropriate and adapted interventions for these populations, there is a need to understand the unique challenges of the rural populations. This provides an opportunity for reciprocal innovation. We can learn from what has worked in other parts of the world and adapt and test them in rural America and vice versa. For example, we can learn from HIV differentiated service delivery models in sub-Saharan Africa and adopt a similar model of differentiated service such as the American barbershop. That is what Rural Health Equity Research Network (HERN) is about: promoting equitable health care through four pillars: evidence-based interventions, implementation strategies, health technology and community partnership.
CL: Rural populations are among the most medically underserved in the United States, with rural-urban disparities in health outcomes often exceeding racial and ethnic disparities for cardiovascular conditions like heart failure or sudden cardiac death or non-cardiovascular conditions like opioid overdoses. Health equity research must be directed to where disparities are starkest, in order to raise awareness and implement innovative solutions at scale.
I also believe that strong and increasingly entrenched stereotypes about rural living may be an important driver of these health disparities, both directly through the biased acts of healthcare individuals and indirectly through systemic inequities. The parallels with race and racism are evident to many with lived rural experience. Also, along these lines, rural communities are not monolithic—there is a great diversity of experience across rural areas and sub-populations. Consider rural American Indian and Alaska Native communities, for example. The experience of healthcare on the Cherokee Nation is very different than that of the remote frontier regions of Northern Alaska—not just because of obvious environmental reasons such as climate and transportation distances, but also because of cultural differences and differences in how the communities engage with federally funded (but sometimes tribally administered) healthcare.
The solution—at least a genuine first step towards a solution—is true and meaningful engagement with rural communities. We cannot exclusively conduct rural epidemiology from our urban academic ivory towers (although studies of Medicare and other administrative data certainly can lead to important insights). We must get down on the ground with rural practitioners, rural patients, rural community leaders, and understand what their priorities are. This community-based participatory approach to research is required for rural communities to feel ownership of the innovations that arise. And it should be done with a lens towards strengths and opportunities, and not just a focus on deficiencies and challenges.
HOW IS HEART DISEASE DIFFERENT IN WOMEN? WHAT CAN WOMEN DO TO REDUCE THEIR RISK?
SM: Women may be more at risk of heart disease because of their hormonal changes during their lifespan, their smaller heart and blood vessels among other reasons. Women are more likely to get hypertension, obesity or anemia which predispose them to heart disease. The use of hormonal contraceptives may also increase risk of heart disease especially if you smoke or have high blood pressure, diabetes or high cholesterol. For women in childbearing age, pregnancy is considered a stress factor and may bring to light heart diseases such as congenital heart diseases that remained largely undiagnosed and asymptomatic. Pregnant women who also develop gestational high blood pressure, gestational diabetes, or preeclampsia may be at a higher risk for heart disease later in life. Menopause also increases the risk of heart disease as the ovaries stop producing estrogen, a hormone that protects the heart. Women can reduce their risk of heart disease by embracing heart healthy living - such as increasing physical activity and healthy eating- earlier in life. This may also include preparing for a healthy pregnancy by regular monitoring of blood pressure and blood sugar throughout pregnancy.
CL: This is another health equity issue that is being brought to the forefront. There’s been a history of advocacy for women’s cardiovascular health, but there seems to be more momentum in this area. For example, women may experience different cardiovascular risks than men—sometimes lower risks, sometimes higher. Conditions like “broken heart syndrome” or stress cardiomyopathy are more commonly diagnosed in women. Myocardial infarction—what we think of as a traditional heart attack—can happen to women with normal coronary arteries more often than men. Other rare conditions like fibromuscular dysplasia and spontaneous coronary artery dissection have a gender difference. There are conditions that we see in low- and middle-income countries, like rheumatic heart disease that also show a female predominance.
Additionally, there is an increasing awareness of the cardiovascular risks of pregnancy and the fact that the dismal maternal mortality rates we see in our country, especially among Black women, are being driven in large part by cardiovascular disease. It’s not just bleeding complications—it’s heart attacks, heart failure, and blood clots in the lungs. There is emerging interest in tackling these disparities through public health approaches and through reimagining patient centered care for pregnant women through multi-disciplinary cardio-obstetrics clinics.
FROM A GLOBAL PERSPECTIVE, ARE THERE HEART CONDITIONS THAT ARE IMPORTANT IN LOW- AND MIDDLE-INCOME COUNTRIES THAT ARE LESS OF A PROBLEM FOR US IN THE UNITED STATES? WHAT IS THE UW DEPARTMENT OF GLOBAL HEALTH DOING WITH REGARD TO THESE DISEASES?
CL: Rheumatic heart disease or RHD is a devastating valvular heart disease that can affect children and young people, but also sometimes presents later in mid-life. In low- and middle-income countries, RHD may account for 15-20% of all acute heart failure admissions. In these countries, RHD has a devastating economic impact on individual lives but also on society because these are young people who experience many years of life lost due to disability and death.
The UW, and specifically the UW Department of Global Health, has been conducting research and capacity building in RHD for over a decade. When I was at Case Western, I first began collaborating with UW investigators like David Watkins and Greg Roth who have led a number of important population health projects in RHD. We continue to have a robust program of translational and population projects that are aiming to understand the disease, but also how to strengthen health systems to tackle the heavy burden of disease with limited resources. To bring the discussion full circle, one project that uses Artificial Intelligence guided hand-held ultrasound began as an RHD project in Uganda and is now being tested by the Cincinnati Children’s team in rural Arizona as a project in our AHA Rural Health Equity Research Network. A true “reciprocal innovation."
SM: Cardiovascular disease is the leading cause of death globally mainly due to ischemic heart disease and stroke. Over 80% of these deaths occur in low- or middle-income countries (LMIC) and they also occur early i.e. before the age of 60. These deaths are largely driven by resource constraints with limited primary health care programs to prevent, identify, diagnose and treat heart disease and its risk factors early. In the US, there has been a decline in mortality due to heart disease as a result of improved hypertension treatment and control, decreased smoking, access to statins to lower cholesterol and acute care to manage heart attacks. Most common risk factors in low- and middle-income countries include hypertension, high cholesterol, poor diet, and tobacco. Low- and middle-income countries also suffer a double burden of both communicable and non-communicable diseases. Some infectious diseases lead to complications that lead to CVD such as HIV and Rheumatic fever. For example, rheumatic fever which is caused by bacteria causing strep throat and easily treated by antibiotics, if left undiagnosed and untreated, leads to Rheumatic Heart Disease which is more complex to treat. Congenital heart diseases are also common in low- and middle-income countries and are diagnosed late due to lack of primary prevention programs.
To address the growing burden of cardiovascular disease globally, the Global Cardiovascular Health Program was launched in November 2021 as a joint effort between the Department of Global Health and Division of Cardiology at the University of Washington. The Program allows University of Washington to coordinate and build upon ongoing work addressing cardiovascular disease prevention and care. The program has 21 core and affiliate faculty with more than 40 projects globally, including programs in Brazil, Cambodia, Kenya, Liberia, Mozambique, Nepal, Peru, Rwanda, South Africa, Uganda and Vietnam. These include implementation science projects, cardiovascular disease modelling, cardiovascular risk factor screening and management, stroke risk diagnosis and management, digital tools for heart failure management, Rheumatic heart disease screening and treatment, Intersecting HIV and heart health challenges, Scaling out and Scaling up the Systems Analysis and Improvement Approach, and health policy implementation in low- and middle-income countries.