Progress Toward Elimination of Health Disparities

The following discussion highlights progress toward the elimination of health disparities. The disparities are illustrated in the Disparities Table (see Figure 12-2), which displays information about disparities among select populations for which data were available for assessment.

Nine objectives had significant racial and ethnic disparities. The Asian or Pacific Islander population had the lowest CHD death rate (12-1), which was half the rate for the black non-Hispanic population. Although rates declined for both groups, the disparity between black non-Hispanic and Asian or Pacific Islander populations increased by 10 to 49 percentage points from 1999–2002.

The white non-Hispanic population had the best rate for congestive heart failure hospitalizations among persons aged 65 to 74 years (12-6a). Notably, the data for objective 12-6—data on heart failure hospitalizations from the National Hospital Discharge Survey—are subject to large variation due to small sample sizes and race and ethnicity classification error due to the increasing absence of reporting of race and ethnicity for many of the sampled hospitals, especially in recent years. The hospitalization rate of the black non-Hispanic population was more than twice the rate of the white non-Hispanic population in this age group. The American Indian or Alaska Native population had the best stroke death rate (12-7), which was half the rate of the black non-Hispanic population. Compared with the American Indian or Alaska Native population, the disparities for stroke death rates increased by 10 to 49 percentage points for the Asian or Pacific Islander, black non-Hispanic, and white non-Hispanic populations.

The white non-Hispanic group had the best group rate for three objectives with significant racial and ethnic disparities: knowledge of heart attack and stroke symptoms in persons aged 20 years and older (12-2 and 12-8) and controlled high BP in persons aged 20 years and older with high BP (12-10). Knowledge of stroke signs and symptoms (12-8) showed disparities of at least 100 percent between the Asian population and Hispanic population in comparison with the white non-Hispanic population (best).

The Mexican American population had the lowest percentage of high BP in persons aged 20 years and older (12-9)—27 percent in 1999–2002, compared with 43 percent in the black non-Hispanic population. The black non-Hispanic group had the best rate for BP monitoring among persons aged 18 years and older and with high BP (12-12). The Asian population and the population identifying themselves with two or more races had the best cholesterol screening rates (12-15).

Efforts to reduce the disparities in cardiovascular health among ethnic and racial populations are under way. One such effort is Salud para su Corazon (SPSC), a comprehensive education and outreach initiative committed to increasing knowledge and practice of heart-healthy behaviors in Latino communities through the use of promotores de salud, or lay health workers.^{28, 29} Messages and supporting materials incorporate culture, lifestyle, language, and community-based values and are distributed through various community channels. In 2001, a partnership was established to take SPSC to the U.S.-Mexico border region.³⁰

Honoring the Gift of Heart Health serves as a health educator's guide for implementing culturally and linguistically appropriate heart-healthy training in Tribal communities, thereby increasing awareness and stimulating action about the adverse impact of CVD among the American Indian population.^{31, 32}

Your Heart, Your Life (Su Corazon, Su Vida) is a manual used to train lay health workers who teach and promote healthy lifestyle behaviors within their specific communities.³³ Regional training workshops have been, or are being, conducted that cover Indian Health Service and Tribal service areas in Alaska, Arizona, Colorado, North Dakota, Oklahoma, Oregon, and Tennessee.

Significant disparities from the best group rate also continued to exist for select racial and ethnic populations regarding knowing the warning signs of stroke (12-8). To address this gap, a new grassroots education program called Know Stroke in the Community has been launched.³⁴ The program focuses on educating populations at high risk for stroke, including older adults and black non-Hispanic and Hispanic populations, in communities that have extensive health care systems in place to treat stroke. In less than 6 months, the program identified 63 stroke champions, who conducted more than 350 education events, and delivered stroke education messages and materials to more than 100,000 people.

Women had better rates than men for all eight objectives and subobjectives with significant gender disparities, including CHD death rate (12-1), persons aged 20 years and older knowing the signs and symptoms of heart attack and stroke (12-2 and 12-8), heart failure hospitalizations among persons aged 65 to 84 years (12-6a and b), controlled BP among persons aged 20 years and older with high BP (12-10), BP monitoring by persons aged 18 years and older with high BP (12-12), and blood cholesterol screening within the past 5 years among persons aged 18 years and older (12-15). While the rate of women trained in CPR (12-4) and the rate for stroke deaths (12-7) among women were better than the rates of men, the differences were not statistically significant.

Multiple initiatives seek to promote women's cardiovascular health and reduce disparities in treatment. A program called Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) helps women with little or no health insurance gain access to screening and lifestyle interventions that can reduce their risk for heart disease and other chronic diseases.³⁵ The WISEWOMAN program includes 15 projects in 14 States and addresses high BP and cholesterol, nutrition and weight management, physical inactivity, and tobacco use. Launched in 2002, the national "Heart Truth" campaign aims to raise awareness of the danger of heart disease.³⁶ The campaign's goal is to heighten women's awareness about their risk of heart disease, encourage them to talk with their doctor, and take appropriate action.

Persons with at least some college had the best rates for all seven objectives with significant education disparities. In 2002, the rates for CHD deaths and stroke deaths (12-1 and 12-7, respectively) among persons with less than a high school education were about three times the rates of persons with at least some college, while the rates of high school graduates were twice the rates of persons with at least some college. The disparities between high school graduates and the best group on these two objectives increased between 1999 and 2002. The proportion of persons with less than a high school education who do not know the early warning signs of stroke (12-8) was more than double the rate of persons with at least some college. The proportion of persons with high blood pressure and less than a high school education who do not monitor their blood pressure (12-12) was almost three times the proportion of persons with at least some college who do no monitoring. Between 1998 and 2003, this disparity increased by 10 to 49 percentage points. Finally, the disparity in rates for blood cholesterol screening in the past 5 years among persons aged 18 years and older (12-15) with less than a high school education and persons with at least some college who do no monitoring exceeded 100 percent. The disparity between high school graduates and persons with some college increased between 1998 and 2003.

Only one of the three objectives with disparity data by income level showed significant income disparities. The middle/high-income group had the best rate for high BP among persons aged 20 years and older (12-9). Between 1988–94 and 1999–2002, the disparity between the poor and middle/high-income populations decreased by 10 to 49 percentage points. All income groups moved away from the target. The decrease in disparity occurred because the middle/high-income population moved away from the target at a faster rate than did the poor population. In 1988–94, 24 percent of the middle/high-income population had high blood pressure; by 1999–2002, this rate had increased to 29 percent. Comparable rates of the poor population were 31 percent and 32 percent, respectively. The poor population group had the best mean total cholesterol level (12-13).

Persons without disabilities had better rates than persons with disabilities for three objectives: knowledge of stroke symptoms (12-8), high BP (12-9), and high blood cholesterol levels (12-14). Persons with disabilities had better rates than did persons with disabilities for controlled BP (12-10) and BP monitoring (12-12).

One objective, 12-15, had a significant geographic disparity. Persons living in urban or metropolitan areas had higher rates for blood cholesterol screening within the past 5 years among those aged 18 years and older than did persons living in rural or nonmetropolitan areas.

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