Dr. Sarah Mayer from Wake Forest Baptist Medical Center takes Tracey Johnson's blood pressure at the General Assembly building. Johnson, from Washington County, was in Raleigh to lobby for the day. Photo: Rose Hoban
Dr. Sarah Mayer from Wake Forest Baptist Medical Center takes Tracey Johnson's blood pressure at the General Assembly building. Johnson, from Washington County, was in Raleigh to lobby for the day. Photo: Rose Hoban

By Taylor Sisk

Researchers from East Carolina University and the University of North Carolina-Chapel Hill have been selected to participate in a $9.5 million grant to address health disparities in the rural South.

This will be a five-year, multi-institutional study to compare strategies for reducing high blood pressure among low-income African-Americans throughout the rural southeast. Research teams have been assembled at ECU’s Brody School of Medicine, the University of North Carolina School of Medicine and the UNC Cecil G. Sheps Center for Health Services and the University of Alabama at Birmingham

ECU researchers on this project to study hypertension in the rural South include, from left, Alyssa Adams, a research specialist in family medicine; Doyle Cummings, a professor of family medicine and public health; and Hope Landrine, director of the Center for Health Disparities. Photo credit: Cliff Hollis

The project is funded by the Washington, D.C.-based Patient-Centered Outcomes Research Institute, established under the Affordable Care Act.

Researchers will study rural communities throughout the “Black Belt,” a region, stretching from Maryland to eastern Texas, so called for its high percentage of rural black communities. It has the nation’s highest rate of cardiovascular disease mortality.

High blood pressure – or hypertension – can lead to heart disease and stroke.

‘A multitude of factors’

According to the Centers for Disease Control and Prevention, nearly one in three adults in the U.S. has hypertension. The rate is higher still among rural residents, and the rate for blacks in the U.S. is among the highest in the world.

An ECU press release last week announcing the study states: “According to the N.C. State Center for Health Statistics, 38.9 percent of adults in eastern North Carolina reported being told by a doctor that they had hypertension. Even more alarming was the 46.6 percent of African-American respondents in the East who reported having hypertension – a rate approximately 25 percent higher than that reported by white respondents.”

The study will focus on what the researchers refer to as the “‘triple threat’ of risk factors,” related to race, geography and income status.

In an interview, Doyle Cummings, a professor of family medicine and public health at the Brody School of Medicine who will head the ECU team of researchers, said, “It seems very clear that African-Americans who live in rural areas and have a lower socioeconomic status account for a very high proportion of the risk.

“That’s the group that seems to be at highest risk for developing hypertension in general and uncontrolled hypertension in particular.”

Cummings said there are a “multitude of factors” that make this demographic so susceptible to uncontrollable hypertension. He cited first poor access to health care services in rural areas.

“People in rural areas sometimes don’t have access to the same quality of care, the same breath of care, as folks in other areas,” he said.

He then cited affordability issues and a shortage of “opportunities to be healthy: access to healthy food and to safe places to exercise and to keep weight lower.”

Health literacy is also an issue.

“A number of our patients don’t even understand that high blood pressure is a high risk factor for stroke,” Cummings said. “They may know they have high blood pressure, but they don’t connect that with having a stroke or having a heart attack down the road.”

Two-strategy approach

This research will employ two strategies: One will explore the issue from within the health care-delivery system – specifically, how patients who are at high risk for uncontrolled blood pressure are being treated in doctors’ offices.

The researchers will look, for example, at how effectively practices are recognizing the risks for uncontrolled blood pressure, whether it’s being appropriately diagnosed, if practices tend to measure blood pressure correctly, do they intensify medications when necessary and how well are they educating their patients.

The objective of this approach, Cummings said, is to better systematize care. He said the practice-based approach is in keeping with a movement to conduct research that partners academic centers with practices in underserved areas.

The other strategy is a community-based intervention. The researchers will deploy “peer advisers”: individuals from the community in which they’ll work, many with hypertension themselves, trained to deliver what Cummings called a “carefully scripted intervention strategy” to those at risk.

The advice they’ll offer will include the importance of seeing a doctor regularly and ensuring the patient has the proper medications and is taking them.

It’ll also entail helping those at risk better understand the effects of lifestyle behaviors and help with changes to diet and exercise that can lead to weight loss and blood pressure control.

One cohort in the study will participate in both strategies, another in one or the other strategy and a third will be followed as they continue with their usual care without intervention.

What works?

Cummings said both ECU and the University of Alabama at Birmingham have used the peer-adviser approach in the past, and that it’s been particularly effective within black communities, where there’s often a distrust of the health care-delivery system, founded in large measure, historically, on limited or no access to the system or mistreatment.

The researchers intend to study some 2,000 patients at 80 practices in Alabama and North Carolina.

Cummings said that probably about two-thirds of the practices his team will work with will be in the eastern part of the state.

The overall objectives, he said, are to better understand how to help primary care practices make changes to bring more patients’ blood pressure under control, and to examine which of the two strategies seems to work more effectively or if future initiatives should pursue the two together.

This research, Cummings said, is “absolutely central to the mission of the Brody School of Medicine. Our mission is really about trying to improve the health status in North Carolina and, in particular, in eastern North Carolina.

“We’re very concerned about this idea of disparities – that in North Carolina there are some folks who don’t seem to have access to care and outcomes that we’d like to see.”

[box style=”2″]This story was made possible by a grant from the Winston-Salem Foundation to examine issues in rural health in North Carolina. [/box]

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Taylor Sisk

Taylor Sisk is a writer, editor, researcher, producer and documentary filmmaker who served as the rural health reporter from 2015 into 2016. He has served as a managing and contributing editor of The Carrboro...