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.
The following conversation was edited for length and clarity. If you would like to read their full answers, please visit this full Q&A blog post with Drs. Longenecker and Masyuko.
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.
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.
HOW DOES RURAL HEALTH EQUITY FIT INTO A GLOBAL CARDIOVASCULAR HEALTH PROGRAM?
CL: 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. 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.
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.
WHY IS FOCUSED OUTREACH TO RURAL POPULATIONS IMPORTANT?
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.
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.
SM: 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.
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 the 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.
HOW IS HEART DISEASE DIFFERENT IN WOMEN?
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.
CL: This is another health equity issue that is being brought to the forefront. Women may experience different cardiovascular risks than men—sometimes lower risks, sometimes higher. 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.
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?
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. We 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 American Heart Association 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. 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.
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.