Identify and prioritize high burden communities by county, census tract, zip codes, rural, or non-metropolitan status Prioritize persons living in poverty; those with low literacy Prioritize racial/ethnic minorities, especially African Americans, American Indians/Alaska Natives, and Hispanic/Latino population groups with high CVD risk Recognize examples of community resilience Identify supportive community resources Assess and leverage self-awareness of existing community leaders Assess community needs, readiness, and desire to address CVD disparities Leverage disparities data on country of birth, nativity, and acculturation, limited English proficiency Overlay datasets from different sources, whenever possible
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Limitations of county-level data for large metropolitan areas Community distrust of research Loss of precision of census data particularly during inter-censal years in small communities Adverse social determinants of health and multi-morbidity Cultural variation and need for support in health literacy Feelings of helplessness, and hopelessness Dependency on others’ awareness and support Prejudice, discrimination, overt and institutional racism Inadequacy and inconsistency in access to health care Disability from stroke and lower extremity amputation associated with diabetes-magnifying hopelessness and dependency
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Insist that researchers recognize the community’s self-identification and needs assessment Create solutions which support lifespan wellness of individuals and communities Mitigate contextual challenges (remote areas) Employ social media in both rural and urban settings Rely on members of the community as cultural and context interpreters Identify community organizations where the patients and their supporters gather—extend care beyond the primary care office Recognize and leverage strength in diversity View community health more holistically Use community-centric grant supplements to support technical assistance to communities Identify resilient communities Improve health literacy
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Identify partners at the local and state levels Foster upward mobility of self-determined community leaders Incentivize patients to be better able to self-manage and help others Challenge researchers to help community develop more resilience Have an open, and on-going call for partners Recognize partners and acknowledge their contributions Leverage virtual connectivity to garner energy and trust from like communities Integrate community members into the research at an early stage
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Vital statistics data and representative sample surveys e.g.:
500 Cities: Local Data for Better Health CMS Geographic Variation Dashboard CMS Medicare Chronic Condition Dashboard CDC Atlas of Heart Disease and Stroke County Health Rankings and Roadmaps
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