Missouri Community, Public Health, and Primary Care Linkage

Abstract

This pilot project worked to establish linkages among community-based organizations, health care providers, and public health systems. The partnerships were created to help ensure identification, referral, and follow-up for community members with uncontrolled high blood pressure or pre-hypertension to lay the groundwork for sustainable referral and health education support systems in rural communities. The evaluation shows the project helped some participants control their blood pressure and change their blood pressure management behaviors.

Introduction

About 2.23 million of over six million Missouri residents live in rural areas of the state. Rural Missourians as a whole have lower levels of income, education, and access to health care, as well as a higher prevalence of risk behaviors that lead to adverse health status and decreased life expectancy.

Cardiovascular disease is the number one killer among rural residents in Missouri, similar to the rest of the state. However, the age-adjusted heart disease and stroke death rates were significantly higher among rural residents than among urban residents. Among rural residents, the prevalence of cardiovascular disease risk factors is higher than that among urban residents. For example, in 2011, a higher percentage of rural residents were obese (32.2% in rural vs 28.9% in urban) and had high blood pressure (37.4% in rural vs 32.6% in urban) than urban residents. A higher percentage of rural residents than urban residents were also current smokers (24.6% in rural vs 21.6% in urban) and had not engaged in any leisure-time physical activity in past 30 days (26.4% in rural vs 22.0% in urban).¹

To reduce the urban and rural gap in cardiovascular disease risk, the Missouri Heart Disease and Stroke Prevention Program (HDSP) collaborated with 10 county health departments in 2011–2012 to establish linkages among community-based organizations, health care providers, and public health systems. The partnerships were created to help ensure identification, referral, and follow-up for community members with uncontrolled high blood pressure or pre-hypertension to lay the groundwork for sustainable referral and health education support systems in the communities.

The objective of this study is to evaluate the effectiveness of the project in helping community members modify their behaviors and improve their high blood pressure management and control. The Missouri Department of Health and Senior Services Institutional Review Board reviewed and approved the project.

Methods

Project Description

Ten county health departments were selected to participate in the project based on their proven track records in working with community partners, some pre-established relationships with the health care community and serving low income rural communities. In addition, they had existing health educators or registered nurses who are knowledgeable about high blood pressure to carry out the intervention, and therefore no additional training was necessary. The 10 county health departments participating in the project were Ozark, Reynolds, Texas, Pemiscot, McDonald, Douglas, Carter, Oregon, Dunklin, and Newton.

For the intervention, each county health department established partnerships with community-based organizations to help the members control blood pressure. The health educator or registered nurse from the county health department went to the community-based organizations to provide group education for the organizations’ members about the cause, classification, prevention and management of high blood pressure. Blood pressure was measured during education sessions. Participants with pre-hypertension and uncontrolled HBP were referred to partnering health care providers for medical care and invited to participate in the follow-up intervention. Informed consent was obtained from each participant for completing an initial (pre-) and a final (post-) questionnaire and to allow the health educator or nurse to contact them periodically to provide education and support for up to one year. The health educator or nurse contacted participants periodically to provide lifestyle education, identify barriers to high blood pressure control, and assist participants with overcoming barriers. These services were provided at no cost to participants. However, the cost of physician care and medications were not covered by this project. Participants had to use whatever resources were available to them to pay for their medical care and medications.

Data Collection and Analysis

Data were collected using several instruments including the attendance sheet, presentation planning form, pre- and post-questionnaires, and the follow-up documentation form. Information on the program operation was collected through monthly reports, quarterly conference calls, and periodic site visits.

The pre- and post-survey data and other data were entered into an Excel spreadsheet and analyzed using SAS. For 121 participants who completed both pre- and post-questionnaires, the percentage of participants with different risk behaviors (e.g. smoking, physical inactivity), blood pressure management behaviors (e.g. taking medication, seeing doctors, changing diets), and blood pressure status were calculated and compared before and after the intervention. Chi-square test was used to determine if the post-intervention change was statistically significant.

External Comparison Group

Because it was not feasible to have a control group, we compared the percentage of blood pressure control among participants of this project with that among Missouri WISEWOMEN Program participants.² The Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) Program is supported by CDC and designed to reduce the risk of heart disease and stroke among low-income, underinsured, or uninsured women through clinical screenings, risk factor assessment, and lifestyle interventions. During June 30, 2005 through June 29, 2012, 515 women with high blood pressure were enrolled in the Missouri WISEWOMAN Program. After participating in the program for 11 to 18 months, 41.2% of these participants gained control their blood pressure.²

Results

Program Reach and Socio-Demographic Characteristics of Participants

A total of 287 education sessions were held in 199 community organizations in which 4405 community members attended, 815 attendees (18.5%) were referred for medical care, and 243 (5.5%) were recruited to participate in the follow-up interventions. All 243 participants completed the pre-questionnaire, and 121 participants completed both pre- and post-intervention questionnaires. Those who completed both the pre- and post-questionnaires were similar to those who only completed the pre-questionnaire in terms of age, sex and weight status. However, those who completed both questionnaires were more likely to be white, college graduates, and with household incomes of $15,000 or more than those who only completed the pre-questionnaire (See Table 1).

Table 1.

Characteristics of project participants

Characteristic	Participants completed pre-and post-questionnaires	Percent	All participants	Percent
Number of Participants	121	100	243	100
Age
<25	3	2.5	10	4.1
25–34	10	8.3	22	9.0
35–44	19	15.7	41	16.9
45–54	23	19.0	49	20.2
55–64	28	23.1	59	24.3
65+	30	24.8	54	22.2
unknown	8	6.6	8	3.3
Gender
Male	41	33.9	75	30.9
Female	80	66.1	168	69.1
Race and Ethnicity
White	109	90.1	210	86.4
African American	3	2.5	21	8.6
Hispanic	1	0.8	2	0.8
unknown, other	9	7.4	12	4.9
Education
No High School	0.0	11	4.5
Some High School	10	8.3	16	6.6
High School	39	32.2	96	39.5
Some College or Technical	25	23.1	52	21.4
College degree	40	33.0	54	22.2
unknown	7	5.8	14	5.8
Income
< $15,000	17	14.0	72	29.6
$15,000–$35,000	26	21.5	27	11.1
$ 35,000 +	33	27.3	61	25.1
unknown	45	37.2	83	34.1
Medical Insurance
Yes	87	71.9	171	70.4
No	19	15.7	47	19.3
unknown	15	12.4	25	10.3
Weight Status
Underweight	6	4.9	5	2.0
Normal	20	16.5	53	21.8
Overweight	37	30.6	72	29.6
Obese	48	39.7	101	41.6
unknown	10	8.3	12	4.0

Duration of Follow-up and Documentation

Participants were followed up for various lengths of time. Among 121 participants who completed both pre- and post-intervention questionnaires, 23 (19%) were followed for six months or more, 70 (58%) were followed for one to six months, 28 (23%) were followed for less than one month or had no follow-up information. Intervention intensity varied across counties. In some counties, health educators met participants monthly, while in other sites they only met once during the entire follow-up period. The level of detail in documentation of the follow-up education and problem-solving varied across sites. While a few counties kept very detailed documentation, records kept in other counties were sketchy.

Self-reported and Measured Blood Pressure during Education Sessions

Among 121 participants, 53 (43.8%) self-reported that they had previously been told they had high blood pressure on two or more occasions by health care professionals, 20 (16.5%) reported they had been told on only one occasion, and 13 (10.7%) reported they had been told they had pre-hypertension (See Table 2). The blood pressure measured during the education sessions showed that 18 of the 121 participants (14.9%) had stage II hypertension (BP≥ 160/100), 44 (36.4%) had stage I hypertension (140/90≤ BP<159/99), and 45 (37.2%) had blood pressure within pre-hypertension range (120/80≤ BP<139/89), of which 30 had been diagnosed as having hypertension before (See Table 2).

Table 2.

Blood pressure and behavior changes after intervention among participants who completed pre- and post-intervention questionnaires.

	Pre N=121 n percent		Post N=121 n percent		Difference Post-Pre n percent		Chi-squared Test p value
Self-report blood pressure
Ever been told having HBP on 2+ occasions	53	43.8	-	-	-	-	-
Ever been told having HBP on one occasions	20	16.5	-	-	-	-	-
Ever been told having pre-hypertension	13	10.7	-	-	-	-	-
Normal BP or HBP only during pregnancy	0	0.0	-	-	-	-	-
No answer	35	28.9
Measured blood pressure
<120/80	0	0.0	18	14.9	18	14.9
120/80 – 139/89	45	37.2	55	45.5	10	8.3
140/90 – 159/99	44	36.4	19	15.7	−25	−20.7	p<0.001
160/100 or greater	18	14.9	15	12.4	−3	−2.5
Unknown	1	0.8	13	10.7	12	9.9
Taking HBP medication
All or most of the time	52	43.0	70	57.9	18	14.9
Only occasionally	5	4.1	4	3.3	−1	−0.8	P=0.020
Not on medication	61	50.4	45	37.2	−16	−13.2
No answer	2	1.7	2	1.7	0	0.0
Seeing doctor for HBP
Yes	50	41.3	76	62.8	26	21.5	P=0.002
No	66	54.5	45	37.2	−21	−17.4
No answer	5	4.1	0	0.0	5 4.1
Changing behavior to control HBP (multiple choices)
Preparing more meals at home	41	33.9	69	57.0	28	23.1	P<0.001
Reducing salt	47	38.8	69	57.0	22	18.2	P=0.005
Reducing alcohol	6	5.0	9	7.4	3	2.5	P=0.424
Exercising	46	38.0	54	44.6	8	6.6	P=0.296
Eating more fruit and vegetables	47	38.8	67	55.4	20	16.5	P=0.010
Taking medication as prescribed	37	30.6	59	48.8	22	18.2	p<0.004
Trying to lose weight	45	37.2	53	43.8	8	6.6	P=0.295
Trying to maintain weight	17	14.0	38	31.4	21	17.4	P=0.001
Trying to quit smoking	8	6.6	11	9.1	3	2.5	P=0.473
No answer	27	22.3	10	8.3	−17	−14.0
Total number of changes	294	-	429	-	135	-
Smoking Cigarettes
Every day	17	14.0	16	13.2	−1	−0.8
Some days	4	3.3	5	4.1	1	0.8	P=0.931
Not at all	98	81.0	99	81.8	1	0.8
No answer	2	1.7	1	0.8	−1	−0.8
Leisure-time physical activity
Yes	78	64.5	85	70.2	7	5.8	P=0.481
No	36	29.8	32	26.4	−4	−3.3
No answer	7	5.8	4	3.3	−3	−2.5
Physical activity among those with leisure-time physical activity
5 or more times per week	21	26.9	28	32.9	7	-	P=0.020
Less than 5 times a week	41	52.6	52	61.2	11	-
Unknown frequency	16	20.5	5	5.9	−11	-
Total	78	-	85	-	7	-

Blood Pressure Management Behavior and Life-style Changes after the Intervention

Among 121 participants who completed both pre- and post-intervention questionnaires, 43.0% (52 people) reported they were taking HBP medication all the time or most of the time before the intervention. After the intervention, the proportion increased significantly to 57.9% (70 people), a net increase of 14.9% (18 people, p=0.020) (Table 2). Similarly, the number of participants who were seeing doctors for high blood pressure increased significantly from 41.3% pre-intervention to 62.8% post-intervention, a net increase of 21.5% (p=0.002). The percentage of participants who reported they were trying to change behaviors to control their blood pressure also increased significantly after the intervention. The participants who prepared more meals at home increased from 33.9% to 57.0% (p<0.001), participants trying to reduce salt intake increased from 38.8% to 57.0% (p=0.005), participants trying to maintain weight increased from 14.0% to 31.4% (p=0.001), and participants trying to eat more fruits and vegetables increased from 33.8 to 55.4% (p=0.010). In terms of physical activity, seven additional participants (an increase of 5.8%, p=0.481) were engaging in leisure-time physical activity, and among those who were engaging in leisure-time physical activity, seven additional participants were physically active five or more times per week (p=0.020) (Table 2). Smoking status and frequency of eating high sodium foods did not change after the intervention.

Blood Pressure Change after the Intervention

Among 107 participants from whom both pre- and post-intervention blood pressure data were collected, 62 had stage I or II hypertension, and 45 had blood pressure between 120/80 and 139/89, having either controlled high blood pressure or pre-hypertension before the intervention (See Table 3). Among the 62 participants with hypertension before the intervention, 40 (62.5%) gained control at the end of the intervention, compared to 41.2% among the Missouri WISEWOMAN Program participants. Among the 45 participants with pre-hypertension, 10 (22.2%) became normal, 9 (20.0%) deteriorated to stage I and 3 (6.7%) changed to stage II hypertension. The net increase in the number of controlled or normal blood pressure among 107 participants was 38 (35.5%) (Table 3).

Table 3.

Blood pressure among project participants who completed both pre- and post-intervention questionnaires and with known initial and final blood pressure data.

Initial Blood Pressure	Number of participants	Final Blood pressure
		<120/80	120/80 – 139/89	140/90 – 159/99	160/100 or greater
120/80 – 139/89	45	10	23	9	3
140/90 – 159/99	44	7	26	4	7
160/100 or greater	18	1	6	6	5
Total	107	18	55	19	15

Barriers for Care and Management of High Blood Pressure

Seventy-four participants reported barriers to caring for their HBP in the pre-intervention questionnaire. The most frequently reported barriers to seeing their health care provider or taking their medication to control HBP were the cost of medicine (42%), lack of medical insurance (37%), side-effects of the medication (17%), lack of time (6%), the cost of doctor (4%), falling out of habit or forgetting (4%), and lack of transportation to clinic or pharmacy (4%).

Discussion

Cardiovascular disease is the number one killer in Missouri.³ Hypertension is one of the major risk factors for cardiovascular disease. Therefore prevention and control of blood pressure is very important for reducing cardiovascular events and associated health care costs.⁴

In this project, health educators linked community organizations and clinics, and provided health education and follow-up counseling to community members. The evaluation data show that the intervention is effective in changing high blood pressure care and management behaviors and lifestyle factors. Following the intervention, an increased number of participants visited doctors and took medications to control their blood pressure. More participants were motivated and intended to increase physical activity and eat a healthier diet for blood pressure control. In addition, more people gained control of their blood pressure.

Based on the data from 107 participants from whom both pre- and post-intervention blood pressure data were collected, 38 (35.5%) additional participants gained control of their high blood pressure or changed from pre-hypertension to normal blood pressure. If we assume the intervention had the same effect on all 243 participants, then 86 participants would have gained control at the end of the intervention period. However, 86 may be a high estimate because we know those from whom both pre-and post-intervention blood pressure data were collected tended to have a higher level of education and household income, and a longer duration of follow-up than those participants with only pre-intervention data. Therefore, it would be reasonable to project that the intervention may have helped between 38 and 86 participants either gain control of high blood pressure or return to normal blood pressure from pre-hypertension.

The overall annual cost of the project, including project management and evaluation, was approximately $300,000. Of the $300,000, about $50,000 covered partial salaries and benefits of the DHSS project manager and program evaluator and the remainder was awarded to the LPHAs to support salaries and benefits of the health educators and nurse practitioners.

Therefore, we estimate on average the cost of gaining control of blood pressure was between $3,488 and $7,895 per person. In addition to helping the follow-up participants gain control of their blood pressure, the project provided education to more than 4,000 community members and referrals to more than 800. There were several limitations in the implementation and evaluation of this pilot project that may have affected the results. The health educators and nurses involved in the project were required to conduct project activities in addition to their regular responsibilities. Therefore, the time that some were able to devote to the project was limited. Staff turnover was quite frequent, which impacted the county health departments’ ability to complete project activities and data collections as specified in the contract. In addition, there was no concurrent comparison group. Therefore, determining whether the improvement was completely a result of the project is not possible. However, we believe the program was at least partially responsible for the findings.

Although the project helped a good number of participants gain control of their high blood pressure, improvements are needed to make the intervention more effective. First, the change in smoking behavior is limited. Second, although the project helped many participants with stage I and stage II hypertension gain control, a high proportion (12 out of 45) with pre-hypertension range blood pressure deteriorated to stage I or stage II hypertension, which shows additional efforts are needed to address behavior change. Third, this project is limited to high blood pressure prevention and control. In the future, other chronic diseases and conditions should be included in the intervention because of interconnectedness among chronic diseases. Finally, although the most frequently reported barrier to taking medication to control HBP was the cost of medicine (42%), no effort was made to collect information on the types and costs of medications prescribed. In the future, the information should be collected to better understand and help participants overcome cost barriers.

We are aware of only one similar project that has been conducted in resource-limited rural communities. The Community Health Educator Referral Liaison Project conducted in one rural and two urban/suburban communities in Michigan showed that the community health educator referral liaisons helped patients reduce risky health behaviors (e.g., drinking, smoking, physical inactivity) by linking them with community resources, offering counseling and encouragement over the telephone, and providing feedback to referring physicians.⁵

Conclusions

The pilot project helped some participants control their high blood pressure and change their blood pressure management behaviors. It looks like a promising approach if we include other chronic diseases in the intervention and improve local capacities in chronic disease prevention and control.

Biography

Shumei Yun, MD, PhD, Ellen Ehrhardt, MS, Lisa Britt, BS, Barbara Brendel, Janet Wilson, MEd, MPA, and Anita Berwanger, MA, RD, LD, are with the Division of Community and Public Health, Missouri Department of Health and Senior Services, Jefferson City, Missouri.

Contact: Shumei.Yun@health.mo.gov