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Epidemiology and Prevention of Cardiovascular Disease: A Global Challenge, Second Edition provides an in-depth examination of epidemiologic research and .
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Skip to content. Perusall turns often-skipped solitary reading assignments into engaging collective activities students don't want to miss. It is important to note that large numbers of African American women live in rural areas, particularly in the southern United States. This fact, combined with the high death rates, results in a substantial burden of mortality. Much has been written about the ethnicity- and poverty-associated disparities in mortality in the United States.

Although our knowledge base is woefully incomplete in this matter, many factors likely account for the American mosaic of CVD mortality. Structural barriers to health include high levels of poverty, maldistribution of health care workers, absent or inadequate health infrastructure, remote location, and social isolation, particularly among the elderly and, most often, female rural Americans.

Low socioeconomic status has been shown repeatedly to correlate with low levels of knowledge about health maintenance, poor access to preventive care, and reliance on emergency departments or other episodic, discontinuous sources for primary care. In a community-based study done by Willems et al. The combination of minority status and rural residence may have a particularly negative impact on coronary heart disease risk factors.


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Available data suggest that women in general may receive suboptimal care for acute CVD. Data on the diagnosis and management of coronary heart disease illustrate the disparity in treatment. Women are less likely to receive an electrocardiogram and electrocardiogram monitoring, less likely to be admitted to a coronary care unit, and less likely to receive a cardiology consultation. African American women are much less likely than men or White women to have access to lifesaving therapies for heart attack.

Most of the 1 million US patients who have heart attacks each year are candidates for reperfusion therapy reopening of blocked arteries , either thrombolytic drugs or primary angioplasty. These findings suggest that there are salient explanations for the mosaic pattern of CVD death in the United States and that changing this pattern presents enormous challenges that will not be easily met. Ensuring equitable access to health care is an important public policy goal, however, and a significant body of research and policy analysis has been focused on documenting barriers to access for vulnerable populations and suggesting policy options to eliminate such barriers.

Rural populations have often been viewed as especially vulnerable with respect to health care access. Poorly developed and fragile health infrastructures, socioeconomic hardships, and physical barriers such as distance and unavailability of transportation all contribute to limiting access in rural areas. Problems in access to care for CVD are parallel for urban and rural women.

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But the magnitude of the problems is greater for rural women because of isolation, lower socioeconomic status, and lack of resources. Rural residents are more likely to suffer from chronic disease such as CVD; at the same time, the low proportion of CVD specialists in rural areas is of particular concern with regard to access to care. Lack of medical care resources such as coronary care unit beds and cardiac rehabilitation units also limit opportunities for CVD intervention and treatment. For those not covered by Medicare, lack of affordable access is a major barrier to adequate and timely health care.

Different patterns of insurance coverage and employment patterns are seen in rural residents. When rural residents are employed by a firm, the firm is usually small, does not pay for medical leave, and generally either is unable to provide comprehensive health insurance or offers no insurance coverage at all. The inhabitants of rural areas tend to have lower rates of private insurance coverage and higher rates of public insurance coverage than do residents of more populated areas.

Adequate health literacy is very important to motivate any behavioral modification necessary for good cardiovascular health. The absence of adequate prevention resources, such as safe and affordable physical activity programs, access to healthy and affordable food sources, and health insurance reimbursement for preventive services, is also an impediment to CVD prevention. Four strategies could, if implemented, improve the cardiovascular health of women who live in rural America.

While the strategies are interrelated, they can be viewed as distinct in a logical framework, each requiring their own set initiatives, infrastructure, and skill base. To identify and treat secondary metabolic causes of CVD including hypertension, diabetes, and dyslipidemia, it is necessary to address issues affecting access to high-quality health care.

Insurance coverage; sufficient numbers of local health care providers, including CVD specialists; transportation; and continued education among providers and in the community must be offered in a gender specific and culturally appropriate manner.

Epidemiology And Prevention Of Cardiovascular Diseases: A Global Challenge

Intervention regarding primary causes of CVD, such as overnutrition related to overweight and obesity and cigarette smoking, is also essential. Information must be disseminated in various forms and by various means with respect to diversity of gender, age young versus old , and ethnicity. Education and dissemination of information among health care providers, patients, communities, and policymakers legislators, public health officials, health policymakers, and health insurance agencies are critical.

Lack of insurance coverage is a major barrier to access, and creating policy to remove this barrier and improve access is crucial for the well-being of the rural populace. Given the variable employment patterns and less employer-based insurance in rural communities, state high-risk insurance plans to provide coverage to the rural residents would be an asset. Since , active insurance pools have operated in 26 states, and 7 states have provided an alternative to private insurance through BlueCross BlueShield associations; however, the conversion of these associations to for-profit entities will decrease the number of states that provide open enrollment with affordable premiums.

Unfortunately, data on the numbers of rural residents who have enrolled in these programs are not available. The Jackson Heart Study is an observational epidemiological study investigating environmental and genetic factors that influence the progression of CVD in African Americans. The study's target sample consists of participants in 3 counties, including both metropolitan and nonmetropolitan geographic areas.

#TomorrowsDiscoveries: Preventing Cardiovascular Disease – Erin Michos, M.D.

The study will provide premier information regarding cardiovascular disease among African Americans in addition to providing models for community outreach and education. The model of a causal sequence from lifestyle to CVD shows a linear relationship between behavioral risk factors, metabolic risk factors dyslipidemia, type II diabetes, and hypertension , and cardiovascular events coronary heart disease, cerebrovascular accident, congestive heart failure, and end-stage renal disease.

Modifications of this model must include the environmental and social causation factors related to racism, sexism, discrimination, as well as specific cultural dynamics such as spirituality, place of birth, migration patterns, and acculturation. Consideration must be given to designing long-term strategies that take into account the influence of socioeconomic status and cultural beliefs on individual perceptions of health and willingness to adopt lifelong behavioral modifications.

This shift should come from community input and from experienced researchers with an understanding of key issues and challenges for rural women. Ethnicity, gender, and geography are powerful modifiers of health in this country. It is possible that geography is more powerful than any risk factor yet to be discovered. The proximate influences on health that are tied to race may include socioeconomic status, education, biological risk factor prevalence, health-seeking behaviors, inequities in health care delivery systems, unique stressors tied to ethnic minority status, and genetic predisposition, as well as other factors yet to be postulated.

Epidemiology and Prevention of Cardiovascular Diseases: A Global Challenge

Geographic concentration of disease burden, likewise, may have many causes, including inadequate health care infrastructure, remote location, and environmental exposures unique to a given locale infectious diseases and other possibilities. These multidimensional influences interact in a way that causes CVD mortality statistics to range absurdly from one region to the next, and from one racial group to the next, among ethnic groups that constitute one nationality—the American nationality. The root causes of such huge disparities are clearly many. Resolution of these inequities will require comprehensive action strategically appropriate to the affected groups.

The study has significance for developing countries since many of the baseline levels of risk common in the late s in the United Kingdom are the norm in many developing countries today.

Epidemiology and Prevention of Cardiovascular Diseases: A Global Challenge | SpringerLink

There are a few studies that provide more direct insight into the causes of recent increases in CVD incidence and mortality in low and middle in-. For example, in their study on the rise of CHD mortality in Beijing from to , Critchley et al.

Another likely contributor is a rise in smoking. There has been a steady rise in global cigarette consumption since the s, which is expected to continue over the next decade if current trends continue. In , researchers estimate that 6. This increase in the total number of smokers around the world is driven predominantly by global population growth and is expected to continue unless smoking rates are drastically reduced. By , if current smoking and population growth trends continue, the global annual cigarette consumption could rise to between 6.

This growing burden of tobacco is increasingly falling on low and middle income countries. In fact, three of the top five cigarette-consuming countries are low or middle income countries China, the Russian Federation, and Indonesia. China alone consumes approximately 2. By , WHO projects that more than 80 percent of tobacco-related deaths will occur in developing countries Shafey et al.

In addition to increasing consumption trends, the amount of tobacco produced globally has nearly doubled since , with production increasing more than percent in low and middle income countries, where by , approximately 85 percent of tobacco was grown Shafey et al. In addition, as tobacco use has declined in rich countries, transnational tobacco companies have increasingly focused on expanding markets for their products in low and middle income countries Bump et al.

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The Grand Challenge of Cardiovascular Epidemiology: Turning the Tide

An emerging body of evidence suggests that rapid dietary changes associated with nutritional transition, along with a decrease in levels of physical activity in many rapidly urbanizing societies, also may play a particularly important role in the rise of CVD observed in developing countries Stein et al. The nutritional transition currently occurring in many low and middle income countries has created a new phenomenon in which it is not uncommon to see both undernutrition and obesity coexist in the same populations Caballero, ; Dangour and Uauy, ; Reddy et al.

Undernutrition has been the hallmark of the low and middle income countries of Africa, Latin America, and South Asia for decades. This situation is progressively being replaced by a distinct trend at the other end of the spectrum. While the global undernourished population is plateauing,.