Global cardiovascular disease prevention: A call to action for nursing Community-based and public...

Journal of Cardiovascular NursingVol. 26, No. 4S, pp S35YS45 x Copyright B 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Global Cardiovascular Disease Prevention:A Call to Action for NursingCommunity-Based and Public HealthPrevention Initiatives

Barbara J. Fletcher, MSN, RN, FAHA, FPCNA, FAAN; Cheryl Dennison Himmelfarb, PhD, RN;Maria Teresa Lira, RN, FPCNA; Janet C. Meininger, PhD, RN, FAAN; Sala Ray Pradhan, MSN, RN,ARNP-C; Joanna Sikkema, MSN, ANP-BC, FAHA, FPCNA

Policy changes are necessary to promote cardiovascular disease prevention. These will involve community-based and

public health initiatives for primary and secondary prevention of cardiovascular disease. In this article, we discuss

such interventions, community-based participatory research that has been conducted in this area, and implications

for capacity building in genetics research. Finally, areas for future research in this area will be identified.

KEY WORDS: community-based participatory research, prevention

Policy Changes Needed to PromoteCardiovascular Disease Preventionat the Community Level

The goal of this article is to take a close look atcommunity initiatives that reduce cardiovascular (CV)mortality, including the use of community-based par-ticipatory research (CBPR). Interplay exists betweengenetics and environmental factors in the developmentof CV disease (CVD). There is an opportunity to fur-ther our understanding of this interplay via CBPR as

many socioeconomic and environmental factors can bedirectly linked to one’s community.

Several highly respected organizations in health caresuch as the American Heart Association (AHA) and theInternational Heart Health Network have long realizedthe integral role of the community environment in im-plementing primordial (health promotion),1 primary, andsecondary prevention for CVD. Both organizations havepublished statements regarding initiatives for addressingCV health and thereby decreasing CV mortality globally.

The AHA guide for improving CV health at thecommunity level provides a comprehensive approach toreducing the burden of CVD and promoting CV healththrough improving local policies and environments.1

The emphasis focuses on improvements in facilities andresources in the places where people work and live ineffort to achieve the following goals: cessation of to-bacco use; avoidance of environmental tobacco smoke;reduction in dietary saturated fat, cholesterol, sodium,and calories; increased plant-based food intake; in-creased physical activity; and access to preventive healthcare services.1

The International Heart Health Network providesa policy framework for population approaches. It callson governmental agencies, the private sector, voluntaryhealth organizations, employers, and health care pro-viders to ‘‘join forces in eliminating this modern epidemicby adopting new policies, making regulatory changes,and implementing health promotion and disease pre-vention programs directed at entire populations.’’1

The vast majority of CVD and stroke can be attributedto a few deleterious behaviors and lifestyles many times

S35

Barbara J. Fletcher, MSN, RN, FAHA, FPCNA, FAANClinical Associate Professor, School of Nursing, Brooks College ofHealth, University of North Florida, Jacksonville, Florida.

Cheryl Dennison Himmelfarb, PhD, RNAssociate Professor, The Johns Hopkins University School of Nursing,Baltimore, Maryland.

Maria Teresa Lira, RN, FPCNANurse Researcher, Hospital FACh, Clinica Las Condes, Chile, Santiago.

Janet C. Meininger, PhD, RN, FAANProfessor, Schools of Nursing and Public Health, University of TexasHealth Science Center at Houston.

Sala Ray Pradhan, MSN, RN, ARNP-CNurse Practitioner, Mayo Clinic Jacksonville, Division of Cardiology,Jacksonville, Florida.

Joanna Sikkema, MSN, ANP-BC, FAHA, FPCNAFaculty and Director of Acute Care Nurse Practitioner Program,University of Miami School of Nursing and Health Studies, Florida.

The authors have no conflicts of interest to report.

CorrespondenceBarbara J. Fletcher, MSN, RN, FAHA, FPCNA, FAAN, School ofNursing, University of North Florida, 4567 St Johns Bluff Rd South,Jacksonville, FL 32224-2673 ([email protected]).

DOI: 10.1097/JCN.0b013e318213ef97

Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.1

encouraged or perpetrated by the communities in whichpeople live. Modifying harmful behavior and encouraginga healthful lifestyle within the community have thepotential to significantly alter global CV mortality. Giventhe current high prevalence of CVD risk factors and ofCVD itself, a 3-pronged approach, including primordial,1

primary, and secondary prevention, must be incorpo-rated in community-based CVD prevention models(Figure). The Figure represents a 3-pronged approachfor community-based CVD prevention. The modelincludes implementation of community programs andCBPR to target prevention at the primordial, primary,and secondary levels. Prevention is achieved throughimproved management of major CV risk factors.

Many community-based efforts suffer from inade-quate resources to implement needed interventions.However, proper implementation of merely a single in-tervention can be beneficial and create an impact onCV health in a community. For example, a workplace-wellness study randomized subjects to either an activeintervention versus usual care.2 The active interventionimplemented a multifaceted approach providing healtheducation, nutritional counseling, smoking cessationcounseling, physical activity promotion, and physicianreferral.2 Significant benefits were demonstrated throughquality-of-life scores and reduction in body fat, choles-terol, blood pressure, and total health risk, with a 48%reduction in medical claim costs.2 With strong supportand collaborative efforts from the community andpolicy makers, program planners can set priorities andimplement and evaluate effective programs (Table 1).Table 1 provides examples of programs developed andimplemented via collaborative efforts of policy makersand health care professionals. Another representation

of successful policy-level intervention is the recent in-troduction of community-level policy regarding publicand workplace smoking restrictions. These restrictionshave resulted in a significant decrease in the rate ofhospital admissions for acute myocardial infarction.3

Community-level research initiatives, CBPR, and rolesfor CBPR in CV genetic and environmental explora-tion are integral to reducing this modern-day epidemicof CVD in local populations and subsequently impactthe larger global community.

Research Initiatives forCardiovascular Disease Preventionat the Community-Based Levels

A research base exists providing evidence thatcommunity-level interventions can change community-wide behaviors.1,4Y8 For more than 3 decades, commu-nity prevention trials in the United States and abroadhave supported the notion that behaviors can be changedthrough concerted efforts to organize communities, edu-cate them through mass messaging and direct education,provide screenings for risk factors, and change environ-ments through local programs and policies. Screeningtools must be sensitive to specific populations. For ex-ample, one of the first CV risk prediction tools was theFramingham equation, which has provided a basis forthe majority of risk stratification instruments devel-oped worldwide; the equation is being modified inefforts to address the limitations of the original tool.2Y6

One such modification is currently being developed inSantiago, Chile. Here, the Framingham equation wasmodified based on numerical values that were derivedvia observational data from this country.

FIGURE. Community-based cardiovascular disease (CVD) prevention. This figure represents a 3-pronged approach forcommunity-based CVD prevention. The model includes implementation of community programs and community-basedparticipatory research to target prevention at the primordial, primary, and secondary levels. Prevention is achieved throughimproved management of major CV risk factors.

S36 Journal of Cardiovascular Nursing x July/August 2011


Additional research has identified schools, worksites,religious organizations, and health care facilities assites to facilitate community-wide behavior change.1

Community-based prevention initiatives include a rangeof risk-reducing, disease prevention strategies to supporthealthy behaviors and must be easily accessible withina neighborhood. Several large-scale community-basedinitiatives have proven to be successful and can serve asmodels for implementing targeted CVD risk reduction.Three successful programs are discussed here.

New York City Community-BasedPrevention Model

For the past 6 years, the New York City Community-Based Prevention Model has implemented public policyand community-based preventive services that targettobacco use and healthy food availability in key im-poverished neighborhoods of New York City (east andcentral Harlem, south Bronx, and north Brooklyn).These include providing a healthy food environmentwith fresh fruit and vegetables through vendors, foodstands, and government-supported food stamps, healthbucks (for the purchase of healthy foods), and farmersmarkets located in neighborhoods. This program alsofocuses on providing safe, structured fitness programsfor children and adults and neighborhood-based medi-cal providers and clinics.9

Centers for Disease Control andPrevention’s Health Communities Program

The Centers for Disease Control and Prevention (CDC)have embarked on a very successful initiative, ‘‘CDC’sHealth Communities Program.’’ This national programprovides resources and funding for chronic diseaseprevention initiatives at the community level; these haveled to a variety of successful local-level initiatives thathave improved community CV health. A few examples

are listed in Table 1. These large interdisciplinary pro-grams have targeted the work and home environmentsof vulnerable populations, successfully supporting be-havior change for chronic disease prevention.

Worksite risk reduction, faith-based risk reduction,and nurse-managed risk reduction programs are exam-ples of common delivery modalities for providing CVDpreventive tools. They have been documented to bequite successful.

Several studies reported the benefit of providing CVDrisk reduction at worksite locations. The convenience ofworksite location promotes employee participation,especially when incentives for reaching goals are pro-vided. These may be in the form of monetary rewards,days off from work, or employer recognition.10,11

There is a strong evidence base supporting the part-nership of faith-based organizations and community-based health promotion initiatives. These organizationshave been engaged to provide both screening and healtheducation in the areas of high blood pressure, diabetes,obesity, tobacco use, and cholesterol management.Faith-based organizations have been found to be espe-cially effective in providing these services to uninsuredand vulnerable populations. A review of the literatureperformed by DeHaven et al12 found that, of 340programs, the majority (43.4%) were ‘‘faith placed,’’developed by health professionals outside the congre-gation, versus 24.5% that were ‘‘faith based,’’ devel-oped by an internal health ministry. These programsreported significant improvement in overall health sta-tus, increased fruit and vegetable consumption, anddecreases in weight and blood pressure. Evidence sug-gests that most of these programs were targeted toAfrican Americans.12Y14

The effectiveness of nurse-managed programs forCV risk reduction, including individual, group, andcommunity interventions, has been well documented inthe literature.15Y17 It was also reported that use of

TABLE 1 Examples of Effective Community-Based Programs

& New York State Heart Healthy Program) Zero trans-fats in all New York City restaurants) Education to encourage drinking low-fat milk in New York worksites and faith communities

& Prohibiting smoking in restaurants and bars in most of US& Rails to Trails Program in US& Health Web as a School Teacher Tool in North East Florida& Minnesota ‘‘Vitality Project’’ addressing diet, exercise, and living habits& CDC’s Health Communities Program

) Targeting the Taqueria: Implementing Healthy Food Options at Mexican American Restaurants (Steps to a HealthySalinas, California)

) Evaluating Mobilization Strategies With Neighborhood and Faith Organizations to reduce Risk for Health Disparities (REACH):Kansas City, Missouri

) A Community Response to the Food Environment (Pioneering Healthier Communities: West Michigan)) A Comprehensive Worksite Wellness Program in Austin, Texas: Partnership Between Steps to a Healthier Austin and CapitalMetropolitan Transportation Authority

) A Pebble in the Pond: The Ripple Effect of an Obesity Prevention Intervention Targeting the Child Care Environment (Steps toa Healthier Arizona) (http://www.cdc.gov/healthycommunitiesprogram/evaluation-innovation/successarticles.htm)

Global CVD Prevention S37


nurses who are indigenous to the community and eth-nically, linguistically, and experientially sensitive to com-munity needs enhanced program effectiveness andoutcomes.18,19 Thus, providing community-based nurse-managed CVD risk reduction programming has beenfound to significantly impact the health of communities.

Vulnerable populations are at particularly high riskfor CVD and must not be overlooked in the develop-ment of community-based educational tools, screening,and disease management. Traditionally, the most vul-nerable populations have the highest incidence of CVDand the least access to risk reduction and disease pre-vention initiatives. These CV health disparities resultfrom a complex interplay of factors, including ethnicity,socioeconomic status, access to health care, and sexand provider bias.20Y22 Disparities commonly manifestthemselves as limited availability of easily accessibleand affordable healthy foods, absence of safe exerciseenvironments, and limited access to preventive healthcare. The opportunity to engage in risk-factor modi-fication and healthy lifestyle changes is limited andtherefore increases the CVD burden in these pop-ulations. Incorporating cultural, ethnic, and socio-economic parameters into community-based programspromotes lifestyle change and improves the healthstatus of the local and global population. One programaddressing CV risk from a culturally and ethnicallysensitive stance is the Well-integrated Screening andEvaluation for Women Across the Nation.

Well-integrated Screening and Evaluationfor Women Across the Nation

The Well-integrated Screening and Evaluation forWomen Across the Nation program had 10 uniquecommunity-based projects incorporating approximately8164 women across the United States.23 This programevolved from a CDC initiative for the early detection ofcervical cancer and breast cancer (National Breast andCervical Cancer Early Detection Program) and hasexpanded to include CVD screening and intervention.These projects developed culturally and regionallyappropriate nutrition and physical activity interventionsfor a variety of racial and ethnic populations. Theywere funded and operated by a combination of govern-ment, state, and territorial health departments andtribal agencies. Program participants were screened forhigh blood pressure, high cholesterol, abnormal glu-cose, and obesity. Many were also screened for tobaccouse, poor dietary habits, and sedentary lifestyle, in orderto better provide unique, culturally relevant interven-tion strategies for the specific cohort. This large-scalestudy was designed to evaluate the effectiveness of ‘‘en-hanced’’ risk reduction interventions, compared with‘‘minimum’’ interventions or usual care. Minimum inter-vention was defined as baseline screening for CVD risk

factors and minimal on-site counseling, education, andreferral. Repeat screening was recommended at 6 and12 months. Women enrolled in the ‘‘enhanced’’ inter-vention received all services of the minimum interven-tion plus specially designed community-based educationtailored to the population, including racial, ethnic, andage considerations. These projects used a combinationof developed resources that were adapted for the localenvironment. Examples include the following:

h New Leaf: A comprehensive risk reduction programdesigned for a Southern, multiethnic, low literacypopulation

h Vida Saludable, Corazon Contento: A Spanish-languageadaptation of New Leaf used in North Carolina

h Traditions of the Heart: An adaptation of New Leafused in Alaska, which was revised to include a12-week, interactive group program incorporatingNative Alaskan tradition

h Physician-Assisted Counseling and Evaluation: A pro-gram used in Connecticut to promote physical activity

h Active Living Every Day: A program used in SouthDakota to promote physical activity

h ABCs for Good Health: Developed by the US De-partment of Agriculture and was coupled with the10 000 Steps Program in Nebraska.

The results of this multicenter, multiethnic studyshowed that those who had obtained the enhancedinterventions reported less fat in their diet and improve-ments in cholesterol panels, blood pressure profiles, andsmoking cessation. The study reported that culturaladaptation involves much more than translation ofdocuments and must include identifying barriers tochange cultural norms. Some of these include suchfactors as social isolation, unsafe neighborhoods, andlack of access to healthful foods. The benefits of ex-tending participation to family members and friends,using local community health workers who could en-courage attendance, arranging transportation, providingchild care, encouraging exercise in safe environments(eg, YMCA, local indoor swimming pools), and extend-ing hours for participation were also reported.23Y25

Community-Based Participatory Research

Community-based participatory research is neither aresearch design nor a method, but rather an orientationor an approach to conducting research in partnershipwith a community. It may be used in observational(nonexperimental) or experimental research and mayincorporate quantitative and/or qualitative methods.26

Community-based participatory research has beendefined as a ‘‘systematic inquiry, with the participationof those affected by the issue being studied, for thepurpose of education and taking action or effectingsocial change.’’27



Debate is present regarding terms that representdifferent ideological stances and historical traditions ofvarious approaches to CBPR.28 There are, however,certain core principles and values that have evolvedover time and transcend these variations. These prin-ciples include working with existing communities;building on strengths and resources of the community;facilitating collaborative, equitable partnerships; pro-moting mutual learning and capacity building amongpartners; and considering health issues in an ecologicalcontext, with explicit recognition of the multiple deter-minants of health and disease. Competence is devel-oped through an iterative, cyclical process designed tobe sustainable and committed to continuing work overthe long term, with dissemination of knowledge andfindings to all partners.29

There is increasing recognition of the value of CBPR,particularly as an approach to addressing health dis-parities in areas of research that require behavioraland/or environmental changes to prevent or amelioratea health problem. Sustained efforts using participatoryapproaches to address environmental issues have beenpublished. Recently, investigators interested in the pre-vention and control of CVD have been challengedto move CBPR into the mainstream of preferred re-search approaches.30

Variations in Design and Examples ofCBPR Focused on Prevention ofCardiovascular Disease

Examples of CBPR focused on primary or secondaryprevention of CVD have been published. The studiesincluded in this section are (1) research described by oneof several terms that included the word ‘‘participatory’’;(2) studies using 1 or more strategies that incorporatedCBPR principles in the design, implementation, and/ordissemination of the research; (3) studies focused onsome aspect of primary or secondary prevention ofCVD; and (4) studies published in English. These ex-amples do not necessarily represent the full spectrumof relevant research. Studies done in countries outsidethe United States and Canada may be underrepresented.

In Table 2, examples of CBPR strategies are pre-sented by stage of the research process. Five studiesprovided examples of involvement of the community inplanning and oversight.31Y35 Community involvementin assessment and/or building community capacity toengage in research was illustrated in 5 studies.32,36Y39

Community participation in the study implementationstage of research, including community members’ in-volvement in the design and delivery of interventions inexperimental studies, was evident in 4 studies.31,35,40,41

Three studies provided examples of community mem-bers’ involvement in analysis and/or interpretation anddissemination of data.32,37,42 Several studies involved

CBPR strategies in more than 1 stage of the researchprocess; 2 additional reports described CBPR strategiesin all stages.43,44 There were more examples of com-munity participation in earlier than in later stages ofthe research process. This is similar to the trend ob-served for the broad range of CBPR research,45 not justthose focused on CV health. Various research ap-proaches were used including qualitative or descriptiveapproaches, ethnographic studies, observational studiesbased on survey data and other measurements, and ex-perimental designs (Table 2). Some of the studies wereclassified as ‘‘methodological,’’ because they focused ondevelopment of an intervention or measurement.

There are some barriers to dissemination of CBPR.Scientific rigor may be compromised in some instancesin favor of approaches that are compatible with thecommunity’s values and norms. Because CBPR usuallyinvolves recursive processes, rather than a linear ap-proach to research design and methods, it may bedifficult to report CBPR using standard manuscriptheadings (background, methods, findings, discussion).Journal reviewers may not be familiar with the prin-ciples of CBPR, which complicates finding appropriatereviewers and publication outlets. Despite said bar-riers, CBPR demonstrates a promising research modal-ity to use in focusing on the disparities existing amongCVD prevention and how it relates to specific com-munities on both a local and global scale.

Building Community Capacity forParticipation in Genetic Research inCardiovascular Disease Preventionand Reducing the Potential forHarm/Exploitation

Cardiovascular disease arises from a complex web ofcauses that encompass genetic and environmentalfactors and their interactions. Although familial pat-terns are discernable, the mode of inheritance is com-plex, with many genetic factors involved. Each geneticfactor may make a small contribution to risk of diseaseand operate in concert with combinations of othergenetic factors and environmental risks, including life-style behaviors.46,47 Understanding this complex webof causative factors is necessary to refine strategies forpreventing or delaying the pathophysiologic processesthat lead to clinically apparent CVD states.

Genetic studies of any of the complex diseases,including CVD, require large samples and access todiverse populations. Review of the literature on par-ticipation in genetic studies indicates that much of theresearch on building community capacity for partici-pation and reducing the potential for exploitation andharm is not disease specific. Common themes thatemerged included analysis of (1) building capacity



TABLE 2 Examples of Community-Based Participatory Research Studies for the Prevention of

Cardiovascular Disease, by Stage of Research

Research Stage ReferenceResearch Approach/and

Location CBPR Strategies

Planning and oversight Pazoki et al31

(2007)& Experimental; Iran & Set priorities for research in collaborative group

sessions with community members, academicresearchers, health care providers, and policy makers

Boyer et al32

(2005)& Observational;southwest Alaska

& Interacted with community leaders to gain access tothe community and its members; local researchassistant engaged to translate and serve as liaisonbetween community members and the researchteam; committed to protecting participants fromdiscrimination and exploitation

Mohatt et al33


& Local tribal leaders nominated rural communities forparticipation and provided advice on recruitmentof participants

Levy et al34

(2004)& Observational;Chicago, Illinois

& Engaged community leaders and experts in writinggrant proposal

Kannan et al35

(2008)& Methodological;Detroit, Michigan

& Planning and oversight through a community-basedsteering committee

Assessment/andBuilding CommunityCapacity

Boyer et al32


& Conducted workshops on genetics for health directors,tribal council members, and village representatives;extensive interaction with the community throughpresentations and bilingual, local, research coordinators

Kalra et al36

(2004)& Qualitative; AsianIndian communities inNorthern California

& Community-based groups assessed perceptions ofrisk for cardiovascular disease and identifiedcomponents of a culturally relevant intervention

Higgins et al37

(2006)& Qualitative; Pacificnorthern areas of UnitedStates and Canada

& Through focus groups and individual interviews,members explored social and economic contextsshaping heart healthYrelated experiences

Grigg-Saitoet al38 (2008)

& Qualitative; Cambodianimmigrants inMassachusetts

& Obtained information through ‘‘communityconversations’’ about knowledge, needs, attitudes,beliefs, strengths, and behaviors in relation to CVD,diabetes, and access to care; outreach strategies toincrease community participation including door-to-door outreach to socially isolated residents; peersupport groups; business, faith based, media, andprovider outreach; special events. Educationalworkshops, learning tours, exercise groups to buildskills and participation

Ebbesen et al39

(2004)& Methodological;4 provinces in Canada

& This is an example of community capacity buildingat the health systems level; capacity building effortsof the Canadian Heart Health Initiative aredescribed, and critical issues in measurement ofhealth promotion capacity are identified

Design and Delivery ofIntervention; StudyImplementation

Kannan et al35

(2008)& Methodological;Detroit, Michigan

& Community representatives designed and modifiedstudy materials to match regional and cultural foodpreferences; community members assessedreadability of materials and enhanced usefulness offeedback to participants through visual cues andpositive reinforcement

Pazoki et al31

(2007)& Experimental; Iran & Community advisory board tailored the study to the

target community by providing input on readabilityand cultural appropriateness of interventionmaterials and length of the program

Wilcox et al40

(2007)& Experimental; churchesin South Carolina

& A delayed intervention for the comparison group wasdelivered so that an experimental approach would beacceptable to the church leaders; church memberswere trained to deliver the intervention through theirexisting church ministries; spiritual messages wereintegrated into all physical activity promotion messages

Allen andScott41 (2003)

& Review article; variousUS locations

& Studies provide evidence of involvement ofcommunity health workers in primary and secondaryprevention of coronary heart disease as membersof multidisciplinary teams



through community engagement and consultation,(2) ethical issues related to ongoing genetic studies aswell as biobanking of specimens for future studies, and(3) sharing benefits of genetics research.

Building Capacity Through CommunityEngagement and Consultation

In building capacity for participation in genetics re-search, it is important to consider values, beliefs, literacy,experience, knowledge levels, and preferred learningstyles of the population.48 For instance, an article eval-uates Hindu perspectives on genetic research in anIndian American community in Houston, Texas.49,50

Another explores the opinions of African Americansregarding genetic testing. More negative views wereelicited from African Americans when compared withwhite participants in a genetic epidemiology study ofrisk for colon cancer. After controlling for confoundingfactors, African Americans were more likely to believethat genetic research would result in higher insurance,reinforce racism, not benefit minorities, and that minori-ties are more likely to be used as ‘‘guinea pigs’’ inresearch.49,50 To address these and other related con-cerns of discrimination and exploitation of minorities ingenetic research, there is increasing momentum to de-velop models of community engagement to educate,build consensus, and empower individuals and com-munities in policy making for genetic research.51

Community engagement can range from investigator-controlled advisory panels, to more equitable partner-ships between researchers and community leaders and

members. The Marshfield Clinic Personalized MedicineResearch Project in the United States (Wisconsin) en-gaged the community throughout the process for apopulation-based biobank, from the planning stagesthrough to dissemination. Central to this communityengagement was the formation of a community advisorygroup. This group, composed of 19 members residing inthe target zip codes, was advisory to the researchers,with the agenda set by the principal investigator. Theyserved as a sounding board to review alternative ap-proaches in the community, recruitment strategies,issues of confidentiality, incentives for participation,and frequency of contact with participants.52 In con-trast, the Healthy Environments Partnership, whichinvestigated the prevalence of biologic risk factors ofCVD and social and physical environmental exposuresas mediators of risk-factor inequalities, involved thecommunity collaboratively in all stages of the researchprocess.43 It was affiliated with the Detroit CommunityAcademic Urban Research Center, with participation ofpublic health and academic institutions, as well ashealth services and community-based organizations.53

Ethical Issues Related to GeneticStudies and Biobanks

In the United States, biobanking of specimens is takingplace to provide an infrastructure of data for ongoingand future studies.54 Increases in genetic research sincethe completion of the human genome project and inbiobanks for the collection and storage of human tis-sues and cells have brought ethical issues into focus.

TABLE 2 Examples of Community-Based Participatory Research Studies for the Prevention of

Cardiovascular Disease, by Stage of Research, continued

Research Stage ReferenceResearch Approach/and

Location CBPR Strategies

Data Analysis andDissemination

Boyer et al32


& Community members in 1 village explored data toset goals for health promotion based on the results

Arthur et al42

(2001)& Qualitative; Ontario,Canada

& Participants reviewed results of data analysis todesign a program that they thought would benefitother women living with heart disease

Higgins et al37

(2006)& Qualitative; Pacificnorthern areas of UnitedStates and Canada

& Participants were involved in analysis anddissemination of data on factors and conditions thatshape heart-related health behaviors from theperspective of low-income, single mothers

All Stages of theResearch Process

Schulz et al43

(2005)& Observational; Detroit,Michigan

& The research team, which included representativesof health service organizations and communityorganizations along with academic researchers,collaborated on all aspects of the research process:planning, design, implementation, interpretation,and dissemination

Chotibanget al44 (2009)

& Qualitative; Chiang-MaiThailand

& University-based researchers worked collaborativelywith school personnel, parents, food vendors, andchildren to design, implement, and evaluate aprogram to promote healthy eating and physicalactivity among school-aged children

Abbreviations: CBPR, community-based participatory research; CVD, cardiovascular disease.



Although informed consent has driven the efforts toprotect the rights of humans involved in research, theestablishment of biobanks has challenged traditionalmethods and norms for obtaining consent of partici-pants. In some cases, participants are asked to giveblanket consent for all future studies using their speci-mens. In other studies, samples are deidentified, andthe study is declared exempt from the requirementfor informed consent. The fact that it is impossible todeidentify genetic information is one of the criticalethical issues in the current debate on making geneticdatabases publicly available.55,56 On the other hand,public availability of large genetic databases is consid-ered essential for progress in genetic research and per-sonalized medicine, including pharmacogenomics. Thelatter provides a basis for tailoring specific interven-tions and drugs to those individuals who have thegenetic propensity to respond to them.57 Tiered con-sent procedures are emerging, along with additionalsafeguards to protect privacy and to reduce the po-tential harm associated with breaches of privacy.56

Opinions on these and other issues related to informedconsent for biobanking were reported in recently pub-lished studies.58,59

In population-based research, it is important toinvolve community leaders, obtain their approval, andto then engage with the community as a whole beforeapproaching potential participants in genetics re-search.48,60 Although there is the potential for apopulation to benefit from participation in genetic re-search, there is also the potential for harm, exploita-tion, and stigmatization for populations that providebiological samples for genetic research. A recent legalsettlement between a Native American tribe and a uni-versity in the United States illustrates this potential forharm.61 Controversies arose surrounding the futureuses of genetic samples beyond the research topics in-cluded in the informed consent process. Removing do-nors’ identifying information from the samples did noteliminate the risks to the population. Thus, the ethicaldebates continue regarding risks and benefits of geneticresearch for populations, as well as the processes forobtaining informed consent for future uses of storedsamples.

Sharing Benefits of Genetics Research

Genetics research is proliferating in both developedcountries and developing countries with limited re-sources. Caution is necessary to ensure that popula-tions from countries with limited resources are notexploited as participants in genetics research that willbenefit only populations from developed countries.62

Patenting of biological entities such as genes and single-nucleotide polymorphisms raises questions aboutwhether participants or communities should share in

profits for use of their biological materials in researchand development.48,63

Community-Based Translational Research

The usual route for translational research is from the‘‘bench’’ (basic research) to the ‘‘bedside’’ (clinical re-search) and back. Although this is an important route,the more challenging translation for population healthis the route from the bench or the bedside to thecommunity and back. With the bedside as the primarydestination, attention is placed on disease states andtheir treatments. For translational research to have animpact on population health through prevention of dis-ease and promotion of health, translation to the com-munity is essential.64

Interventions to prevent disease are subjected to thesame rigorous tests as clinical research in humans, therandomized controlled trial. However, when interven-tions are found to be efficacious under ideal circum-stances, they are rarely tested further to demonstrateeffectiveness under ‘‘real world’’ conditions or for fea-sibility of broad dissemination in the community.Furthermore, many interventions that have been effica-cious in the short term are not sustainable over the longterm. Much of the effort to prevent CVD and the cor-responding research initiatives are focused on interven-tions to change behavior at the individual level. There isincreasing recognition that the contexts in which healthbehaviors occur have a powerful influence on theirlikelihood of occurring. For example, consider the re-lationship between salt consumption and its link toelevated blood pressure. Individuals can be taught andeven motivated to consume less salt, but how easy is itto enact that behavior in an environment of processedfoods? Social-ecological models that incorporate multi-ple layers of influences on health behaviors are framingmany community-based, translational research studiesfor the prevention of CVD.65,66

Genetic-Environmental Interactions andImplications for Population-BasedCardiovascular Disease Prevention

The clinical manifestations of CVD are end points of acomplex set of processes that are affected by multiplefactors and mechanisms. Coronary artery disease, asconceptualized by Lanktree and Hegele,67 is the resultof inflammation, coagulation, dyslipidemia, dysglyce-mia, hypertension, plaque growth, instability, and soon. Each of these processes may be fueled by a complexset of genes that may be responsive to environmentalfactors such as infection, stress, exercise, diet, smoking,and chemical exposures. A new era of CVD preventionwill emerge with the increasing understanding of gene-gene and gene-environmental interactions.



Needed: Community-Based Researchfor Implementation of CardiovascularDisease Prevention

Community-based participatory research is an ap-proach to qualitatively and quantitatively evaluate localpopulation patterns related to the environment they livein as well as how that environment persuades theirlifestyle. This style of research can be applied to CVDprevention when considering how to effectively reach alocal community. Several questions one might considerfor guidance in reaching a specific community include(1) what tool to promote CV health and CVD pre-vention is best suited for this population consideringsocioeconomic status and culture? And (2) what is thebiggest deterrent to promoting CVD prevention in thiscommunity? Ultimately, CBPR shows great promise asan up and coming valuable commodity to the preven-tion of CVD at the local and subsequently global level.

A unique opportunity exists to incorporate CBPRand community-based genetic research. This is anemerging concept not only in the setting of CV risk andCVD prevention but also in genetic research as a whole.Research examining gene-gene and gene-environmentinteractions will certainly guide future CVD preventionefforts at a local and global level. However, it remains tobe seen exactly how this promising modality willmanifest itself in the field of CVD prevention as re-searchers address some of the remaining questions sur-rounding consent, ethics, and benefit sharing.

Conclusion

Cardiovascular disease is attributable to both genetic andenvironmental factors that share a closely intertwinedrelationship. Community-based programs providingculturally and socioeconomically relevant guidance thatfocuses on diet modification, physical activity, andsmoking cessation are key to changing environmentalfactors that link local and global populations to CVD.Several large-scale successful models have been outlinedincluding the AHA’s guide for improving CV healthat the community level and the International HeartHealth Network’s policy framework for populationapproaches. All health care professionals, local work-forces, faith-based organizations, and nurse managedrisk reduction programs are important to the develop-ment and implementation of community-based pro-grams. Given the target audience of this article, it shouldbe noted that nurses in particular have the opportunityto become community leaders in CV health promotion.Equipped with knowledge and specialized training inhealth promotion, nurses are perfectly positioned todirect, guide, and implement these community initia-tives. Nurses must demand policy change and involvethemselves in implementing diet modification, smoking

cessation, and increasing physical activity among all agegroups within their communities. Ultimately, the goal ofall health care professionals should be to penetrate theplaces people work, socialize, and spend their free timewith education and guidance regarding a lifestyle thatwill positively affect their health and is the first step tochanging CVD risk and ultimately the mortality of anentire community.

Summary and Implications

This manuscript addresses community-based and pub-lic health prevention initiatives. Specifically addressedare initiatives for CVD prevention at the communitylevel, community policy changes needed to promoteCVD prevention, CBPR, and CVD risk stratificationmodels. Each of these initiatives poses a ‘‘call to actionfor nurses and nursing’’ and will involve specificnursing activities, strategies, and nursing research toaddress better outcomes in CVD prevention.

Acknowledgment

The authors thank Isabel Cruz, PhD, RN, FluminenseFederal University, Rio de Janeiro, Brazil, for her sug-gestions in this manuscript.

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