Using participatory research to challenge the status quo for women’s cardiovascular health

053 Impact of Socioeconomic Status on Cardiovascular Risk Factors and Health Behaviours in Youth

Objective: Our study aims to examine whether and how pre-pandemic conditions shaped change in well-being among partnered and lone mothers in Germany. Background: The lives and daily routines of parents changed dramatically because of the pandemic, which affected their mental health. Particularly mothers reported increased psychological distress during the pandemic, which is likely related to the higher load of care responsibilities mothers shouldered to compensate for pandemic-related childcare and school closures. Yet mixed findings emerged on the pandemic’s impact on lone mothers, who were already suffering from poorer mental health compared to partnered mothers. Method: We use longitudinal data from a probability sample surveyed before and during the pandemic to examine changes in maternal well-being (i.e., subjective psychological well-being and general life satisfaction), and differences between lone and partnered mothers in Germany (N = 3,578; 14.3% lone mothers at baseline). Results: Socioeconomic status was positively associated with changes in maternal well-being, but no difference emerged between lone and partnered mothers. Although levels of pre-pandemic social support and parenting stress did not affect changes in maternal well-being among partnered mothers, these factors were associated with a less pronounced decline in maternal well-being among lone mothers. Conclusion: The lack of differences between lone and partnered mothers could be due to implemented institutional safety nets for lone mothers, and increased relationship strain for partnered mothers, during the pandemic.

Lone mothers are a disadvantaged population, with research in several countries indicating that they experience low levels of physical and mental health. While research has demonstrated a socioeconomic gradient for cardiovascular disease (CVD), little research has explored lifestyle and clinical risk for CVD and prevalence of CVD events in lone mothers. The purpose of this study is (1) to compare select CVD lifestyle risks (smoking, obesity, physical activity), health, and relevant sociodemographic variables in partnered versus lone mothers; (2) to examine the relationship between partner status and having experienced a CVD event (myocardial infarction [MI], congestive heart failure [CHF], stroke). Data from the U.S. National Health and Nutrition Examination Survey III (NHANES III) included 1,446 women over 60 years with one or more children less than 17 years old. Lone mothers included women who were widowed, divorced, separated, never married, or married without the spouse living in the household (n = 623; weighted sample represents n = 3,904,450). Partnered mothers included women who reported living as married or married with the spouse in the household (n = 832; weighted sample represents n = 8,614,362). Weighted logistic regression was used to compare the prevalence of CVD risk factors in lone (43%) ver sus partnered (57%) mothers. Multivariate modeling was used to examine the relationship between partner status, CVD risks, and Coronary Heart Disease (CHD) events. Compared with partnered mothers, lone mothers were less educated and reported lower levels of income, health, and social support; and they were more likely to report non-White ethnicity. Lone mothers were more likely to be current smokers, overweight or obese, and physically active than partnered mothers. Those with clinical risks for CVD, including diabetes, elevated C-reactive protein, hypercholesterolemia, or hypertension, or all of these were more likely to be lone mothers. After adjusting for age, we found that mothers who had experienced a CVD event (MI, CHF, or stroke) were 3.3 times more likely to be a lone mother than a partnered mother (95% confidence interval (CI) 3.24, 3.31). Lone mothers are at increased risk for CVD. Health professionals and lone mothers should collaborate in the development of programs and policies not only to reduce lone mothers' risk for CVD, but also improve their conditions of living. Support was received from Heart & Stroke Foundation of Canada, NINR Grant #2 P30 NR04001.

Participatory action research combines research, education and social action. Each of these elements reflects health education research and practice. Indeed, health education, health promotion and participatory research have converged in these respects. Participatory research is well suited to the philosophies and theories underpinning community-based health education and health promotion. The nature of participatory research is such that funding agencies, especially those awarding research funds, tend to be challenged in their attempts to assess proposals. This is true at least for those agencies operating under traditional criteria for reviewing standards, which may not be appropriate for participatory research. As well, it may reflect a broader lack of common understanding about the processes and expectations, the apparent untidiness of projects (comparing with traditional research) which by their nature offer no standard methods, deadlines, procedures or predetermined outcome measures. The Study of Participatory Research in Health Promotion [1], commissioned by the Royal Society of Canada, attempted to clarify the topic by providing a working definition and a set of guidelines for use by funding agencies when appraising projects purporting to be participatory research. The guidelines emphasize how the nominal ways of conducting health research in populations need to adapt to meet the educational and policy expectations of participatory research. The study also examined current practical examples of participatory research in the field of health promotion in Canada. This summary of the results of the project provides detailed guidelines flowing from a review of experience in the field and consultation with groups engaged in participatory research.

Participatory action research combines research, education and social action. Each of these elements reflects health education research and practice. Indeed, health education, health promotion and participatory research have converged in these respects. Participatory research is well suited to the philosophies and theories underpinning community-based health education and health promotion. The nature of participatory research is such that funding agencies, especially those awarding research funds, tend to be challenged in their attempts to assess proposals. This is true at least for those agencies operating under traditional criteria for reviewing standards, which may not be appropriate for participatory research. As well, it may reflect a broader lack of common understanding about the processes and expectations, the apparent untidiness of projects (comparing with traditional research) which by their nature offer no standard methods, deadlines, procedures or predetermined outcome measures. The Study of Participatory Research in Health Promotion [1], commissioned by the Royal Society of Canada, attempted to clarify the topic by providing a working definition and a set of guidelines for use by funding agencies when appraising projects purporting to be participatory research. The guidelines emphasize how the normal ways of conducting health research in populations need to adapt to meet the educational and policy expectations of participatory research. The study also examined current practical examples of participatory research in the field of health promotion in Canada. This summary of the results of the project provides detailed guidelines flowing from a review of experience in the field and consultation with groups engaged in participatory research.

Preeclampsia: Exposing Future Cardiovascular Risk in Mothers and Their Children

BackgroundChildren are the focus of numerous health interventions throughout the world, yet the extent of children’s meaningful participation in research that informs the adaptation, implementation, and evaluation of health interventions is not known. We examine the type, extent, and meaningfulness of children’s participation in research in qualitative health intervention research.MethodA scoping study was conducted of qualitative published research with children (ages 6–11 years) carried out as part of health intervention research. Following Arksey and O’Malley’s scoping study methodology and aligned with the PRISMA-ScR guidelines on the reporting of scoping reviews, the authors searched, charted, collated, and summarized the data, and used descriptive and content analysis techniques. Ovid MEDLINE was searched from 1 January 2007 to 2 July 2018 using the keywords children, health intervention, participation, and qualitative research. Study selection and data extraction were carried out by two reviewers independently.ResultsOf 14,799 articles screened, 114 met inclusion criteria and were included. The study identified trends in when children were engaged in research (e.g., post-implementation rather than pre-implementation), in topical (e.g., focus on lifestyle interventions to prevent adult disease) and geographical (e.g., high-income countries) focuses, and in qualitative methods used (e.g., focus group). While 78 studies demonstrated meaningful engagement of children according to our criteria, there were substantial reporting gaps and there was an emphasis on older age (rather than experience) as a marker of capability and expertise.ConclusionsDespite evidence of children’s meaningful participation, topical, geographical, and methodological gaps were identified, as was the need to strengthen researchers’ skills in interpreting and representing children’s perspectives and experiences. Based on these findings, the authors present a summary reflective guide to support researchers toward more meaningful child participation in intervention research.

Background: The Predicting Risk of CVD EVENTs (PREVENT) equations were developed with minimal representation from Hispanic/Latino adults. Objective: To describe the ten-year risk of total cardiovascular disease (CVD) using PREVENT and estimate the discordance rate in Hispanic/Latino adults. Methods: The Hispanic Community Health Study/Study of Latinos is a population-based cohort of 16,415 diverse Hispanic/Latino adults aged 18-74 from four urban communities (Bronx, NY; Chicago, IL; Miami, FL; and San Diego, CA). At baseline (2008-2011), participants underwent a comprehensive examination which included questionnaires, anthropometric measurements, and fasting blood draws. Among 4,829 participants 30-79 years of age, without a history of CVD, examined in 2008-2009 and followed through 2019 (at least ten years), we used baseline information on age, sex, blood lipids, systolic blood pressure, body mass index, estimated glomerular filtration rate, diabetes status, smoking status, and anti-hypertensive or lipid lowering medication use, to calculate ten-year risk of total CVD (heart disease, stroke, or heart failure) using the base model PREVENT equation. CVD events were adjudicated from hospital records by an independent panel of clinicians through Dec 2019. We calculated the ten-year risk of total CVD using the base PREVENT equation. These analyses were weighted and accounted for the complex survey design of the study. We then calculated the discordance rate by comparing the predicted to observed number of CVD events overall and according to sex. Results: In a diverse sub-population of HCHS/SOL, the mean age was 47.3 years, and 52.0% were female. Using the PREVENT equation, the mean ten-year CVD risk score was 5.2%; and 67.9% had a <5.0% risk of CVD; 9.0% had a 5 to <7.5% risk of CVD, 5.7% had a 7.5 to <10.0% risk of CVD, 8.6% had a 10.0 to <15.0%, 4.1% had a 15.0 to <20.0% risk of CVD, and 4.7% had a ≥20% risk of CVD. Over ten years, 224 CVD events were predicted, and 110 CVD events were observed (discordance rate: 103.6%). Men compared with women had higher risk of CVD (5.7% vs. 4.8%, p<0.05) and CVD was more likely to be overpredicted among males (discordance rate: 178.6%) than females (discordance rate: 55.9%). Conclusion: In this diverse sample of Hispanic/Latino adults, the base PREVENT equation for total CVD overestimated risk of CVD, especially among males. These data identify a potential limitation of the PREVENT equation for Hispanic/Latinos adults.

This study aimed to determine how the frequency of impaired perception of cardiovascular disease (CVD) risk is correlated with health literacy in individuals with high CVD risk in two regions with different socioeconomic levels. A descriptive study was conducted. The Systematic Coronary Risk Estimation, recommended by the European and Turkish Cardiology Societies, provides recommendations based on individuals' actual CVD risk levels. According to the Systematic Coronary Risk Estimation, participants suffering from diseases were identified as high and very high risk. The perception of risk was determined by subjectively assessing the risk level of the individuals. The European Health Literacy Survey Questionnaire was used. The Mann-Whitney U test, Chi-squared test and Spearman's correlation analysis were used to analyse the data. We also conducted a logistic regression analysis to identify factors contributing to impaired perception of CVD risk. A total of 384 individuals, aged between 40 and 70years (with a mean age of 58.35±8.33years), were included in the study. These individuals had a high risk of CVD and were registered to family health centres from two different socioeconomic levels. Out of the 384 participants, 201 individuals belonged to the lower socioeconomic level region and 183 individuals belonged to the higher socioeconomic level region. A total of 61.7% of the participants with high CVD risk had an impaired perception of CVD risk. The health literacy level of 59.9% of individuals was either inadequate or problematic. The health literacy score of participants with impaired risk perception (29.59±9.07) was lower than those with correct risk perception (35.83±10.94; P <0.001). Factors that affected the perception of CVD risk included age, education level, working status, occupation, a family history of CVD, the CVD risk assessment by health professionals and the recommendation of health professionals to individuals for CVD screening. It is necessary for health care professionals to make risk assessments and perform interventions to improve health literacy to raise the awareness of individuals with high CVD risk on their actual risk.

The current study investigated whether greater maternal support during adolescence is associated with lower levels of cardiovascular disease (CVD) risk in adulthood, and whether maternal support serves as a moderator or a mediator of the socioeconomic status (SES) and CVD risk association. In addition, potential moderators and mediators of the association between adult CVD risk and adolescent maternal support and SES were tested. Using the National Longitudinal Study of Adolescent to Adult Health (n = 11,013), we examined relations between maternal support during adolescence (M = 15.3 years) and CVD risk in young adulthood (M = 28.7 years) via path analysis. Maternal support was assessed by a composite of adolescent and mother report. CVD risk was calculated with a Framingham-based prediction model that uses age, sex, body mass index, smoking, systolic blood pressure, diabetes, and use of antihypertensive medication. Greater maternal support in adolescence was related to lower CVD risk in young adulthood (B = -0.56, 95% CI: -0.91 to -0.20, p < .01). The interaction between adolescent SES and maternal support was not significant, (p > .05), but there was an interaction between maternal support and race such that African American adolescents were more sensitive than Whites to the effects of maternal support on CVD risk (B = -0.90, 95% CI: -1.56, -0.25, p < .01). In addition, there was no evidence that maternal support mediated the association between SES and CVD risk (p > .05), and there was no association between SES and maternal support (p > .05), adjusting for confounders. However, the relations of adolescent maternal support and SES to adult CVD risk were mediated by young adult health behaviors and financial stress but not by depressive symptoms. Greater maternal support during adolescence appears to act independently of SES when impacting CVD risk and may operate through health behaviors and financial stress. (PsycINFO Database Record

The goal of this American Heart Association Guide for Improving Cardiovascular Health at the Community Level (AHA Community Guide) is to provide a comprehensive inventory of evidence-based goals, strategies, and recommendations for cardiovascular disease (CVD) and stroke prevention that can be implemented on a community level. This guide advances the 2003 AHA Community Guide1 and the 2005 AHA statement on guidance for implementation2 by incorporating new evidence for community interventions gained over the past decade, expanding the target audience to include a broader range of community advocates, aligning with the concepts and terminology of the AHA 2020 Impact Goals, and recognizing the contributions of new public and private sector programs involving community interventions. In recent years, expanding arrays of programs and policies have been implemented in increasingly diverse communities to provide tools, strategies, and other best practices to potentially reduce the incidence of initial and recurrent cardiovascular events. The AHA Community Guide complements the AHA statement entitled “Population Approaches to Improve Diet, Physical Activity, and Smoking Habits”3 and supports the AHA 2020 goal4 to “improve the cardiovascular health of all Americans by 20%, while reducing deaths from CVDs and stroke by 20%.” The present AHA Community Guide supports the AHA 2020 goal by identifying exemplary regional or national programs that encourage cardiovascular health behaviors and health factors (formerly addressing risk behaviors and risk factors) from which communities might acquire proven strategies, expertise, and technical assistance for improving cardiovascular health. The AHA Community Guide seeks to prevent the onset of disease (primary prevention) and to maintain optimal cardiovascular health (primordial prevention) among broader segments of the population. Prior research indicates that using public health strategies such as sodium reduction in processed foods to lower blood pressure,5–8 tobacco laws to promote smoking cessation,9–11 and modification of …

This paper calls for the critical and ongoing examination of the often invisible harm that occurs in traditional participatory research (and evaluation) efforts. The authors argue that this harm is caused by and must be understood within the context of white supremacist and colonial systems that inform practice standards and norms. In response, we introduce a Community Harm Risk Assessment (CHRA) Reflective Praxis Guide grounded in principles of Diversity, Equity, Inclusion, and Justice (DEIJ) and trauma-informed practices as a radical participatory process for harm reduction in evaluation and participatory research. This new approach is explored in the context of opening a Center to support the implementation of the CHRA and a Community Harm Risk Assessment Review Board (CHRARB), an initiative motivated by the lead author’s nearly two decades of experience in conventional participatory research (and evaluation) methods and observing how these methods and the misuse of these methods, can cause more harm than healing to individuals and communities intended to benefit through our work. This paper will provide an overview of the literature that speaks to observed limitations currently present in participatory research methods, share harmful practices present in participatory research (and evaluation) work, and introduce the Center, CHRARB, and CHRA reflective praxis guide for practitioners, applied researchers, and evaluators to address harm with more intentionality in their work, as well as strategically shift research and evaluation practices away from colonial and white supremacist norms.

Recent efforts to increase emergency medical services (EMS) prehospital research productivity by focusing on reducing systems-related barriers to research participation have had limited effect. The objective of this study was to explore the barriers and motivators to participating in research at the agency and provider levels and to solicit suggestions for improving the success of prehospital research projects. The authors conducted a qualitative exploratory study of EMS personnel using focus group and focused interview methodology. EMS personnel affiliated with the Pediatric Emergency Care Applied Research Network (PECARN) hospitals were selected for participation using a purposive sampling plan. Exploratory questioning identified identified factors that influence participation in research and suggestions for ensuring successful research partnerships. Through iterative coding and analysis, the factors and suggestions that emerged from the data were organized into a behavioral change planning model. Fourteen focus groups were conducted, involving 88 EMS prehospital providers from 11 agencies. Thirty-five in-depth interviews with EMS administrators and researchers were also conducted. This sample was representative of prehospital personnel servicing the PECARN catchment area and was sufficient for analytical saturation. From the transcripts, the authors identified 17 barriers and 12 motivators to EMS personnel participation in research. Central to these data were patient safety, clarity of research purpose, benefits, liability, professionalism, research training, communication with the research team, reputation, administrators' support, and organizational culture. Interviewees also made 29 suggestions for increasing EMS personnel participation in research. During data analysis, the PRECEDE/PROCEED planning model was chosen for behavioral change to organize the data. Important to this model, factors and suggestions were mapped into those that predispose (knowledge, attitudes, and beliefs), reinforce (social support and norms), and/or enable (organizational) the participation in prehospital research. This study identified factors that influence the participation of EMS personnel in research and gathered suggestions for improvement. These findings were organized into the PRECEDE/PROCEED planning model that may help researchers successfully plan, implement, and complete prehospital research projects. The authors provide guidance to improve the research process including directly involving EMS providers throughout, a strong theme that emerged from the data. Future work is needed to determine the validity of this model and to assess if these findings are generalizable across prehospital settings other than those affiliated with PECARN.

Our goal is to describe the effect of race and ethnicity on stroke epidemiology, personal beliefs, access to care, response to treatment, and participation in clinical research. In addition, we seek to determine the state of knowledge on the main factors that may explain disparities in stroke care, with the goal of identifying gaps in knowledge to guide future research. The intended audience includes physicians, nurses, other healthcare professionals, and policy makers. Members of the writing group were appointed by the American Heart Association Stroke Council Scientific Statement Oversight Committee and represent different areas of expertise in relation to racial-ethnic disparities in stroke care. The writing group reviewed the relevant literature, with an emphasis on reports published since 1972. The statement was approved by the writing group; the statement underwent peer review, then was approved by the American Heart Association Science Advisory and Coordinating Committee. There are limitations in the definitions of racial and ethnic categories currently in use. For the purpose of this statement, we used the racial categories defined by the US federal government: white, black or African American, Asian, American Indian/Alaskan Native, and Native Hawaiian/other Pacific Islander. There are 2 ethnic categories: people of Hispanic/Latino origin or not of Hispanic/Latino origin. There are differences in the distribution of the burden of risk factors, stroke incidence and prevalence, and stroke mortality among different racial and ethnic groups. In addition, there are disparities in stroke care between minority groups compared with whites. These disparities include lack of awareness of stroke symptoms and signs and lack of knowledge about the need for urgent treatment and the causal role of risk factors. There are also differences in attitudes, beliefs, and compliance among minorities compared with whites. Differences in socioeconomic status and insurance coverage, mistrust of the healthcare system, the relatively limited number of providers who are members of minority groups, and system limitations may contribute to disparities in access to or quality of care, which in turn might result in different rates of stroke morbidity and mortality. Cultural and language barriers probably also contribute to some of these disparities. Minorities use emergency medical services systems less, are often delayed in arriving at the emergency department, have longer waiting times in the emergency department, and are less likely to receive thrombolysis for acute ischemic stroke. Although unmeasured factors may play a role in these delays, the presence of bias in the delivery of care cannot be excluded. Minorities have equal access to rehabilitation services, although they experience longer stays and have poorer functional status than whites. Minorities are inadequately treated with both primary and secondary stroke prevention strategies compared with whites. Sparse data exist on racial-ethnic disparities in access to surgical care after intracerebral hemorrhage and subarachnoid hemorrhage. Participation of minorities in clinical research is limited. Barriers to participation in clinical research include beliefs, lack of trust, and limited awareness. Race is a contentious topic in biomedical research because race is not proven to be a surrogate for genetic constitution. There are limitations in the current definitions of race and ethnicity. Nevertheless, racial and ethnic disparities in stroke exist and include differences in the biological determinants of disease and disparities throughout the continuum of care, including access to and quality of care. Access to and participation in research is also limited among minority groups. Acknowledging the presence of disparities and understanding the factors that contribute to them are necessary first steps. More research is required to understand these differences and find solutions.

Are We There Yet? Pediatric Screening for Inflammatory Biomarkers and Low Cardiorespiratory Fitness to Identify Youth at Increased Risk of Cardiovascular Disease