For their study, Johns Hopkins physicians, nurses and public health workers joined forces with the community health advisory board of Sandtown-Winchester, a 72-square block neighborhood of more than 10,000, mostly African-American residents in West Baltimore, with the goal of helping residents lower their blood pressure. High blood pressure-related heart disease death rates in this community are among the highest in the United States. In 1991, 35 percent of residents were hypertensive, and only 15 percent had controlled blood pressure.
Community-based health workers trained by the Johns Hopkins team identified people with hypertension, then visited those patients at home up to five times over a 40-month period to educate them about blood pressure control. Three years after the initial visit, the residents' average blood pressure reading had dropped by 4.5 mmHg systolic (the upper number) and 4 mmHg diastolic (the lower number). In addition, the percentage of individuals who were controlling their blood pressure doubled. Study results are published in the summer issue of the journal Ethnicity & Disease.
"We've had excellent treatment for blood pressure for over 30 years," says David M. Levine, M.D., Sc.D., M.P.H., lead author of the paper and a professor of medicine, public health and nursing at Johns Hopkins. "If patients are able to come in and remain in medical care, adhering to treatment recommendations, they do well. But most urban residents are not in that group, especially if they live in high-risk communities. Academic health centers can reach out to these communities, but it's best to do so in a partnership approach."
In setting up the program, the Johns Hopkins team trained community-based health workers for three months in blood pressure management and monitoring, education and counseling, social support, and community outreach.
The initial community survey found 817 people with hypertension. Eighty-six percent knew they had high blood pressure; 14 percent were newly detected during the survey. Researchers randomly assigned residents of each census block to either one home visit or five. Of the 817, 789 agreed to participate in the study, with 387 assigned to five visits and 402 to one visit.
Forty months after enrollment, researchers were able to re-interview 471 participants: 53 had died, five were incarcerated, 23 were too sick to be interviewed, and 191 had moved, leaving no follow-up address. Twenty-two participants could not be reached at home, and 24 refused to be interviewed.
There was no statistically significant difference in lowered blood pressures among participants in the one- and five-visit groups. The percentage of participants with controlled blood pressure increased from 16 to 36 in the five-visit group, and from 18 to 34 in the one-visit group.
Levine acknowledges the challenges in setting up such programs, including enlisting support from community leaders and local health providers.
"We wouldn't have had the access to this community that we did without the participation of leaders from their health advisory board," he says. "They were tremendously instrumental in getting us access to households, letting us disseminate our messages, and helping us build trust."
Also key in a successful partnership, Levine says, is maintaining relationships with the community. The Johns Hopkins team is continuing to work with Sandtown-Winchester residents on blood pressure control, and based on the partnership, has started health programs to address substance abuse, obesity and arthritis. The team also worked closely with a free health clinic for residents that had been established.
The study was funded by the National Heart, Lung and Blood Institute. Study coauthors were Lee R. Bone, R.N., M.P.H.; Martha N. Hill, R.N., Ph.D.; Rebecca Stallings, M.H.S.; Allan C. Gelber, M.D., Ph.D.; Anne Barker, R.N., B.S.N.; Elder C. Harris; Scott L. Zeger, Ph.D.; Kaytura L. Felix-Aaron, M.D.; and Jeanne M. Clark, M.D., M.P.H.
Levine, David M. et al, "The Effectiveness of a Community/Academic Health Center Partnership in Decreasing the Level of Blood Pressure in an Urban African-American Population," Ethnicity & Disease, Summer 2003, Vol. 13, pages 354-361.
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