Q&A: Broad data grouping hid CVD mortality risk among Native Hawaiians, Pacific Islanders
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Key takeaways:
- Culturally tailored interventions may help physicians address cardiovascular health disparities among patients of Native Hawaiian or Pacific Islander descent.
- Healio spoke with researchers to find out more.
Health data aggregation has hidden a high rate of CVD mortality among Native Hawaiian and Pacific Islander groups, but primary care providers can play an important role in reducing these disparities, according to researchers.
Rebecca Woodruff, PhD, MPH, an epidemiologist at the CDC, Joseph Keawe'aimoku Kaholokula, PhD, professor and chair of Native Hawaiian Health at the University of Hawai'i, and colleagues recently published an analysis of CVD mortality among Native Hawaiian and Pacific Islander groups.
Their evaluation, which includes data from 2018 to 2022, revealed that adults in this population have a high rate of mortality from CVD — a fact that has been hidden because Native Hawaiian and Pacific Islanders have previously been grouped with the Asian population for statistical analysis.
The researchers reported 10,870 CVD-related deaths among Native Hawaiian and Pacific Islander adults — 19% from cerebrovascular disease and 72.6% from heart disease — in the period studied.
Compared with Asian adults, Native Hawaiian and Pacific Islander adults had a 1.5 times higher CVD race-stratified age-standardized mortality rate (ASMR) (243.9 [95% CI, 242.6-245.2] vs. 369.6 [95% CI, 362.4-376.7] deaths per 100,000 persons). This population saw the third highest CVD ASMR in the country, after Black (558.8 deaths per 100,000 persons; 95% CI, 557.4-560.3) and white (423.6 deaths per 100,000 persons; 95% CI, 423.2-424.1) adults.
Healio spoke with Woodruff and Kaholokula to learn more about the study and what PCPs need to know.
Healio: Why did you decide to study CVD mortality in this population?
Woodruff: The CDC monitors national death rates from CVDs, like heart disease and stroke, which are leading causes of death in the United States. To do this, our team used the information collected on death certificates. In 2018, all U.S. states updated their death certificates to collect information on race groups in a standardized way that included a checkbox option for Native Hawaiian or Pacific Islander race. Before 2018, some states had an option for Native Hawaiian or Pacific Islander, but others provided an option only for “Asian or Pacific Islander” race, which combined the Asian group and the Native Hawaiian or Pacific Islander group together. When all states updated their death certificates to provide a response option for Native Hawaiian or Pacific Islander race separate from Asian race, it created a new opportunity to calculate national CVD death rates for this population.
Healio: Why is researching health equity important?
Woodruff: At the CDC, our goal is to produce research that helps us achieve more equitable health outcomes in the U.S. Certain populations die from CVDs at much higher rates than others. We need data like these to help us focus our limited prevention resources to have the greatest public health impact. Part of our job is to make sure that we have an accurate understanding of the populations with the highest death rates from CVDs. In the case of this study, that meant calculating CVD death rates for the Native Hawaiian and Pacific Islander population separately from the Asian population. When we did this, we showed that Native Hawaiian and Pacific Islander adults had a high death rate from cardiovascular diseases.
Healio: What are the reasons behind the disparities you observed?
Kaholokula: The health disparities we are seeing in Native Hawaiian and Pacific Islander populations are likely the result of Western colonialism in the Pacific region. This population has experienced and continues to endure the exploitation of their cultural and natural resources, indifferences to their traditional knowledge and customary practices, displacement from their ancestral lands and structural and interpersonal discrimination. These disruptions and changes have profoundly shaped the social and economic reality and environmental conditions of Native Hawaiian and Pacific Islander peoples, potentially reducing opportunities to do the things we know prevent CVDs. For example, changes to their food ecosystems and economic deprivation have made accessing fresh fruits and vegetables more challenging while making calorie-dense, processed foods an affordable and convenient option. Native Hawaiian and Pacific Islander populations might also have more limited access to high-quality, culturally appropriate health care necessary to manage risk factors like high blood pressure, cholesterol and blood sugar levels. Compared with the general U.S. population, they have more people on public insurance or with no insurance for their health care.
Healio: Are there any potential solutions to reduce these disparities?
Woodruff: One of the first steps is to make sure that we collect data in a way that key public health indicators can be reported for the Native Hawaiian and Pacific Islander population — separated from the Asian population. This foundational step allows us to understand what might be driving the high CVD death rate found in our paper. Additional research to help explain why these health inequities are occurring could help identify the best approaches to improve cardiovascular health for this population. Additionally, policy, systems and environmental changes that help make living a heart-healthy lifestyle easier can benefit everyone, including making it easier to eat a healthy diet, be physically active, not use tobacco products and get enough sleep. And improving access to high-quality, culturally appropriate health care can help patients control their blood pressure, reduce their cholesterol levels, managing their blood sugar and achieve and maintain a healthy body weight, all of which can reduce CVD risk.
Kaholokula: Given the cultural nuances and unique social drivers of health operating for Native Hawaiian and Pacific Islander communities, culturally responsive lifestyle interventions are needed to prevent or effectively manage cardiometabolic-related conditions in these communities. Culturally responsive interventions leverage their community, family and/or cultural assets while accounting for the economic realities they face. Ideally, interventions that go beyond the individual to also impact families and communities offer the promise of sustained changes to healthier eating, regular exercise and stress management. For example, a lifestyle program based on hula, the traditional dance of Hawai‘i, was found effective in significantly improving blood pressure control in Native Hawaiians with previously uncontrolled hypertension and in reducing their 10-year risk for CVD.
Healio: What can PCPs specifically do to help and make a difference in their communities?
Woodruff: PCPs have an important role to play in addressing CVD and related risk factors among Native Hawaiian and Pacific Islander patient populations. PCPs can aid in the prevention, early identification and management of CVD and its risk factors. Lifestyle modifications with broad benefit include eating well, being physically active, quitting tobacco and getting enough sleep. PCPs can also support patients in controlling blood pressure, reducing cholesterol levels, managing blood sugar levels and achieving and maintaining a healthy body weight. A team-based care approach that includes diverse providers has been shown to be an effective strategy for improving patient health. Reducing risk factors can help prevent CVD from developing in the first place and slow its progression over time.
Kaholokula: Given the social and cultural drivers of health operating for many Native Hawaiian and Pacific peoples, there is a need for health care that is responsive to their socioeconomic realities when asking for lifestyle modifications. Many of them work multiple jobs, live in multigenerational households and reside in neighborhoods with limited access to fresh fruits and vegetables and physical activity options. And there are language barriers and health literacy issues to overcome. Providers need to not only understand these challenges for a Native Hawaiian or Pacific Islander patients but account for them in the medical recommendations they offer. It is often necessary to include family members in medical decision-making while being respectful of cultural and communication nuances across different Native Hawaiian and Pacific Islander groups. For many of them, treating their medical condition goes beyond the physical to also include their emotional and social concerns because many see them interrelated.
Healio: What is the take-home message for PCPs here?
Woodruff: Native Hawaiian and Pacific Islander adults have a high rate of death from CVD and a substantial proportion of these deaths occur before the age of 65 years. Interventions to aid in the prevention and management of CVD risk factors are well known and have been summarized by national organizations — for example, Million Hearts. Culturally tailored interventions are likely required to maximize effectiveness within health systems and communities.