Marianna Examination Survey on Hypertension Report 2010

Marianna Examination Survey on Hypertension (MESH) Report 2010

A publication of the Arkansas Minority Health Commission

Acknowledgements The Arkansas Minority Health Commission extends thanks and appreciation to those that facilitated the MESH study, project, and report, including: The citizens of Marianna, Arkansas, who gave their time and effort in the implementation of this research project, and without whom, this work would not be possible.

Mayor Taylor, and Earnestine Taylor Bessie Jones and the Marianna Housing Authority for their generous, in-kind support Community Partners/ liaisons: Cleota Bursey-Lee County Cooperative Clinic Veronica Sellers- Lee County Health Unit Tracia Coney-Tinzie Pauline Kennedy Ruby Davis Lee County Workforce Development Marianna Water Company Dr. Camille Jones, for her vision and direction The MESH Research Team, for their expertise and dedication: Dr. Namvar Zohoori-Arkansas Department of Health Dr. Leavonne Pulley-UAMS College of Public Health Dr. Zoran Bursac-UAMS College of Public Health Patricia Minor, R.N.-AMHC Project Manager Dr. Al Edney of Abbott Nephrology Division at UAMS College of Medicine Judy Smith, Past Executive Director Arkansas Minority Health Commission Dr. Creshelle R. Nash and Sister A. Joy

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Table of Contents List of Tables and Figures............................................................... iii Executive Summary......................................................................... 1 Introduction................................................................................... 5 Background.................................................................................... 7 Methodology................................................................................... 9 Results............................................................................................ 12 Discussion...................................................................................... 25 Citations........................................................................................ 29 Appendices: Data Tables................................................................. 31 Notes............................................................................................. 39

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List of Tables and Figures Table 1

Demographics of study population

Figure 1

Prevalence of selected chronic risk factors and outcomes, by self-report

Figure 2

Knowledge of all heart attack and stroke symptoms

Figure 3

Population with some form of insurance, by sex and race

Figure 4

Population with some form of insurance, by age range

Figure 5

Could not see a doctor due to cost, by sex and race

Figure 6

Could not see a doctor due to cost, by age

Figure 7

Could not get medicine due to cost, by sex and race

Figure 8

Could not get medicine due to cost, by age range

Figure 9

Diagnosed and undiagnosed hypertension

Figure 10

Diagnosed and undiagnosed diabetes

Figure 11

Told have high cholesterol, by age

Figure 12

Had blood cholesterol checked, by sex and race

Figure 13

Had blood cholesterol checked, by age

Figure 14

Seeing a dentist, by frequency and race.

Figure 15

Smoking status

Figure 16

Current smoker, by age

Figure 17

Overweight and obese, by sex and race

Figure 18

Overweight and obese, by age

Figure19

Conceptual model of MESH project.

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Executive Summary The Arkansas Minority Health Commission (AMHC), established in 1991, follows a legislative mandate to conduct research into racial and ethnic health disparities in Arkansas, including specifically in relation to hypertension and stroke prevention. Because high blood pressure is modifiable and associated with most strokes (Sacco, 1997), it is critical to study rates of hypertension. AMHC conceived the Marianna Examination Survey on Hypertension (MESH) five years ago, in 2005, when Arkansas’ stroke mortality rate was the highest in the nation. Marianna is a predominantly African American, rural town in Lee County that typifies minority communities in eastern Arkansas.

The MESH study estimates the prevalence of diagnosed and undiagnosed hypertension, controlled and uncontrolled hypertension, diagnosed and undiagnosed diabetes, stroke and kidney diseases and their risk factors within the adult population of Marianna. The MESH study also produced findings on disparities in minority health and healthcare. To collect these data, this study utilized an extensive questionnaire of disease risk factors, physical examinations of blood pressure, and analysis of blood and urine samples.

The MESH study is the first population-based examination in Arkansas. This type of research, though expensive, is coveted because it enables researchers to predict the rate and severity of undiagnosed disease risk factors within a given population. By gaining an accurate picture of public health conditions, health advocates can effectively plan prevention and intervention programs and create appropriate health policies. Another attribute of the MESH study is that it allows for longitudinal research. Researchers who succeed in securing funding can reproduce the study to reveal changes within the population’s health over time. Such information is valuable for assessing the effectiveness of health improvement activities, policies, and preventive measures, including efforts to reduce and eliminate racial and ethnic disparities in health and healthcare.

In addition, longitudinal research can identify emerging health trends and new or unaccounted factors that affect health status, which is especially important for medically underserved populations, such as Marianna, Arkansas.

Less than 10% of all respondents could recognize all the signs of a heart attack or stroke

Further, the MESH study is a unique and significant contribution to health research because it is the first longitudinal, population-based examination in the nation to study a predominantly rural, African American population. Results can be generalized to eastern Arkansas, and learning from the findings may be relevant to other rural, African American communities in similar, southern states.

This study may serve as a model for future research that focuses on rural, African American populations. Arkansans and AMHC can take pride in the success of the MESH study and its exemplary contribution to national health research and minority studies. Initial findings of the MESH study are listed as follows:

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• Many chronic disease risk factors in Marianna (e.g., obesity, diabetes, high blood pressure) exceed the state average of chronic disease risk factors and do not meet the national goals for public health standards. These chronic disease risk factors lead to increased numbers of heart attacks and strokes in the community.

• Less than 10% of all respondents could recognize all the signs of a heart attack or stroke. In the event of a medical emergency, it is important to be able to recognize these signs to get help quickly for oneself or others.

• Twenty percent of participants reported having been previously diagnosed by a healthcare practitioner as having high blood pressure and were currently taking medicine for this condition, but also had a blood pressure rating greater than or equal to 140/90 when tested during the MESH study. This group is considered to have “uncontrolled” hypertension.

• About two-thirds of the population (63%) had high blood pressure that is controlled to recommended levels, and one in five people in Marianna had diagnosed diabetes.

• Five percent of people had undiagnosed high blood pressure, and 7% had undiagnosed diabetes.

• More than one quarter of Marianna citizens (28.3%) smoke cigarettes or other tobacco products, with no significant differences by gender or race.

• Nearly three-quarters of the population (74%) were overweight or obese. The MESH study found no significant racial disparity in obesity. However, women were more likely to be overweight or obese than were men.

• Health insurance coverage revealed racial disparities and age disparities. Caucasians were more likely to have health insurance than were African Americans. Older individuals were more likely to have health insurance than were younger people, in part due to older citizens’ access to public insurance for seniors. However, citizens who have health insurance do not necessarily have access to health care.

• Twenty-five percent of African Americans reported they could not see a doctor due to the cost, in contrast to 10.9% of Caucasians who reported this cost to be prohibitive. In addition, African Americans reported not getting a medication due to cost more than Caucasians reported not getting a medication due to cost.

74% of the population were overweight or obese 2

The MESH study was by design participatory; AMHC trained and employed community members to carry out the study and relied on citizen participation to provide the survey data and lab samples.

In accordance with AMHC’s mission, this work extends beyond scholarly research to help create social change by informing strategies to improve the health and healthcare of minorities. The MESH study makes available its population level data to Marianna citizens, minority health researchers, community-based organizations, and agencies that seek to reduce and eliminate racial and ethnic health disparities in Arkansas and the South through research, programs, or policies.

Results of the MESH study identify health and healthcare needs in Marianna related to chronic diseases. Areas to improve include both primary and secondary preventive measures (i.e., preventing a disease before it manifests and managing risk factors after a disease has developed). Potential activities for health improvement are listed below.

1. Increase the availability of safe and accessible areas for physical activity; 2. Increase awareness of proper, balanced nutrition and the value and need for exercise and eating healthily; 3. Improve access to fruits and vegetables and other healthy foods; 4. Decrease advertising of and access to tobacco products; 5. Promote public education about the risk factors of chronic diseases; 6. Improve health literacy and chronic disease self-management skills among citizens; 7. Implement a health education campaign for healthcare professionals to learn about cardiovascular disease and disparities in health and healthcare; and 8. Address differences in race, ethnicity, gender, and age when targeting health improvement interventions within the community.

The MESH project supports Marianna’s initiatives to improve its citizens’ health and reduce cardiovascular and kidney diseases and their risk factors. Ongoing work in Marianna includes: (a) sharing important findings of the study by distributing fact sheets; (b) convening a public forum to discuss findings; and (c) collaborating with Marianna’s community planning groups to help advance health improvement initiatives and community-wide activities based on outcomes of the MESH study.

Ultimately, the MESH project seeks to help Arkansans improve control of high blood pressure, decrease cardiovascular disease and kidney disease, and eliminate racial and ethnic disparities and other health disparities in Arkansas and other southern states.

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Introduction Arkansas is among the states with the highest poverty and poorest health in the nation. Racial and ethnic minorities (African Americans, Asians, Latinos/Hispanics, Native Americans/ Indian Americans, Pacific Islanders, and others) are particularly at risk of having low income and poor health.

Unfortunately, on both national and state levels, minority communities persistently experience poor health outcomes, with a disproportionately high rate of disease and death. People of color die at younger ages from cardiovascular disease, diabetes, HIV and AIDS, cancer, and other life-altering illnesses and conditions than do Caucasians (Mead, 2008). Almost one in four Arkansans self-identifies as belonging to a racial or ethnic minority group (U.S. Census, American Community Survey, 20062008). Thus, while Arkansans in general suffer from poorer health than the national average, these 750,000 Arkansans are especially at risk of experiencing the burden of disease.

The Arkansas Minority Health Commission (AMHC) seeks to reduce and eliminate these disparities by helping to improve the health and healthcare of minority populations. Established through Act 912 in 1991, the Arkansas General Assembly charges AMHC be a comprehensive entity in Arkansas that is knowledgeable about minority health disparities. AMHC accomplishes its legislative mandate to gather and analyze information relating health disparities, minority health status, and delivery of and access to health services in several ways. Methods include: (a) the development, implementation, and dissemination of a statewide survey of health status and service availability; (b) identification of gaps in health service delivery; and (c) publication of evidence-based data that illuminate appropriate strategies to decrease racial and ethnic health disparities in Arkansas.

The AMHC, Marianna Examination Survey on Hypertension (MESH) investigates the prevalence of cardiovascular and kidney disease and risk factors, and health disparities in the city of Marianna, which is a predominantly African American, rural town in eastern Arkansas. In addition to conducting this research, the MESH project offers health expertise to the citizens of Marianna through health education and support of their public health initiatives. This project exemplifies actions that can bring about positive change in the health and lives of minority Arkansans and all citizens, and may serve as a model for other communities.

The Arkansas Minority Health Commission works collaboratively with other agencies and institutions that share a similar focus on minority health. In the MESH study, AMHC collaborated with the University of Arkansas Medical Sciences, College of Public Health (COPH), the Arkansas Department of Health (ADH), and the citizens, agencies, and mayor of Marianna, Arkansas.

The MESH project will: • Increase awareness about diseases in minority communities; • Emphasize prevention in high risk communities; • Promote cooperation between academic researchers and community members to improve community health; • Support collaborative, community efforts to develop health improvement initiatives; • Disseminate findings to community members via fact sheets and public forum; and • Share relevant lessons through ongoing study and collaboration with other rural, minority communities in the South.

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This project aims to be a catalyst for health improvement on multiple levels: individual, behavioral changes among Marianna citizens who participated in the study; community level change through Marianna’s new public health initiatives; population level change through improved health strategies that target minority health and healthcare; and policy changes informed by this new, relevant data.

The MESH project, including the study and its correlating outreach, is a model for positive change in similar, rural communities.

The Vision The vision of the MESH project is to improve minority health and healthcare and eliminate racial and ethnic disparities through the following strategies: 1. Educate citizens and healthcare professionals about prevalent diseases; 2. Emphasize prevention and healthy behaviors in high risk communities; 3. Promote cooperation and collaboration to improve community health; and 4. Inform minority health initiatives, health policies, and future research.

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Background The Marianna Examination Survey on Hypertension (MESH) is a population-based examination and survey of cardiovascular and kidney diseases and their risk factors in adults of representative households of the city population of Marianna, Arkansas. The MESH study grew out of AMHC’s recognition that: (a) Arkansas had the highest stroke mortality rate in the nation; (b) there is a strong link between hypertension and stroke; and (c) minorities suffer from cardiovascular disease and other diseases at a disproportionately high rate.

In addition, AMHC realized the need for population-based, physical examination data, particularly in relation to cardiovascular disease. Arkansas’ previously existing health research draws from citizens’ self-reports of diagnoses but contains no data from physical exams. While such studies are helpful in other ways, only population-based, physical exams can predict the rate and severity of undiagnosed health risk factors within a population.

Further, longitudinal studies on the health of African American, rural populations are virtually nonexistent—not only in Arkansas, but nationwide. The MESH study’s longitudinal design allows researchers who have the financial backing to reproduce the study every few years to reveal health changes within representative, African American populations. Thus, this study’s capacity to predict disease prevalence and map changes in health status fills a critical, minority health research need.

The researchers chose to study Marianna, located in Lee County along the eastern border of Arkansas, because the city is representative of medically underserved, minority communities in the Delta region. At the time of the study, the town had approximately 5,000 residents, with fewer than 2,000 households; nearly three-fourths of the population was African American, about one-fourth of the population was Caucasian, (US Census, 2000). Education, per capita income, and family size and membership are typical of the region. Notable characteristics of the area include lush farmland, forests, waterways, and civic pride (Chamber of Commerce, 2010). The city mayor’s interest in Marianna participating in the study made this city a compatible choice for the MESH project. Results from this study can be generalized to the Arkansas Delta. In addition, findings may be relevant to other medically underserved, rural, African American communities in the South.

The MESH study estimates the rate and severity of diagnosed and undiagnosed hypertension and diabetes, and risk factors for stroke, cardiovascular disease, and kidney disease in Marianna. Specifically, this study determines: • • • •

High blood pressure prevalence (diagnosed and undiagnosed); Percent of population with high blood pressure controlled to recommended levels; Diabetes prevalence (diagnosed and undiagnosed); and Prevalence of three markers of kidney disease (serum creatinine, serum cystatin C, and urine albumin/ creatinine ratio).

The researchers began the study in June 2005, and completed their work in May 2007. Participants included 453 adults who verbally responded to the 39-page survey and completed the initial physical examination to measure blood pressure; 273 of these participants also completed a second physical examination to test blood pressure. A second screening of blood pressure is necessary because 7

in order for a diagnosis of hypertension to be valid, blood pressure must be tested on at least two separate occasions. These latter participants additionally contributed blood and urine samples to a laboratory for analysis of markers for diabetes, heart disease, and kidney disease [laboratory values for serum glucose, serum lipids (cholesterol, LDL, HDL and triglycerides), hemoglobin A1C, C-reactive protein, and hemoglobin].

Medical researchers analyzed risk factors, as identified by the survey, physical examination, and laboratory tests, for health and healthcare disparities based on race, ethnicity, sex, and age. These analyses will inform the development of policies, future research, and interventions to improve minority Arkansans’ control of high blood pressure, decrease the presence and severity of stroke, cardiovascular disease, and related risk factors, and decrease the development of kidney disease due to diabetes and high blood pressure. Such actions would especially benefit racial and ethnic minorities, who disproportionately suffer from these diseases and poor health.

In addition to inquiring about risk factors related to stroke, cardiovascular disease, and kidney disease, the MESH survey gathered a wealth of other information about the state of health and health practices of Marianna citizens, such as levels of stress and depression and use of complementary and alternative medicine. Further analysis of these diverse data will yield additional insights into needed policies, programs, and research to improve health in rural, African American communities and to reduce and eliminate disparities in health and healthcare in Arkansas and other southern states.

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Methodology To design this unique study, the Marianna Examination Survey on Hypertension, the research team drew upon its collective expertise as researchers of population-based examinations, behavioral studies, and epidemiology (study of diseases in the population). The MESH study included a verbal questionnaire, physical examinations, and lab analyses. The methodology, research design, and research procedures are discussed below.

The process of determining the questions to include in the survey was systematic but collaborative, allowing for feedback and discussion. Examples of questionnaire topics include: 1. Demographic information (e.g., race, sex, age, education, employment status, and health care coverage); 2. Health information (e.g., medical history, family history, cardiovascular disease risk factors, and ability to engage in activities of daily living); 3. Health related behaviors and attitudes (e.g., diet and nutrition, physical activity, sleep habits, and perceptions of high blood pressure medications); and 4. Behavioral risk factors (e.g., tobacco and alcohol use, depression, anxiety, and use and type of medications).

Most questions were pre-validated questions used in national surveys including the National Health and Nutrition Examination Survey (NHANES), the Behavioral Risk Factor Surveillance System survey (BRFSS), and the National Health Interview Survey (NHIS). Additional questions were taken from other cardiovascular disease studies.

The MESH study is a population-based, representative study. Population-based means that researchers estimate how many people have a given condition within the entire population, based on a valid sample of the population. Representative means that researchers use statistical methods, such as random selection and weighting of responses based on census information, to develop estimates that reflect the full population. Thus, the individuals who participated in the MESH study scientifically represent the entire population of Marianna, so the study’s findings can be generalized beyond the participants to Marianna. Further, because the demographics of the city of Marianna are representative of similar towns in the region, results can be generalized to minority communities throughout eastern Arkansas.

To develop a cross-sectional, population-based sample of Marianna, the researchers first needed a complete an accurate list of all occupied, residential addresses within the city limits. To compile this list, the researchers took the following steps: (a) obtained a list used by the 911 operators; (b) hired several local citizens to verify in person the physical address of all residential buildings on every street in Marianna; and (c) requested postal workers to review the list and add any missing addresses. The researchers then double-checked the list for common errors, such as incorrect designations of east or west. When the master list of residential addresses was sufficiently complete, a computer-based, sampling methodology randomly selected 1,200 addresses from the list.

The researchers set the initial recruitment goal to enroll 800 participants. AMHC trained, certified, and employed four community members to enroll participants, administer the survey, perform a

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physical examination that included taking blood pressure, and schedule appointments for participants to undergo a second examination at a local laboratory and contribute blood and urine samples for analysis. The second recruitment goal was for at least half (400) of the initial enrollees to follow through with the second exam and lab samples.

Certification followed a defined 40-hour training session over a 1-week period. Training to become an interviewer included the following activities: modeling of interviewing skills, round robin practice sessions, mock interviews that were graded, and evaluation of accuracy of delivery of the questions and recording of answers to participant questions. Training to conduct physical examinations included blood pressure sound detection using standardized tapes and practical hands-on sessions with the blood pressure meters (sphygmomanometers), multiple-sized blood pressure cuffs, and stethoscopes.

A physical examination involves measuring blood pressure 3 times in a row. In addition to blood pressure measurement, interviewers learned how to measure arm span as a proxy for height, and how to obtain valid abdominal circumference measurements.

Interviewers conducted the initial blood pressure measurements in participants’ homes. To identify hypertension and gain a valid diagnosis, blood pressure must be tested on at least two separate occasions. Healthcare professionals administered the second physical examination of blood pressure at a laboratory, rather than in participants’ homes, because this study also included laboratory work. The clinical needs of lab work (i.e., refrigeration facilities, medical waste collection, and access to centrifuge for processing blood samples) required participants to go to the laboratory to donate blood and urine samples.

Two laboratories were utilized, one at the Arkansas Department of Health’s local health unit and another at a federally qualified, local community health center. The professionals who drew the blood (phlebotomists) had previous experience in phlebotomy. In addition, to assure consistency in the MESH study, AMHC extensively trained these individuals to ask the precise research questions, perform the physical examination and laboratory tests, and process the samples in a standardized manner.

The MESH study used the blood and urine samples to test the rate and severity of hypertension, diabetes, and markers of kidney disease. Specifically, the laboratory conducted the following: (a) tests in serum—glucose, hemoglobin A1C, cholesterol, triglycerides, HDL, creatinine, cystatin C, hemoglobin, CRP; and (b) tests in urine—urine albumin, urine creatinine, urinary albumin to creatinine ratio, and urinalysis. Researchers estimated the sampling error to be +/- 5%.

To maintain the confidentiality of participants, no names were recorded on the laboratory specimens or the questionnaires. Instead, all data forms were coded with a unique non-informative number to prevent identification of subjects.

The study gained publicity through AMHC’s advertisements in the local newspaper and other media.

The mayor of the city of Marianna recorded a public service announcement for the radio, urging citizens to participate if asked. The research staff gave public talks to raise awareness of the importance of research into cardiovascular health, and AMHC encouraged community organizations to lend their support to enhance citizens’ participation in the study.

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Selected households were mailed an informational brochure that explained the study and informed citizens that a trained interviewer would knock on the door to seek participation. The interviewers visited the selected households, described the survey, and asked an adult to list all adults in the household, aged 18 or older. Then the interviewers randomly selected one adult per household to enroll in the study. Minors and citizens who did not speak English or who were incapable of responding to the questionnaire were ineligible for the study. Volunteer participants were not accepted.

If the selected adult was present, the interviewer provided the informed consent and privacy notification form and asked the adult to participate. Upon consent, the interviewer administered the 39-page questionnaire requiring participants’ verbal responses and the physical examination. A nonmonetary gift was presented to each participant at the completion of the questionnaire and home examination. The interviewer then scheduled an appointment for the participant to go to a clinical lab that would give a second physical examination, draw blood, and collect a urine specimen to test for risk factors for cardiovascular and kidney diseases. The lab presented a Wal-Mart gift card, worth $25, to each participant upon completion of the blood draw.

If the selected adult was not present, the interviewer left his or her name and contact information, a brochure about the study, and planned a return for a later date, attempting to coordinate a time to interview the selected adult, rather than making random, repeated visits to the home. If after three attempts (two during the week and one on the weekend), the selected adult was not contacted, or stated he or she was not willing to participate, the household was crossed off the list, and no one else from that household was permitted to substitute for the selected individual (i.e., no volunteers were accepted).

While the MESH study did not meet its recruitment goal, the final enrollment over a 2-year period was 453 participants who took the survey and the initial physical examination. Of these, 273 participated in the second exam and contributed lab samples. This figure represents more than 10% of the adult population, which is a satisfactory percentage for a successful population estimate. The preliminary analyses of quantitative data are described and illustrated in the following section of this report.

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Results The MESH study produced a broad range of health data from the questionnaire, physical examinations, and lab samples. This report provides preliminary analyses of these combined data, giving special attention to disparities related to race, sex, and age. Results are presented in the following categories: (a) overall chronic disease risk factors in the community; (b) stoke and heart attack awareness; (c) health care access, including insurance coverage and affordability of doctor visits and medicine; (d) health status, including hypertension or high blood pressure, diabetes, and high blood cholesterol; and (e) behavioral risk factors, including testing cholesterol levels, oral health care, tobacco use, and being overweight or obese.

Participant responses can be generalized to the entire Marianna population. Further, because Marianna’s population is representative of rural minority communities in the region, results from this study can be generalized to eastern Arkansas. Demographic information of the population of Marianna is listed in the table below.

Demographics of Study Population

Male Female

Weighted % 39.1 60.9

Unweighted % 22.5 77.5

AA White

74.1 25.9

87.4 12.6

18-24 25-44 45-64 65+

9.2 30.3 37.9 22.6

10.2 30 38 21.8

No education Elementary 1-8 Some HS 9-11 HS graduate or GED Some college 1-3 College graduate or more

0.3 12.8 17.7 38.4 19.5 11.3

0.2 13.6 18.8 38.5 19.7 9.2

Table 1. Demographics of study population.

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A. Overall Chronic Disease Risk Factors in Marianna, Arkansas The MESH survey asked participants to report their chronic disease risk factors and the physical exam included calculating participants’ body mass index (BMI). Nearly three quarters of Marianna adults (74%) are overweight or obese (BMI measures greater than or equal to 25). More than half of the participants (59%) self-reported high blood pressure (defined as a physician telling the participant on two or more occasions that his or her blood pressure was high). Nearly half of the participants (48%) self-reported high cholesterol. More than one-quarter of Marianna’s adult population (28%) smoke tobacco products, and one in five participants (20%) self-reported diabetes (see Figure 1).

Self-reports cannot account for the prevalence of high blood pressure, high cholesterol, or diabetes among the segment of the population who are unaware they have these conditions. However, a population-based sample of physical examinations of blood pressure and lab analyses of blood sugar can reliably predict the prevalence of these conditions, even if undiagnosed. Clinical tests revealed hypertension and diabetes to be more prevalent than indicated by self-reports by 5% and 7%, respectively. Clinical tests of cholesterol levels have not been analyzed. Clinical results are discussed further in this chapter.

Prevalence of Selected Chronic Risk Factors and Outcomes, by Self-report

80 70 60

Percentage

50 40 30 20 10 0

tes

D

e iab

P hB

g

Hi

ole

g

h hC

Hi

er

l

o str

nt

rre

Cu

Figure 1. Prevalence of selected chronic risk factors and outcomes, by self-report

k mo

S

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h eig

se

e Ob

rw

e Ov

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B. Stroke and Heart Attack Awareness The ability to recognize signs of a heart attack and stroke indicates a strong awareness of these diseases. Participants had difficulty correctly identifying from lists all of the symptoms of heart attack and stroke. The first list contained five health symptoms, including four correct symptoms of a heart attack. An interviewer read the list and asked participants whether each was a symptom of a heart attack. Only 6% correctly identified all four of the correct heart attack symptoms. Five of the of six health symptoms on a second list were signs of a stroke. Only 9% identified all five of the correct stroke symptoms. This result means that fewer than 1 in 10 of the respondents know all the signs of a heart attack and stroke, a finding which has concerning health implications for getting help quickly in the event of a medical emergency (see Figure 2).

Knowledge of All Heart Attack and Stroke Symptoms 100 90 80

Percentage

70 60 50 40 30 20 10

6

9

0 Heart attack

Figure 2. Knowledge of all heart attack and stroke symptoms

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Stroke

C1. Health Care Access—Insurance Coverage Health insurance coverage is an important aspect to accessing health care. The majority of participants had some form of health insurance (private or public coverage). Results found no significant differences by race or sex, although a trend showed toward Caucasians to be more likely to have health insurance than were African Americans (81.6% versus 74.2%). This trend disappears as the population ages, however. Nearly all of citizens aged 65 or older have insurance coverage (96.2%).

This shift may be largely due to the availability of Medicare, a public insurance for older persons (see Figures 3 & 4).

Population with Some Form of Insurance, by Sex and Race 100 90 80

Percentage

70 60 50 40 30 20 10 0 Male

Female

AA

White

Population with Some Form of Insurance, by Age

65+

45‐64

25 44 25‐44

18‐24

0

10

20

30

40

50

60

70

80

90

100

Percentage Figure 3. Population with some form of insurance, by sex and race Figure 4. Population with some form of insurance, by age range

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C2. Health Care Access—Affordability of Medical Visits For the uninsured or underinsured, cost can be a major obstacle to accessing health care. Middleaged, African American women and men are particularly likely to experience health care as unaffordable. Twenty-five percent of African Americans reported that they could not see a doctor in the past year because of the cost, in contrast to 10.9% of Caucasians who reported this cost to be prohibitive.

Nearly one-third of middle-aged people (29.1%), at least 20% of younger adults (aged 18 - 44), and 11% of older citizens (65 or older) reported being unable to see a doctor in the past year due to cost.

Women reported that cost deterred a visit to the doctor in the previous year more than men reported this cost to be a deterrent during that period (23.2% versus 19.1%); however, this small difference in percentage is not statistically significant (see Figures 5 & 6).

Could Not See a Doctor Due to Cost, by Sex and Race 30

25

Percentage

20

15

10

5

0 Male

Female

AA

White

Could Not See a Doctor Due to Cost, by Age

65+

45‐64

25 44 25‐44

18‐24

0

5

10

15

20

Percentage Figure 5. Could not see a doctor due to cost, by sex and race Figure 6. Could not see a doctor due to cost, by age

16

25

30

35

C3. Health Care Access—Affordability of Medicine The cost of prescription medicine proved to be as unaffordable as the cost of seeing a doctor, and similar patterns of race, age, and sex differences emerged. African Americans were more than three times as likely to report not getting medicine in the past year due to its cost, as were Caucasians (30.3% versus 9.1%). People aged 45-64 (34%) were more than twice as likely to name cost as a reason for not getting medicine in the past year as were adults aged 65 or older (15.2%). Women and men reported being unable to get medicine due to cost at approximately the same rates (26.7% and 21.7%, respectively)—the difference was statistically insignificant (see Figures 7 & 8).

Could Not Get Medicine Due to Cost, Sex and Race 35

30

Percentage

25

20

15

10

5

0 Male

Female

AA

White

Could Not Get Medicine Due to Cost, by Age

65+

45‐64

25 44 25‐44

18‐24

0

5

10

15

20

25

30

35

40

Percentage Figure 7. Could not get medicine due to cost, by sex and race Figure 8. Could not get medicine due to cost, by age range

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D1. Health Status—Hypertension or High Blood Pressure Hypertension is a chronic disease risk factor strongly associated with stroke, heart attack, and kidney disease. According to participant blood pressure measurements and self report approximately twothirds of Marianna’s adult population (64%) has hypertension. Slightly more than one third of the participants (36%) did not have hypertension (non-hypertensive), measured in the safe to moderate blood pressure range of less than 140/90, and reported never having been told that they have high blood pressure. Another third (33%) of participants had been diagnosed with hypertension and were successfully managing their blood pressure with medication and had measurements of less than 140/90. Doctors consider this group to have “controlled” hypertension.

A third group, comprising 20% of the participants, had been diagnosed with hypertension and reported currently taking blood pressure medicine, but also measured in the high blood pressure range of greater than or equal to 140/90. Doctors consider this group to have “uncontrolled” hypertension.

Six percent of participants reported that they had been told by a health care professional that they had high blood pressure but they were not currently taking blood pressure medicine. Finally, 5% of the participants reported having never been told they had high blood pressure, but their blood pressure readings were high. This last group had undiagnosed hypertension. Thus, 2 out of 3 adults in the rural, minority community of eastern Arkansas may have high blood pressure, and as many as 1 in 3 may need further help in managing the disease (see Figures 9).

Diagnosed and Undiagnosed Hypertension

33% Non-hypertensive

36%

Told, on tx, controlled Told, on tx, uncontrolled Told, not on tx Hypertensive but don’t know

5% 6%

20%

Figure 9. Diagnosed and undiagnosed hypertension Note: abbr. tx = treatment

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D2. Health Status—Diabetes Diabetes can cause serious, long-term health problems if left untreated. Therefore, it is in the interest of individual, community, and public health to prevent, identify, and treat this chronic disease.

Diabetes is identified through a blood test, either by measuring blood sugar or another marker of diabetes, called hemoglobin A1C. Although blood sugar is the recommended measure for diabetes, it is only accurate if the person has been fasting. For participants who fasted for at least 8 hours before their blood was drawn, a blood sugar level greater than 126 mg/dL indicated diabetes. For participants who did not meet the fasting requirements, a hemoglobin A1C value of greater than or equal to 6.5 indicated diabetes.

Lab analysis of participants’ blood samples revealed 27% of adults in Marianna have diabetes. The MESH survey confirmed that 20% of participants had been previously diagnosed, and 7% of participants were undiagnosed and had not known that they had diabetes. Among those who knew they had diabetes, 90% said they were currently taking medicine for diabetes and 10% said they were not.

Of those who reported taking medicine for diabetes, 45% percent had their diabetes under control and 55% did not. Thus, nearly one-fifth of the population (19%) has diabetes that is not managed to ensure a safe blood sugar level and may need treatment or improved care to manage the disease (see Figures 10).

Diagnosed and Undiagnosed Diabetes 2%

7%

10%

No diabetes Told, on tx, controlled

8%

Told, on tx, uncontrolled Told, not on tx Not told but high 73%

Figure 10. Diagnosed and undiagnosed diabetes

19

D3. Health Status—High Blood Cholesterol High blood cholesterol is associated with heart attacks and strokes. The survey indicated 46% of the total population of Marianna has high blood cholesterol. Age range was a significant factor in whether a health care professional had told participants in the past year that they had high cholesterol.

Few young adults (4.8% of 18-24 year olds) reported having received this diagnosis. However, the percentage jumped dramatically to 32.6% among 25-44 year olds, and then jumped again, peaking at 59.2% in the middle-aged population (aged 45-64), before decreasing to 44.9% among those aged 65 or older (see Figure 11). No significant differences by sex or race were found in reports of having being told by a health care professional that they had high cholesterol.

Told Have High Cholesterol, by Age Range

65+

45‐64

25‐44

18‐24

0

10

20

30

Percentage

Figure 11. Told have high cholesterol, by age

20

40

50

60

70

E1. Behavioral Risk Factors—Testing for High Cholesterol Prevention is the primary component to maintaining good health. Our individual and societal practices that promote health and wellness, such as through a nutritious diet, exercise, not smoking, and preventive healthcare, help to avert the pain and expense of managing disease. For example, getting a blood test to check cholesterol levels and decreasing cholesterol is a preventive behavior that reduce the risk of a heart attack and stroke.

Women were more likely to have had their cholesterol checked in the past year than were men (73.1% versus 58%), which has interesting implications regarding gender and preventive care, considering approximately the same percentage of women and men in Marianna found healthcare to be unaffordable. Caucasians were more likely to have had their cholesterol checked than were African Americans (79% versus 63%) (see Figure 12).

Willingness to check one’s cholesterol steadily increased by age, from 3 out of 10 young adults in Marianna who had checked their cholesterol in the past year (32.8% of people, aged 18-24), to about 8 out of 10 older citizens who had done so (83.4% of people, aged 65 or older) (see Figure 13).

Had Blood Cholesterol Checked, by Sex and Race 60

50

Percentage

40

30

20

10

0 Male

Female

AA

White

Had Blood Cholestrol Checked by Age 65+

45‐64

25 44 25‐44

18‐24

0

10

20

30

40

50

60

70

80

90

Percentage Figure 12. Had blood cholesterol checked, by sex and race Figure 13. Had blood cholesterol checked, by age

21

E1. Behavioral Risk Factors—Oral Health Gum disease, a lesser well-known risk factor than smoking or obesity, is associated with heart attacks and strokes. Maintaining oral health is a part of preventive care; it is important to brush and floss teeth and receive professional dental cleanings regularly.

Results found the majority of people in Marianna only see a dentist when a dental problem occurs.

This finding had pronounced differences by race, but not by sex or age. More than three quarters of African Americans (76.6%) reported seeing a dentist only when a problem occurs, compared with 47.3% of Caucasians who see a dentist only when a problem occurs. More than one fourth of Caucasian participants (26.8%) reported that they see a dentist on a regular basis, but very few African Americans did so (only 5.6%) (see Figure 14). These findings suggest multiple levels of intervention are needed to improve oral health care in Marianna, and strategies will need to consider attitudes and behavioral differences by race.

Seeing a Dentist, by Frequency and Race 90 80 70 60

Percentage

50 Total 40

African American White

30 20 10 0 Never

When a problem occurs

Figure 14. Seeing a dentist, by frequency and race.

22

Occasionally

Regularly

E3. Behavioral Risk Factors—Tobacco Use Although smoking is commonly associated with lung cancer, not everyone may know that tobacco use is also associated with heart disease and stroke. The MESH survey found that in Marianna, 28.3% are current smokers, 15.9% are former smokers, and 55.8% have never smoked (see Figure 15). Analysis of data found no significant differences by sex or race. However, marked differences in tobacco use were found among different age groups. Among all adults, people age 65 or older were the least likely to be current smokers (13.6%) and adults aged 45-64 were the most likely to be current smokers (36.3%) (see Figure 16).

It is worth noting that the age group who was most likely to be covered by health insurance and least likely to report cost as a deterrent to health care was also the group least likely to report being a current smoker (adults, aged 65 or older). Conversely, the age group who was least likely to be covered by health insurance and most likely to report cost as a deterrent to receiving health care was also the group most likely to report being a current smoker (adults, aged 45-64).

Smoking Status 28.3 Current

55.8

Former Never

15.9

Current Smoker, by Age Range

65+

45‐64

25‐44

18‐24

0

Figure 15. Smoking status Figure 16. Current smoker, by age

5

10

15

20

Percentage

25

30

35

40

23

E4. Behavioral Risk Factors—Overweight and Obesity Weight may be the most confusing chronic disease risk factor. It is easy to get lost in the sea of ideas about diet plans, fitness programs, exercise gadgets, genetic influences, weight loss surgery, and the effects of medications, body image, media pressure, gender roles, cultural expectations, and so many other factors that influence understanding and experience of size, shape, and health. Yet there is an unmistakable link between being overweight or obese and having cardiovascular disease, kidney disease, or a stroke. This risk factor is preventable, yet elusive to so many.

The majority of the population of Marianna is overweight or obese. Middle-aged women are especially vulnerable to this risk. Results showed women were considerably more likely to be overweight or obese than were men (79.1% versus 66.2%). African Americans were slightly more likely to be overweight than were Caucasians (75.8% versus 69%) (see Figures 17). Weight increased with age, peaking in the 45-64 age range at 81.9% (see Figures 18). These and other disparities need to be considered when planning health improvement interventions within the community.

Overweight and Obese, by Sex and Race 100

90

80

Percentage

70

60

50

40

30

20

10

0 Male

Female

AA

White

Overweight and Obese, by Age Range 65+

45‐64

25‐44

18‐24

0

24

10

20

30

40

50

60

Figure 17. Overweight and obese, by sex and race Percentage Figure 18. Overweight and obese, by age

70

80

90

100

Discussion Results of the MESH study point to important areas for improvement of health and health care in Marianna. Numerous chronic disease risk factors—tobacco use, high blood cholesterol, and obesity or being overweight— are at levels that exceed the state average and goals of Healthy People 2010 (a national health plan to identify and reduce the most significant preventable threats to health).

In addition, Marianna’s prevalence and control of established chronic diseases, such as high blood pressure and diabetes, are at undesirable levels. Further, race, sex, and age-based disparities persist in health status, rates of disease, access to healthcare, and practice of preventive or risky behaviors. Both primary and secondary preventive measures are needed to improve health and healthcare. Additionally, community interventions and systems level change need to consider and address the population’s diverse health needs.

Effective public health measures include system level changes, such as policies and environmental changes that affect community factors (Sallis, 2008). For example, increasing the availability of safe and accessible areas for physical activity, and improving access to fruits and vegetables and other healthy foods, will naturally increase the use and consumption of these commodities. Similarly, limiting advertising of, and access to tobacco products, particularly among adolescents, will reduce consumption of these products. A healthy environment is especially important for helping to instill preventive behaviors in children and youth because habits learned in formative years often are practiced for a lifetime.

Parallel with system level interventions, community level interventions are needed to reduce the prevalence of chronic diseases and their risk factors. For example, both public and professional education to learn about risk factors and their role in developing chronic diseases will increase Marianna’s health literacy. In addition, improved treatment and control of established chronic diseases, such as hypertension, diabetes, cholesterol and obesity, must be addressed.

One of the main aims of the MESH project is measurement and control of high blood pressure.

Results from the MESH study show substantial levels of undiagnosed and under-treated hypertension in Marianna. Hypertension can be considered both a disease and a risk factor. Once diagnosed as a disease, secondary preventive measures, principally through proper control and management of high blood pressure, are important. A two-pronged, patient-provider approach can accomplish these measures. The first approach focuses on patients already diagnosed with hypertension. Health literacy and self-management skills can help these individuals improve control of their high blood pressure.

The second approach targets health care providers. Professional education campaigns can aid the health care community in learning the current treatment guidelines to follow in the management of patients with hypertension. In addition, health care providers can put into place the necessary system level changes, with assistance from change experts, to streamline their clinics and improve management of hypertensive patients. One example of a resource is the Arkansas Chronic Illness Collaborative, available through the Chronic Disease Branch of the Arkansas Department of Health.

Hypertension, in addition to being a disease, is a risk factor for other diseases, notably stroke and heart failure. Preventing and controlling hypertension is primary prevention of these other diseases.

Community-wide interventions that address the importance of regular blood pressure screenings will be instrumental in increasing awareness of hypertension and its consequences. Improving diagnosis rates and control of hypertension will benefit individuals and the overall population in Marianna.

The measures recommended for the prevention, control, and management of high blood pressure are equally applicable to the other chronic diseases highlighted in the MESH results.

25

Another main aspect of the MESH study was to examine the degree of health disparities within the community. Race, sex, and age are all factors that affect health and healthcare in Marianna. Compared to Caucasians, African Americans are less likely to see a doctor or to fill a prescription due to cost, and are less likely to have their cholesterol checked, or to see a dentist on a regular basis. Men and younger individuals are less likely to have their cholesterol checked than are women and older individuals. However, women are more likely to be obese than are men, and younger individuals are less likely to see a doctor due to cost than are older individuals.

The chronic disease risk levels among adults aged 45-64 is striking. Of all age groups, this age group was the most likely to be overweight or obese, the most likely to be current smokers, and the most likely to report having been told they have high cholesterol. Among all adults, this group was also the least likely to have health insurance coverage and the most likely to report not seeing a doctor or getting a prescription filled due to cost. Thus, Marianna’s middle-aged population has a significant need for improved health habits and access to health care. Health care interventions, programs, policies, and research must consider the diverse needs of its population to eliminate disparities and improve health and healthcare.

The intent of the MESH study is to use its findings to inform policy, advance research, and support community health activities that benefit the citizens of Marianna and Lee County. Researchers conducting related health studies of rural, minority communities in Arkansas or similar states may access both the survey and examination data. The MESH project involves ongoing outreach with three main components: (a) information sharing, (b) group development, and (c) collaboration and support of Marianna’s community-wide health improvement activity.

Information sharing includes distributing factsheets that show pertinent MESH results (e.g., impact of hypertension and diabetes on the minority population) and socio-environmental factors that influence health. AMHC also convened a public forum to discuss MESH findings.

The Arkansas Minority Health Commission is committed to representing and protecting the interests of the communities they serve. Group development and community involvement help ensure Marianna’s long-term benefit from the MESH study. AMHC is currently working with an established, community-planning group in Marianna to develop their role and responsibility in interacting with researchers. For example, the group may consider it important to: o o o o o o o

Be a liaison to local community Ensure ongoing benefit to the local community Review research findings before dissemination Help communicate findings of research to the local community Identify relevant community questions that researchers can answer from the data Learn about Community Based Participatory Research Be aware of and have input on future research projects planned by researchers

In addition to helping the group to develop its role with researchers, AMHC will collaborate with the community-planning group in support of Marianna’s community-wide health improvement activity or initiative. The community-defined intervention may receive support from AMHC. Further, 26

AMHC will help facilitate Marianna’s networks and partnerships with other health improvement organizations in the state and nation.

As the MESH project continues, its framework can be conceptualized as operating from within two distinct but also interrelated domains: research and community outreach development. Using a community-based, participatory process, this marriage of communication and activity ensures that the learning from MESH will have ongoing benefit to the community by informing its programs, initiatives, and policies. In addition, this method of ongoing MESH work can inform the development of future, community-based health research, activities, and health policy in the state and nation, which is important for improving public health and eliminating disparities in health and healthcare (see Figure 19).

Conceptual Model of Continuous MESH Project Conceptual Model of MESH Project

Community Based Participatory Process Community Outreach and Development Core

Academic Research Core

Community programs projects policies

Improve community health and inform health disparity elimination in Arkansas and the nation

model of continuous MESH project.

Figure 19: Conceptual model of MESH project.

27

The Arkansas Minority Health Commission seeks to fulfill its goals to improve high blood pressure control; decrease cardiovascular disease, kidney disease, stroke, and their risk factors; and reduce and eliminate racial and ethnic health disparities in Arkansas and other southern states. The MESH project helps accomplish these goals. In addition, the Marianna Examination Survey on Hypertension makes a unique and significant contribution to national health research by conducting a populationbased, longitudinal study of a rural, predominantly African American community. Increasing the body of knowledge and research on minority health is important for improving public health and the quality and equity healthcare, and for eliminating disparities based on race, ethnicity, gender, age, and other factors.

28

Citations Risk Factors. Ralph L. Sacco, Emelia J. Benjamin, Joseph P. Broderick, Mark Dyken, J. Donald

Easton, William M. Feinberg, Larry B. Goldstein, Philip B. Gorelick, George Howard,

Steven J. Kittner, Teri A. Manolio, Jack P. Whisnant, and Philip A. Wolf. Stroke.

1997;28:1507-1517 The Commonwealth Fund. Racial and Ethnic Disparities in U.S. Health Care: A Chartbook. Holly

Mead, Lara Cartwright-Smith, Karen Jones, Christal Ramos, and Bruce Siegel. March 2008.

U.S. Census, American Community Survey, 2006-2008.

Chamber of Commerce, Marianna and Lee County. (2010). About Marianna & Lee County

Arkansas. Retrieved May 4, 2010, from http://www.mariannaarkansas.org United Health Foundation. (2006). America’s health: State health rankings–2006 edition. Retrieved

February 7, 2007, from http://www.unitedhealthfoundation.org/ahr2006/Findings.html Ecological Models of Health Behavior. Sallis J, Owen N and Fisher E (2008). In Glanz K, Rimer B

and Viswanath K (Ed.), Health Behavior and Health Education: Theory, Research,

and Practice. 4th ed. (pp. 465-482) United States: Jossey-Bass.

29

Appendices Health Care Access

Male Female AA White 18-24 25-44 45-64 65+

% 76.2 76.7 75.8 74.2 81.6 64.9 70.5 71.3 96.3

Could not see a doctor due to cost Male Female AA White 18-24 25-44 45-64 65+

21.7 19.1 23.2 25.4 10.9 21.9 20.1 29.1 11

Could not get medicine due to cost Male Female AA White 18-24 25-44 45-64 65+

24.8 21.7 26.7 30.3 9.1 20.3 21.6 34 15.2

Has some form of insurance

31

p-value 0.8705 0.2829 <0.0001

0.3615 0.012 0.0122

0.3079 0.0004 0.0053

Blood Pressure

Male Female AA White 18-24 25-44 45-64 65+

% 58.8 55.3 61.1 57.5 62.6 16.8 38.9 68.8 85

Told on 2 or more visits (among ever told) Male Female AA White 18-24 25-44 45-64 65+

76.3 75.9 76.4 79.1 68.9 51.4 60.2 83.8 78.5

Taking BP medicine (among ever told) Male Female AA White 18-24 25-44 45-64 65+

89.7 91.4 88.7 89.8 89.5 77 59.1 92 91.1

Told blood pressure high

p-value 0.3372 0.5214 <0.0001

0.9435 0.1902 0.0069

0.6112 0.9641 <0.0001

32

Diabetes

Told has diabetes Male Female AA White 18-24 25-44 45-64 65+ Had at least 1 HbA1C check (diabetic only) Male Female AA White 18-24 25-44 45-64 65+

33

% 19.5 18.9 19.9 20.5 16.7 5.3 7.2 29.2 25.4 70.3 76.6 66.4 64.4 90.3 70.2 66.4 66.1 79.9

p-value 0.8349 0.5043 <0.0001

0.385 0.0987 0.6093

Cholesterol

Male Female AA White 18-24 25-44 45-64 65+

% 67.3 58 73.1 63 79 32.8 60.7 71.6 83.4

Male Female AA White 18-24 25-44 45-64 65+

45.7 40.8 48.2 44.9 47.6 4.8 32.6 59.2 44.9

Had blood cholesterol checked

Told blood cholesterol high

p-value 0.0069 0.0467 <0.0001

0.3554 0.7467 <0.0001

34

Oral Health

%

p-value

Seeing dentist Never When a problem occurs Occasionally Regularly

7.5 68.9 12.4 11.2

AA Never When a problem occurs Occasionally Regularly

7.3 76.6 10.5 5.6 <0.0001

White Never When a problem occurs Occasionally Regularly

35

8.1 47.3 17.7 26.8

Smoking

%

p-value

Smoking status Current Former Never

28.3 15.9 55.8

Male Female AA White 18-24 25-44 45-64 65+

30.7 26.8 27.6 28.5 24.6 30.2 36.3 13.6

Current smoker 0.4743 0.895 0.0056

36

Overweight and Obesity

Overweight or obese Male Female AA White 18-24 25-44 45-64 65+

37

% 74 66.2 79.1 75.8 69 59.6 77.3 81.9 61.4

p-value 0.018 0.3105 0.0069

Notes

38

Notes

39

A M H C Arkansas Minority Health Commission 1123 S. University Avenue Little Rock, AR 72204 1-877-264-2826 501-686-2720 arminorityhealth.com