Awareness, Treatment and Control of Hypertension among Filipino Americans

1. Awareness, Treatment and Control of Hypertension among Filipino Americans

2. Overview of Project AsPIRE(Asian American Partnership in Research and Empowerment) Background on Project AsPIRE: Development Process Descriptive Study Experimental Study Future Directions

3. CSAAH was founded in 2003 and funded by NIH/NIMHD as a Center of Excellence dedicated to the research and reduction of health disparities affecting Asian Americans through research, training, and partnership. IN 2003: NYU School of Medicine was awarded a grant from the NIH/NIMHD to establish a Project EXPORT Center: EXPORT stands for Excellence in Partnerships, Outreach, Research, and Training) – only one of its kind in the nation to address Asian American health disparities Importance of a center like this: Today, Asian Americans constitute 5 percent of the total U.S. population and are the fastest growing racial/ethnic group in the United States (U.S. Census Bureau, 2004).  They represent a diverse community comprising over 30 countries of origin and representing various cultures, traditional beliefs, religions, years in the U.S., degrees of acculturation, levels of English proficiency, and socioeconomic status.  It is projected that by the year 2050 there will be 33.4 million residents whose only race is Asian, which translates to a 213 percent increase, compared to a 49 percent increase in the U.S. population as a whole over the same period (U.S. Census Bureau, 2004). Yet, despite rapid increases in the population during the last three decades, Asian Americans remain one of the most poorly understood and neglected racial/ethnic minority groups (Lin-Fu, 1993; Ghosh, 2003). IN 2003: NYU School of Medicine was awarded a grant from the NIH/NIMHD to establish a Project EXPORT Center: EXPORT stands for Excellence in Partnerships, Outreach, Research, and Training) – only one of its kind in the nation to address Asian American health disparities Importance of a center like this: Today, Asian Americans constitute 5 percent of the total U.S. population and are the fastest growing racial/ethnic group in the United States (U.S. Census Bureau, 2004).  They represent a diverse community comprising over 30 countries of origin and representing various cultures, traditional beliefs, religions, years in the U.S., degrees of acculturation, levels of English proficiency, and socioeconomic status.  It is projected that by the year 2050 there will be 33.4 million residents whose only race is Asian, which translates to a 213 percent increase, compared to a 49 percent increase in the U.S. population as a whole over the same period (U.S. Census Bureau, 2004). Yet, despite rapid increases in the population during the last three decades, Asian Americans remain one of the most poorly understood and neglected racial/ethnic minority groups (Lin-Fu, 1993; Ghosh, 2003).

4. Mission Kalusugan Coalition is a multidisciplinary collaboration dedicated to creating a unified voice to improve the health of the Filipino community in the NY/NJ area through network development, educational activities, research, community action, and advocacy.

5. Project AsPIRE: Overall Goal To improve the health care access and CVD health status in the NYC Filipino American community through interventions by community health workers

6. The Big Picture

7. Community-Based Participatory Research (CBPR) “A collaborative approach to research that equitably involves all partners in the research process and recognizes the unique strengths that each brings”. --W.K. Kellogg Foundation (2001) CBPR is not a method per se but an orientation to research that may employ any of a number of qualitative and quantitative methodologies. CBPR is not a method per se but an orientation to research that may employ any of a number of qualitative and quantitative methodologies.

8. Descriptive Study

9. What the literature shows: Filipinos and Hypertension Heart disease accounted for 33% of all deaths for Filipino Americans compared to 19% for Vietnamese, 24% for Koreans, 28% for Japanese, and 29% for Chinese. Ryan et al., 2000 The 2004-2006 National Health Interview Survey showed Filipino American adults as having the highest HTN prevalence among Asian Americans at 27%. NHANES

10. What the literature shows: Filipinos and Diabetes Filipinos had a higher incidence of diabetes (34.7% vs. 24.1%) than whites. Ryan et al., 2000 Filipinos (n=294) had higher prevalence of type 2 diabetes and metabolic syndrome compared to White women (n=379) [Filipina women (36.4%), Caucasian women (8.7%)]. Araneta et al., 2002 Diabetes is more common among Filipino (n = 268) than in Whites (n=3164) and other Asian Pacific Islander subgroups (n = 801) [Filipinos (21.2%), Whites (8.1 %), All Asians combined (12.9%)]. Javier et al., 2007; Gomez et al, 2004. BULLET 1: Ryan article: “ Coronary heart disease in Filipino and Filipino-American patients: prevalence of risk factors and outcomes of treatment” Results: - Filipino-Americans have a higher prevalence of hypertension and diabetes (34.7% vs. 24.1%, p<0.001) Filipino-American ethnicity is an independent predictor of higher mortality after catherization laboratory intervention and increased need for late reintervention. BULLET 2: “Araneta article” “Type 2 diabetes and metabolic syndrome in Filipina-American women: A high-risk nonobese population” Cross-sectional study Study population: Community-dwelling women aged 50-69 years Mostly from San Diego county, California Filipino women with diabetes have a greater waist girth BULLET 3: Javier article a. “Filipino Child Health in the United States: Do Health and Health Care Disparities Exist?” Compared with white women, Filipino women have a higher prevalence of diabetes and metabolic syndrome despite the fact that 90% of Filipino women were not defined as obese Study suggests that the high prevalence of diabetes in Filipinos may be missed by health care providers because they are not obese by Western standards (Javier et al., 2007) In general: Several studies have found a relationship between diabetes and hypertension in Filipino Americans: According to the National Vital Statistics Reports (17), in 2002 Filipino mothers (data not available by place of birth) had the highest rate of gestational diabetes among all measured subgroups at 59.8 per 1,000. Another study using national data reported that Philippine-born Filipino mothers are significantly more likely to have diabetes during pregnancy than U.S.-born Filipino mothers BULLET 1: Ryan article: “ Coronary heart disease in Filipino and Filipino-American patients: prevalence of risk factors and outcomes of treatment” Results: - Filipino-Americans have a higher prevalence of hypertension and diabetes (34.7% vs. 24.1%, p<0.001) Filipino-American ethnicity is an independent predictor of higher mortality after catherization laboratory intervention and increased need for late reintervention. BULLET 2: “Araneta article” “Type 2 diabetes and metabolic syndrome in Filipina-American women: A high-risk nonobese population” Cross-sectional study Study population: Community-dwelling women aged 50-69 years Mostly from San Diego county, California Filipino women with diabetes have a greater waist girth BULLET 3: Javier article a. “Filipino Child Health in the United States: Do Health and Health Care Disparities Exist?” Compared with white women, Filipino women have a higher prevalence of diabetes and metabolic syndrome despite the fact that 90% of Filipino women were not defined as obese Study suggests that the high prevalence of diabetes in Filipinos may be missed by health care providers because they are not obese by Western standards (Javier et al., 2007) In general: Several studies have found a relationship between diabetes and hypertension in Filipino Americans: According to the National Vital Statistics Reports (17), in 2002 Filipino mothers (data not available by place of birth) had the highest rate of gestational diabetes among all measured subgroups at 59.8 per 1,000. Another study using national data reported that Philippine-born Filipino mothers are significantly more likely to have diabetes during pregnancy than U.S.-born Filipino mothers

11. Who are we targeting:Filipino Population in NYC & NJ To further understand the makeup of the Filipino community, community leaders also provided feedback about which neighborhoods had large concentrations of Filipinos. Their insight was supported by an examination of U.S. Census 2008 data showing the highest geographic concentrations of Filipinos in the Elmhurst, Woodside, Jackson Heights, Astoria, and Jamaica areas of Queens County, NY and the West Side area of Jersey City, New Jersey. In particular, community partners also identified ethnic enclaves where especially underserved low-income Filipinos resided. GIS technology was used to develop asset maps depicting these concentrations and the resources available for Filipinos. These helped the team create appropriate outreach strategies to reach a sample that was representative of the general Filipino population. To further understand the makeup of the Filipino community, community leaders also provided feedback about which neighborhoods had large concentrations of Filipinos. Their insight was supported by an examination of U.S. Census 2008 data showing the highest geographic concentrations of Filipinos in the Elmhurst, Woodside, Jackson Heights, Astoria, and Jamaica areas of Queens County, NY and the West Side area of Jersey City, New Jersey. In particular, community partners also identified ethnic enclaves where especially underserved low-income Filipinos resided. GIS technology was used to develop asset maps depicting these concentrations and the resources available for Filipinos. These helped the team create appropriate outreach strategies to reach a sample that was representative of the general Filipino population.

12. Experimental Study

13. AsPIRE Screening Data

14. 62% of individuals presented with high blood pressure 66% of hypertensives were aware of their HTN status 34% were unaware of their HTN 19% of individuals who knew their HTN status were NOT taking BP medication Of the remaining 79% who were on medication – Over two-thirds (68%) of individuals still had uncontrolled HTN 62% of individuals presented with high blood pressure 66% of hypertensives were aware of their HTN status 34% were unaware of their HTN 19% of individuals who knew their HTN status were NOT taking BP medication Of the remaining 79% who were on medication – Over two-thirds (68%) of individuals still had uncontrolled HTN

15. a Adjusted for gender b Categories in parentheses are reference groups This table presents a logistic regression model predicting HTN awareness. Adjusting for other   factors, older age (p<0.001), a family history of HTN (p<0.001), and a diagnosis of high cholesterol (p<0.001), and self-reported fair/poor health status (p<0.01) were predictive factors associated with HTN awareness. Age* Consistent with: Angell SY. “of adults 20-44 y/o, only 70.3% knew of their condition, compared with 86.0% among those 45-64 y/o (49).” Bersamin A. “Younger Mexican Americans (25-34y) were significantly less likely to be aware of their HTN than older MAs (75-84y) (35% vs. 72%, OR=5.5).” Wyatt SB. “OR=1.03 (w), 1.05 (m)” Victor RG. “Younger hypertensive adults (aged =45 years) were less likely than older ones (aged 45-64 years) to be aware of HTN (aOR=0.41).” Stockwell DH. “Only older…employees were significantly more aware of their high blood pressure (OR=1.57)” Inconsistent with: McDonald M. “For elders with HTN, higher age is associated with lower rates of awareness, OR=0.71 (75-84y), 0.54 (=85y) vs. 65-74y.” Self Reported Health* Consistent with: Victor RG. “Hypertensive adults who rated their overall health as good to excellent were much less likely than those who rated their health as fair to poor to be aware of their HTN (aOR=0.37)...” High Cholesterol* Consistent with: Wyatt SB. “Having hypercholesterolemia: OR=1.69 (w)” Family History* Consistent with: Victor RG. “those who were unaware of any parental history of HTN were less likely to be aware of their own HTN (1288).” a Adjusted for gender b Categories in parentheses are reference groups This table presents a logistic regression model predicting HTN awareness. Adjusting for other   factors, older age (p<0.001), a family history of HTN (p<0.001), and a diagnosis of high cholesterol (p<0.001), and self-reported fair/poor health status (p<0.01) were predictive factors associated with HTN awareness. Age* Consistent with: Angell SY. “of adults 20-44 y/o, only 70.3% knew of their condition, compared with 86.0% among those 45-64 y/o (49).” Bersamin A. “Younger Mexican Americans (25-34y) were significantly less likely to be aware of their HTN than older MAs (75-84y) (35% vs. 72%, OR=5.5).” Wyatt SB. “OR=1.03 (w), 1.05 (m)” Victor RG. “Younger hypertensive adults (aged =45 years) were less likely than older ones (aged 45-64 years) to be aware of HTN (aOR=0.41).” Stockwell DH. “Only older…employees were significantly more aware of their high blood pressure (OR=1.57)” Inconsistent with: McDonald M. “For elders with HTN, higher age is associated with lower rates of awareness, OR=0.71 (75-84y), 0.54 (=85y) vs. 65-74y.” Self Reported Health* Consistent with: Victor RG. “Hypertensive adults who rated their overall health as good to excellent were much less likely than those who rated their health as fair to poor to be aware of their HTN (aOR=0.37)...” High Cholesterol* Consistent with: Wyatt SB. “Having hypercholesterolemia: OR=1.69 (w)” Family History* Consistent with: Victor RG. “those who were unaware of any parental history of HTN were less likely to be aware of their own HTN (1288).”

16. a Adjusted for gender b Categories in parentheses are reference groups This table presents a logistic regression model predicting medication use among individuals aware of their HTN. When adjusting for all other factors, individuals age 66-85 were 9.7 times more likely and individuals age 56-65 were 3.0 times more likely to be on medication for HTN compared to individuals age 25-55 (p<0.001).  Insured individuals were 2.4 times more likely to be on medication for HTN compared to uninsured individuals (p<0.01).  Individuals who had lived in the U.S. for greater than 15 years were 2.6 times more likely to be on medication for HTN compared to individuals who had lived in the U.S. for 5 years or less (p<0.05). Older age* Consistent with: Bersamin A. “Fewer than 30% of younger MAs (25-34, and 35-44y)…were treated for hypertension. OR: 25-34y=1; 35-44=0.9; 45-54=3.9; 55-64=5.2; 65-74=5.4; 75-84=4.4.” Wyatt SB. “OR=1.04 (w), 1.05 (m)” Stockwell DH. “Only older…employees were significantly more likely to be treated for their high blood pressure (OR=1.80)” Victor RG. “Younger hypertensive adults (aged =45 years) were less likely than older ones (aged 45-64 years) to have it treated (aOR=0.38).” Angell Y. "Treatment was also lower for young adults (55.8%) than for those who were 45-64 y/o or those =65 y/o (50).” Inconsistent with: McDonald M. ““[For elders with HTN, age is associated with lower rates of] treatment, OR=0.70 (75-84y), .60 (=85y) vs. 65-74.” Insurance*Consistent with: Angell SY. “…they [uninsured patients] were also less likely to be receiving treatment (42.6% vs. 76.6%)” Bersamin A. “…fewer than 40% of those with no health insurance were treated for hypertension compared to their respective counterparts. OR: No insurance=1`, Private=1.6, Medicaid=3.” Years in the US* None of the studies have explored immigration status as a predictor for treatment. However, in Bersamin A’s study on Mexican Americans suggested that Mexicans born in the US are significantly less likely to be aware of their hypertension, and that this may be the same in terms of treatment and control. "Although Mexican Americans born in Mexico had similar rates of hypertension treatment and control [as those born in the US], it is possible that their level of cardiovascular disease risk was underestimated in this study since they did not contribute to the population analyzed for rates of treatment or control"  Smoking*Consistent with: Wyatt SB. “OR=0.21 (m); Smoking was associated with decreased awareness and treatment in men. Because smoking rates were higher among men, this finding is consistent with reports that smokers are less likely to use health services and, therefore, may be less likely to be aware of and treated for their condition" a Adjusted for gender b Categories in parentheses are reference groups This table presents a logistic regression model predicting medication use among individuals aware of their HTN. When adjusting for all other factors, individuals age 66-85 were 9.7 times more likely and individuals age 56-65 were 3.0 times more likely to be on medication for HTN compared to individuals age 25-55 (p<0.001).  Insured individuals were 2.4 times more likely to be on medication for HTN compared to uninsured individuals (p<0.01).  Individuals who had lived in the U.S. for greater than 15 years were 2.6 times more likely to be on medication for HTN compared to individuals who had lived in the U.S. for 5 years or less (p<0.05). Older age* Consistent with: Bersamin A. “Fewer than 30% of younger MAs (25-34, and 35-44y)…were treated for hypertension. OR: 25-34y=1; 35-44=0.9; 45-54=3.9; 55-64=5.2; 65-74=5.4; 75-84=4.4.” Wyatt SB. “OR=1.04 (w), 1.05 (m)” Stockwell DH. “Only older…employees were significantly more likely to be treated for their high blood pressure (OR=1.80)” Victor RG. “Younger hypertensive adults (aged =45 years) were less likely than older ones (aged 45-64 years) to have it treated (aOR=0.38).” Angell Y. "Treatment was also lower for young adults (55.8%) than for those who were 45-64 y/o or those =65 y/o (50).” Inconsistent with: McDonald M. ““[For elders with HTN, age is associated with lower rates of] treatment, OR=0.70 (75-84y), .60 (=85y) vs. 65-74.” Insurance*Consistent with: Angell SY. “…they [uninsured patients] were also less likely to be receiving treatment (42.6% vs. 76.6%)” Bersamin A. “…fewer than 40% of those with no health insurance were treated for hypertension compared to their respective counterparts. OR: No insurance=1`, Private=1.6, Medicaid=3.” Years in the US* None of the studies have explored immigration status as a predictor for treatment. However, in Bersamin A’s study on Mexican Americans suggested that Mexicans born in the US are significantly less likely to be aware of their hypertension, and that this may be the same in terms of treatment and control. "Although Mexican Americans born in Mexico had similar rates of hypertension treatment and control [as those born in the US], it is possible that their level of cardiovascular disease risk was underestimated in this study since they did not contribute to the population analyzed for rates of treatment or control"  Smoking*Consistent with: Wyatt SB. “OR=0.21 (m); Smoking was associated with decreased awareness and treatment in men. Because smoking rates were higher among men, this finding is consistent with reports that smokers are less likely to use health services and, therefore, may be less likely to be aware of and treated for their condition"

17. a Adjusted for gender b Categories in parentheses are reference groups This table presents a logistic regression model predicting HTN control among individuals on HTN treatment. When adjusting for other factors, factors related to controlled HTN were younger age (ages 25-55, p<0.05 ); insurance (p<0.01) and no previous diabetes diagnosis (p<0.01). Keeping the reference values similar to the previous tables, we see that individuals age 66-85 are 0.6 times more likely to have controlled HTN and individuals age 56-65 are 0.4 times more likely to have controlled HTN when compared to individuals age 25-55. Odds ratios and confidence intervals below 1.0 signify a protective factor, and in this case, individuals with an odds ratio below 1.0 are less likely to have the outcome – controlled HTN). The same is the case for diabetes diagnosis: individuals who have previously been diagnosed with diabetes are 0.4 times more likely (thus less likely) to have controlled HTN compared to individuals who have not been diagnosed with diabetes. Individuals with insurance are 2.1 times more likely to have controlled HTN compared to uninsured individuals. Age*Consistent with: Knight EL. “=65 significantly associated with poor control. Odds of poor control: 55-64 y/o=1.26; 65-74 y/o=2.5; =75 y/o=2.56.” Angell SY. “Among adults who were being treated…control was lowers among adults =65 years of age compared with 20-44 y/olds” Wyatt SB. Age: “OR=0.97 (w), 1.02 (m)” McDonald M. “[For elders with HTN, age is associated with lower rates of] control, OR=0.59 (75-84y) vs. 65-74.” NOT consistent with: Victor RG. “Younger hypertensive adults (aged =45 years) were less likely than older ones (aged 45-64 years) to have it controlled (aOR=0.60).” Insurance*Consistent with: Angell SY. “…[uninsured patients less likely] to have their hypertension controlled (25.8% vs. 52.0%)” Bersamin A. “MAs with no health insurance also were significantly more likely to have uncontrolled severe HTN than Medicaid recipients (26% vs. 15%, OR=2.0)” DeVore AD. “Participants with private insurance were 3.4 times more likely to have HTN control than those with other forms of insurance.” Diabetes*Consistent with: Wyatt SB. “Having Type II diabetes: OR=1.65 (w).” a Adjusted for gender b Categories in parentheses are reference groups This table presents a logistic regression model predicting HTN control among individuals on HTN treatment. When adjusting for other factors, factors related to controlled HTN were younger age (ages 25-55, p<0.05 ); insurance (p<0.01) and no previous diabetes diagnosis (p<0.01). Keeping the reference values similar to the previous tables, we see that individuals age 66-85 are 0.6 times more likely to have controlled HTN and individuals age 56-65 are 0.4 times more likely to have controlled HTN when compared to individuals age 25-55. Odds ratios and confidence intervals below 1.0 signify a protective factor, and in this case, individuals with an odds ratio below 1.0 are less likely to have the outcome – controlled HTN). The same is the case for diabetes diagnosis: individuals who have previously been diagnosed with diabetes are 0.4 times more likely (thus less likely) to have controlled HTN compared to individuals who have not been diagnosed with diabetes. Individuals with insurance are 2.1 times more likely to have controlled HTN compared to uninsured individuals. Age*Consistent with: Knight EL. “=65 significantly associated with poor control. Odds of poor control: 55-64 y/o=1.26; 65-74 y/o=2.5; =75 y/o=2.56.” Angell SY. “Among adults who were being treated…control was lowers among adults =65 years of age compared with 20-44 y/olds” Wyatt SB. Age: “OR=0.97 (w), 1.02 (m)” McDonald M. “[For elders with HTN, age is associated with lower rates of] control, OR=0.59 (75-84y) vs. 65-74.” NOT consistent with: Victor RG. “Younger hypertensive adults (aged =45 years) were less likely than older ones (aged 45-64 years) to have it controlled (aOR=0.60).” Insurance*Consistent with: Angell SY. “…[uninsured patients less likely] to have their hypertension controlled (25.8% vs. 52.0%)” Bersamin A. “MAs with no health insurance also were significantly more likely to have uncontrolled severe HTN than Medicaid recipients (26% vs. 15%, OR=2.0)” DeVore AD. “Participants with private insurance were 3.4 times more likely to have HTN control than those with other forms of insurance.” Diabetes*Consistent with: Wyatt SB. “Having Type II diabetes: OR=1.65 (w).”

19. Controlled HTN: Systolic <140 and Diastolic <90 Stage 1 HTN: Systolic 140-159 and/or Diastolic 90-99 Stage 2 HTN: Systolic >159 and/or Diastolic >99Controlled HTN: Systolic <140 and Diastolic <90 Stage 1 HTN: Systolic 140-159 and/or Diastolic 90-99 Stage 2 HTN: Systolic >159 and/or Diastolic >99

20. Future Directions States and certain localities should develop surveillance capacity that would include direct assessment of “awareness, detection, treatment, and control of obesity, HTN, dyslipidemia, and diabetes.” Angell SY et al., 2008 Community organizing strategies increase the feasibility of reaching a large community-based population. Coalition building and engagement of multiple sectors (faith-based and community-based organizations, businesses, and health professional associations), optimize recruitment efforts and provide mechanisms to refer participants to necessary healthcare resources, especially to manage and control their HTN. Bullet 1 A scientific statement recently released by the American Heart Association recommended that states and certain localities develop surveillance capacity that would include direct assessment of “awareness, detection, treatment, and control of obesity, HTN, dyslipidemia, and diabetes.” Angell SY, Garg RK, Gwynn RC, Bash L, Thorpe LE, Frieden TR. Prevalence, Awareness, Treatment, and Predictors of Control of Hypertension in New York City. Circulation Cardiovascular Quality and Outcomes 2008;1(1):46-53   Bullet 2 Although it requires extensive efforts, community organizing strategies increase the feasibility of reaching a large community-based population.   Bullet 3 Through coalition building and engagement of multiple sectors such as faith-based and community-based organizations, businesses, and health professional associations, recruitment efforts become optimized and also provide mechanisms to refer participants to necessary healthcare resources, especially to manage and control their HTN.Bullet 1 A scientific statement recently released by the American Heart Association recommended that states and certain localities develop surveillance capacity that would include direct assessment of “awareness, detection, treatment, and control of obesity, HTN, dyslipidemia, and diabetes.” Angell SY, Garg RK, Gwynn RC, Bash L, Thorpe LE, Frieden TR. Prevalence, Awareness, Treatment, and Predictors of Control of Hypertension in New York City. Circulation Cardiovascular Quality and Outcomes 2008;1(1):46-53   Bullet 2 Although it requires extensive efforts, community organizing strategies increase the feasibility of reaching a large community-based population.   Bullet 3 Through coalition building and engagement of multiple sectors such as faith-based and community-based organizations, businesses, and health professional associations, recruitment efforts become optimized and also provide mechanisms to refer participants to necessary healthcare resources, especially to manage and control their HTN.

21. Future Directions Findings from CBPR efforts such as this study can  provide valuable information to policy makers and health departments as to how to address the burden of HTN in similar populations. Community-based screenings provide an effective means of increasing HTN awareness. Behavioral interventions are also critical to improving HTN control. Bullet 1 Findings from CBPR efforts such as this study can  provide valuable information to policy makers and health departments as to how to address the burden of HTN in similar populations.   Bullet 2 Community-based screenings provide an effective means of increasing HTN awareness, especially since they often reach individuals who are uninsured or not accessing the healthcare system. These types of screenings can serve as the first step to connecting untreated individuals to a clinician to receive the appropriate treatment for their HTN.   Bullet 3 Behavioral interventions are also critical to improving HTN control. In particular, the effectiveness of community health workers in improving HTN control is well documented, given their capacity to bridge uninsured individuals to the healthcare system, provide health education and social support and help monitor medication adherence for hypertensive individuals. Brownstein, 2007Bullet 1 Findings from CBPR efforts such as this study can  provide valuable information to policy makers and health departments as to how to address the burden of HTN in similar populations.   Bullet 2 Community-based screenings provide an effective means of increasing HTN awareness, especially since they often reach individuals who are uninsured or not accessing the healthcare system. These types of screenings can serve as the first step to connecting untreated individuals to a clinician to receive the appropriate treatment for their HTN.   Bullet 3 Behavioral interventions are also critical to improving HTN control. In particular, the effectiveness of community health workers in improving HTN control is well documented, given their capacity to bridge uninsured individuals to the healthcare system, provide health education and social support and help monitor medication adherence for hypertensive individuals. Brownstein, 2007

22. This presentation was made possible by Grant Number R24 MD001786 from NIMHD and its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIMHD.  

23. Acknowledgements