摘要：The National Institutes of Health convened a workshop to engage researchers and practitioners in dialogue on research issues viewed as either unique or of particular relevance to rural areas, key content areas needed to inform policy and practice in rural settings, and ways rural contexts may influence study design, implementation, assessment of outcomes, and dissemination. Our purpose was to develop a research agenda to address the disproportionate burden of cardiovascular disease (CVD) and related risk factors among populations living in rural areas. Complementary presentations used theoretical and methodological principles to describe research and practice examples from rural settings. Participants created a comprehensive CVD research agenda that identified themes and challenges, and provided 21 recommendations to guide research, practice, and programs in rural areas. Cardiovascular disease (CVD), the leading cause of death in the United States, disproportionately burdens residents living in rural communities. 1–4 Results from the National Health Interview Survey show CVD prevalence rates of 13.1% for those living in rural areas compared with 11.2% for those living in urban areas. 5,6 Geographic differences in heart disease mortality emerged in the 1980s, leading Cosby et al. 4 to describe the nonmetropolitan (rural) mortality penalty in the United States. Residents of rural counties exhibit a high-risk CVD profile with higher rates of cigarette smoking, obesity, overall (all cause) mortality, mortality from ischemic heart disease, and physical inactivity compared with residents of nonrural counties. 4 Health disparities also vary when taking into account income inequality, measured as the gap between rich and poor residents in a county. Rural counties with the greatest income inequality exhibit greater health disparities than rural counties with smaller income inequality. 7 Variation in CVD and associated risk factors exists within rural areas as does variation in demographic characteristics, such as racial and ethnic status, 8 age, gender, access to primary and specialty care, 9 and insurance status. On the whole, these variations may or may not differ from similar variations in metropolitan areas. 10,11 As much as a 15-year gap in life expectancy exists between US residents in the rural southern or Appalachian states and those in northern states. Without immediate attention, these disparities are likely to widen. 2,9,11 The choice of a definition of “rural” for research, policy, or programmatic purposes can and does influence our understanding of the scope and magnitude of health and health care issues as well as the underlying economic, social, and environmental factors that influence population risk for CVD. Although multiple standard definitions of rural exist, there is no agreement as to one and only one definition. Definitions of rural include measures of population density, distance from metropolitan areas, or combinations of these and other factors. 12 Frequently used designations include counties, rural urban commuting areas, census geography, nonmetropolitan or micropolitan areas (i.e., urban clusters of 10 000 or more persons) , and zip code areas. 12 The census tract approach defines rurality as all territory, population, and housing units located outside of urbanized areas and urban clusters, and classifies about 70 million US residents as currently residing in rural communities. 13 Rural communities are dispersed throughout the United States 14 ( Figure 1 ). Irrespective of the definition used, key demographic, economic, or provider characteristics can be combined with a selected rural definition to more narrowly target and develop interventions, 12 improve our knowledge of how to intervene, and set research priorities. In particular, research and practice must take into account the underlying determinants of health risk disparities in rural areas, however defined. Health risk disparities include greater exposure to environmental hazards 15 associated with working in agriculture, mining, and forestry occupations 16,17 ; the high prevalence of obesity 18 ; general lack of health care access and lower health care service utilization 19–22 ; financial constraints of local governments and community-based organizations; poverty at the individual and community level 7 ; and illiteracy. 18 Open in a separate window FIGURE 1— Distribution of rural areas in the United States. Note . UIC = Urban Influence Codes. Source . US Health Resources and Services Administration. 14 Approaches to achieving meaningful community engagement can also inform intervention development, our understanding of underlying determinants of health risk disparities, and approaches for disseminating and implementing evidence-based intervention approaches to address the CVD burden in rural areas. Just as differences in meaning and use arise when trying to define rural, definitions of community, community engagement, community-based, and community-based participatory research differ depending on the perspective of researchers and community stakeholders. We suggest use of the term community engagement, based on the definition put forward by the Clinical and Translational Science Awards Consortium, Community Engagement Key Function Committee Task Force on the Principles of Community Engagement, to capture all of these related concepts. The consortium, composed of representatives of the Health Resources and Services Administration (HRSA), National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), the Agency for Toxic Substances and Disease Registry, and the Clinical & Translational Science Awards defines community engagement as the process of working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the well-being of those people. Goals of community engagement are described as building trust, enlisting new resources and allies, creating better communication, and improving overall health outcomes as successful projects evolve into lasting collaborations. 23 The Consortium describes community engagement as a continuum of community involvement ranging from outreach to consultation, involvement, collaboration, and shared leadership. Community-based participatory research (CBPR) is described as part of this continuum and as being focused on collaboration and shared leadership. CBPR begins with a research topic and a focus on the aim of achieving social change to improve health outcomes and eliminate health disparities. The CBPR model calls for consideration of 4 dimensions: context, group dynamics and equitable partnerships, intervention, and outcome. 23 The Consortium suggests at least 4 highly relevant ways to think about community. Each perspective (systems, social, virtual, and individual) offers different insights into the process of community engagement. 23 Likewise, “community-based” is used as a setting descriptor for needs or assets assessment, involvement, processes, interventions, approaches, evaluations, and policies. We used the broader term, “community engagement,” as defined by the Consortium when describing our recommendations and guiding principles. We reported the term used by individual presenters in our description of their studies and findings. We recognized that these terms, although not interchangeable, described an active, purposeful process of engaging community stakeholders in meaningful ways depending on the anticipated outcome and purpose of the work. We also acknowledged, along with the Consortium, that if health is socially determined, then health issues are best addressed by engaging community partners who can bring their own perspectives and understandings of community life and health to a project. If health inequalities are rooted in larger socioeconomic inequalities, then approaches to health improvement must take into account the concerns of communities and be able to benefit diverse populations. 23 In response to the need to improve cardiovascular health in rural communities, the National Heart, Lung and Blood Institute (NHLBI) convened a workshop in collaboration with the National Institute of Minority Health and Health Disparities, the CDC, and the Office of Rural Health Policy (OHRP) of the HRSA. The purpose of the workshop was to identify research areas that could be stimulated by funding agencies to advance knowledge and implementation of community interventions to reduce CVD burden in underserved rural communities. The workshop objective was to guide future research to develop, implement, and evaluate family and community interventions to reduce obesity, hypertension, diabetes, and CVD in rural communities of the United States. The intended outcome was a set of research and practice recommendations to NHLBI and other funding partners. The purpose of this article is to present a summary of the workshop along with recommendations to guide and frame future research, practice, and programs aimed at preventing CVD risks in rural communities.
