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amet iaculis. Suspendisse placerat sollicitudin mi, vel ornare
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orci lectus, eu consequat enim.Results
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5. orci lectus, eu consequat enim.
Outcome 1
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amet iaculis. Suspendisse placerat sollicitudin mi, vel ornare
augue hendrerit ac. Nulla sed suscipit sapien. Cras pellentesque
orci lectus, eu consequat enim.
Outcome 2
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amet iaculis. Suspendisse placerat sollicitudin mi, vel ornare
augue hendrerit ac. Nulla sed suscipit sapien. Cras pellentesque
orci lectus, eu consequat enim.Discussion
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amet iaculis. Suspendisse placerat sollicitudin mi, vel ornare
augue hendrerit ac. Nulla sed suscipit sapien. Cras pellentesque
orci lectus, eu consequat enim.Conclusion
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amet iaculis. Suspendisse placerat sollicitudin mi, vel ornare
augue hendrerit ac. Nulla sed suscipit sapien. Cras pellentesque
orci lectus, eu consequat enim.
References
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Publication Italicized and Capped, Vol#(Issue#), Page numbers.
Lastname, O. (2010). Online journal using DOI or digital
object identifier. Main Online Journal Name, Vol#(Issue#), 159-
192. doi: 10.1000/182
Lastname, W. (2009). If there is no DOI use the URL of the
main website referenced. Article Without DOI Reference,
Vol#(Issue#), 166-212. Retrieved from
http://www.mainwebsite.org

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Journal of Cardiovascular Nursing
Vol. 21, No. 6, pp 451Y456 x B 2006 Lippincott Williams &
Wilkins, Inc.
A Framework for Addressing Disparities
in Cardiovascular Health
George A. Mensah, MD, FACP, FACC; Sandra B. Dunbar, DSN,
RN, FAAN
Health disparities are pervasive in the United States. Life
expectancy remains higher in women than in men and
higher in whites than in blacks by approximately 5 years. In
general, the health of racial and ethnic minorities,
poor and uneducated people, and those without health insurance
is worse than the health of the overall
population. The care of these vulnerable groups tends to be of
worse overall quality because they have trouble
accessing the system, because standards of care are applied to
them unevenly, and because health professionals
are not consistently trained in culturally sensitive approaches.
These disparities have been demonstrated in all
aspects of health and healthcare for cardiovascular diseases,

7. including the use of diagnostic and therapeutic
interventions, prevalence of cardiovascular risk factors, and
access to health information. Examination of national
surveys revealed disparities in all cardiovascular disease risk
factors, hospitalizations for major cardiovascular
disease, overall mortality, and quality of life. Eliminating these
disparities is a major public health challenge
in the United States. Their causes and underlying mechanisms,
however, remain incompletely understood.
The healthcare delivery system itself, access to care, quality of
care received, communication barriers, individual
behaviors, culture and lifestyles, and discrimination and bias all
play a part. The pursuit of systems and policy
changes to address these determinants remains crucial. We
present a strategic framework for eliminating health
disparities that takes these determinants into account and
provides an opportunity for cardiovascular nurses to
make an impact on this important issue.
KEY WORDS: cardiovascular risk factors, disparities,
morbidity, mortality, quality of life, racial/ethnic groups
Health disparities are differences in the healthindicators of
populations identified by race,
ethnicity, sex, geographical residence, educational
attainment, or socioeconomic status. These dispari-
ties have been confirmed in many areas of health-

8. care, and nowhere are they more evident than in
cardiovascular health. Although disparities have
been documented throughout the last 2 centuries,
recent data published in the National Healthcare
Disparities Report1 and the National Healthcare
Quality Report2 have emphasized that preventable
disparities are pervasive and that improvements are
possible. The evidence for health disparities in car-
diovascular disease (CVD) and treatment is over-
whelming and compelling.3 In this review, we
address the state of disparities in cardiovascular
health3 and present a conceptual framework to assist
in efforts to eliminate these disparities.4
Disparities in Cardiovascular
Risk Factors
National estimates of the prevalence of measured
and self-reported CVD risk factors are available
from the National Health and Nutrition Examina-
tion Surveys and the Behavioral Risk Factor Surveil-
lance System, respectively. As shown in Tables 1 and
2, important differences in the prevalence of tradi-
tional CVD risk factors exist, and they vary by race/
ethnicity and educational level. Self-reported physical
inactivity was common in all groups, especially in
women. Low intake of fruits and vegetables was also
common and was lowest in black and white men
with low educational level. Importantly, blacks had
the highest self-reported prevalence of diagnosed
diabetes and hypertension. Black and white men
had a higher prevalence of current smoking than did
Mexican American men. The prevalence of having
2 or more self-reported CVD risk factors was highest
among blacks (48.7%) and American Indians/Alaska

9. 451
George A. Mensah, MD, FACP, FACC
Chief Medical Officer, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease Control
and
Prevention, Atlanta, Ga.
Sandra B. Dunbar, DSN, RN, FAAN
Charles Howard Candler Professor of Cardiovascular Nursing,
Nell
Hodgson Woodruff School of Nursing, Emory University,
Atlanta, Ga.
The findings and conclusions in this report are those of the
authors
and do not necessarily represent the views of the Centers for
Disease
Control and Prevention.
Corresponding author
George A. Mensah, MD, FACP, FACC, National Center for
Chronic
Disease Prevention and Health Promotion, Centers for Disease
Control and Prevention, Mailstop K-40, 4770 Buford Highway,
NE,
Atlanta, GA 30341-3717 (e-mail: [email protected]).
Copyr ight © Lippincott Williams & Wilkins. Unauthor iz ed
reproduction of this article is prohibited.
Natives (46.7%) and lowest among Asians (25.9%),
with similar prevalence in women (36.4%) and men

10. (37.8%). People with less than a high school
diploma had the highest prevalence of multiple risk
factors (52.5%). These national trends are mirrored
in targeted community studies. For example, Jain
et al5 reported a higher prevalence of cardiovascular
risk factor clustering in African Americans than in
whites in the Dallas Heart Study. Hutchinson et al6
also showed that an absence of any CVD risk factors
was most common among white subjects in the
Atherosclerosis Risk in Communities Study.
According to the National Health and Nutrition
Examination Surveys (1999Y2002),3 the highest
prevalence of obesity (29.2%) in men was found in
Mexican Americans who had completed a high
school education (Table 2). However, black women
with or without a high school education had a higher
prevalence of obesity (47.3%). Hypertension preva-
lence was high among blacks (39.8%) regardless of
sex or educational status. Hypercholesterolemia was
high among white and Mexican American men and
white women in both groups of educational status.
The prevalence of low concentrations of high-
density lipoprotein cholesterol (an established risk
factor for CVD) and hypertriglyceridemia was most
favorable among African Americans, although among
the most educated women, whites and African Ameri-
cans had a similar prevalence of low high-density
lipoprotein cholesterol (Table 2).3 The prevalence of
hemoglobin A1c at levels of 7% or greater was
highest in African American men and women.
Differences in the prevalence of emerging risk fac-
tors, including C-reactive protein, fibrinogen, homo-

11. cysteine, microalbuminuria, and macroalbuminuria,
were also demonstrated, with the prevalence of al-
buminuria highest in blacks (data not shown).3
Disparities in CVD Prevalence,
Hospitalization, Diagnosis,
and Treatment
Disparities in the measures of CVD burden and care
have been extensively documented.1,7,8 For example,
in 2003, the prevalence of CVD was lowest in Mexican
American men (29.2%) and women (29.3%) and
highest in non-Hispanic black women (44.7%) and
men (41.1%).7 The prevalence of reported heart dis-
ease, ischemic heart disease, hypertension, and stroke
was inversely related to education and income.9
Gender and geographic disparities have been noted
for CVD hospitalizations. For example, among
Medicare enrollees aged 65 years or older, hospitali-
zations for acute myocardial infarction, chronic heart
failure, and stroke were higher in men than in
women.9,10 Whites had the highest prevalence of
hospitalization for acute myocardial infarction, but
the prevalence of hospitalization for chronic heart
failure was higher in African Americans, Hispanics,
and American Indians/Alaska Natives than among
whites. Within the Medicare population, stroke
hospitalization was highest in African Americans,
and heart disease and stroke were clustered primarily
in the southeastern United States.
Disparities in the use of diagnostic and therapeu-
tic interventions have been extensively documented
in the United States. A review focused specifically on
cardiac care, conducted jointly by the Kaiser Family

12. TABLE 1 Unadjusted Prevalence of Risk Factors for
Cardiovascular Disease Among US Adults
Aged 18 Years or Older: Behavioral Risk Factor Surveillance
System, 2003
White African American Mexican American
GHigh School QHigh School GHigh School QHigh School
GHigh School QHigh School
% SE % SE % SE % SE % SE % SE
Current smoker
Men 40.6 1.1 22.9 0.3 41.8 2.7 27.4 1.0 27.3 1.7 22.6 1.1
Women 34.6 0.9 19.9 0.2 25.6 1.6 17.8 0.7 10.6 1.0 12.9 0.7
Total 37.5 0.7 21.4 0.2 33.0 1.5 22.0 0.6 18.6 1.0 17.7 0.7
No physical activity
Men 40.1 1.0 17.7 0.2 42.1 2.7 24.7 1.0 46.5 1.9 24.9 1.1
Women 45.3 0.9 21.5 0.2 50.7 1.9 32.2 0.8 52.2 1.7 33.3 1.0
Total 42.8 0.7 19.7 0.2 46.8 1.6 28.9 0.6 49.4 1.3 29.1 0.8
5 Servings or more of fruit and vegetables
Men 13.3 0.7 18.6 0.3 14.6 2.0 18.9 0.9 18.2 1.6 17.4 1.1
Women 20.6 0.7 29.5 0.2 22.5 1.8 25.8 0.8 24.1 1.5 25.3 1.0
Total 17.1 0.5 24.3 0.2 18.9 1.3 22.8 0.6 21.3 1.1 21.4 0.7
Told to have diabetes
Men 11.9 0.7 7.0 0.2 14.6 1.7 10.1 0.7 9.0 1.0 5.6 0.6
Women 13.3 0.5 5.9 0.1 19.2 1.3 10.6 0.5 11.5 1.0 6.4 0.5
Total 12.6 0.4 6.4 0.1 17.1 1.1 10.4 0.4 10.3 0.7 6 0.4
Reproduced with permission from Mensah et al.3

13. 452 Journal of Cardiovascular Nursing x November/December
2006
Copyr ight © Lippincott Williams & Wilkins. Unauthor iz ed
reproduction of this article is prohibited.
Foundation and the American College of Cardiology
Foundation, concluded that racial/ethnic differences
in angiography, angioplasty, coronary artery bypass
graft surgery, and thrombolytic therapy persisted
even after adjusting for potential confounding fac-
tors.8 For example, African Americans were statisti-
cally less likely than whites to undergo coronary
artery bypass graft surgery in 21 of the 23 most rigor-
ous studies.8
The prevalence of hypertension treatment (35%)
and control (17%) is lowest in Mexican Americans
compared with non-Hispanic whites (49% and 30%,
respectively).11 The percentages of Medicare patients
with acute myocardial infarction who received the
recommended care in 2002 and 2003 were signifi-
cantly lower in blacks and Hispanics than in whites.1
The most recent national healthcare disparities
report concluded that quality of cardiac care differs
by race, ethnicity, and socioeconomic status.1
Disparities in Life Expectancy and
Cardiovascular Deaths
In 2003, life expectancy at birth in the United States
reached a record high of 77.5 years for all gender and
race groups combined; however, marked differences

14. by gender and race persist.
12
Life expectancy for
whites exceeded that for blacks by 5.3 years, with
the lowest value in black men (69 years) and highest
in white women (80.5 years).12 In fact, Satcher et al13
estimated that the gap in life expectancy between
blacks and whites accounts for as many as 83,570
excess deaths each year. Wong et al
14
also estimated
that CVD accounts for approximately a third of the
black-white differences in life expectancy.
In both men and women, the age-adjusted mortal-
ity rate for heart disease and stroke is highest in
blacks (Figure 1).3 Although the mortality rate has
progressively decreased in all race/ethnic groups,
TABLE 2 Prevalence of Traditional Risk Factors for
Cardiovascular Disease Among US Adults
Aged 18 Years or Older: National Health and Nutrition
Examination Survey (NHANES), 1999Y2002
White African American Mexican American
GHigh School QHigh School GHigh School QHigh School
GHigh School QHigh School
% SE % SE % SE % SE % SE % SE

15. Obesity (body mass index Q30 kg/m
2
)
Men 28.4 2.0 27.2 1.1 25.1 1.8 26.9 2.2 22.3 1.7 29.2 2.5
Women 36.8 2.6 29.6 1.5 47.7 3.2 47.1 2.3 37.8 3.0 32.8 2.8
Men and women 32.8 1.7 28.5 1.1 37.2 1.8 38.4 1.6 29.5 1.7
31.0 1.9
Large waist (men, 9102 cm; women, 988 cm)
Men 44.9 2.6 39.6 1.2 29.4 1.8 27.2 1.7 25.2 1.7 34.2 2.0
Women 68.0 3.3 52.9 1.8 71.9 2.3 67.0 1.6 62.2 2.6 53.9 2.9
Men and women 56.8 2.2 46.4 1.4 51.9 1.6 49.8 1.4 42.3 1.2
43.9 1.6
Hypertension
Men 39.3 2.5 29.8 1.2 45.9 2.8 31.8 1.7 21.1 2.2 16.5 2.1
Women 47.4 2.6 31.3 1.3 51.2 2.8 37.0 1.9 24.2 2.4 15.5 1.8
Men and women 43.5 1.9 30.6 1.0 48.7 2.4 34.7 1.3 22.6 1.8
16.0 1.3
Total cholesterol Q200 mg/dL
Men 45.5 3.0 49.2 1.5 37.7 2.8 41.7 2.3 49.2 2.7 45.5 2.8
Women 56.9 2.5 52.4 1.2 45.8 3.0 42.6 2.2 38.7 2.2 37.9 2.2
Men and women 51.4 2.0 50.8 1.0 41.9 2.0 42.2 1.8 44.4 2.0
41.7 1.6
Glycosylated hemoglobin Q7%
Men 7.5 1.3 3.8 0.4 10.1 1.4 3.7 0.7 4.9 0.8 4.3 0.9
Women 6.2 1.2 2.2 0.3 10.9 1.9 6.7 0.9 7.8 1.2 3.6 0.7
Men and women 6.8 0.9 3.0 0.3 10.5 1.5 5.4 0.6 6.3 0.7 4.0 0.6
NHANES 1999Y2000
Low high-density lipoprotein cholesterol (men, G40 mg/dL;
women, G50 mg/dL)

16. Men 41.2 3.1 35.9 2.2 27.0 4.3 23.8 3.4 35.6 3.5 25.6 4.6
Women 54.8 4.3 38.8 2.4 33.8 3.9 39.7 3.4 47.4 2.5 45.7 3.6
Men and women 48.0 3.1 37.4 1.9 30.4 2.9 33.0 2.4 41.1 2.4
36.2 3.0
Low-density lipoprotein cholesterol Q130 mg/dL
Men 49.5 7.0 46.7 2.9 27.2 5.4 31.0 5.8 46.7 4.6 54.3 7.0
Women 33.6 7.5 42.3 2.8 36.3 7.4 25.1 4.3 30.1 4.8 28.0 4.9
Men and women 41.9 5.8 44.4 2.0 31.9 5.0 27.5 4.1 38.8 2.8
41.0 5.2
Triglycerides Q150 mg/dL
Men 38.3 7.7 35.7 3.2 16.8 6.3 Y Y 40.5 4.2 40.2 9.1
Women 39.2 6.2 33.2 3.3 14.0 4.2 11.5 3.0 40.9 5.2 30.0 5.8
Men and women 38.7 4.6 34.4 2.4 15.4 4.2 10.4 2.6 40.7 3.7
35.2 6.6
Reproduced with permission from Mensah et al.3
Disparities in Cardiovascular Health 453
Copyr ight © Lippincott Williams & Wilkins. Unauthor iz ed
reproduction of this article is prohibited.
marked disparities in these rates persist (Figure 1).
Men and African Americans had more premature
deaths than women and whites did, as measured by
years of potential life lost before age 75 years
because of these conditions (Figure 2).
3
For ischemic

17. heart disease and stroke, as well as all diseases of the
heart, the years of potential life lost was highest in
blacks (Figure 2).3 Asians/Pacific Islanders had the
lowest heart disease mortality at all ages, but they
had more stroke mortality than did Hispanics and
American Indians/Alaska Natives, especially at
young ages (data not shown).
Eliminating Disparities in Cardiovascular
Health and Health Care
Eliminating these disparities remains a major public
health challenge in the United States and will require
a concerted effort on the part of all providers,
individually and collectively. The causes of these
disparities are many, and the underlying mechanisms
remain incompletely understood; nevertheless, the
healthcare delivery system itself, access to care,
inadequate study of vulnerable groups, quality of
care received, communication barriers, individual
behaviors and lifestyles, and lack of access to
relevant, literacy-congruent health information
remain important determinants of disparities.15,16
We have proposed a framework incorporating
6 strategic imperatives, 10 focal areas, and multiple
targeted settings (Table 3) as one approach to
exploring interventions for eliminating health dis-
parities.4 The framework illustrates the opportuni-
ties for cardiovascular nurses to take a leadership
role in helping to eliminate disparities by addressing
FIGURE 1. Death rates for diseases of the heart and stroke by
race, ethnicity, and sex: United States, 1980Y2001; age adjusted
to the 2000 US population. Source: CDC, Health United States,

18. 2003. Reproduced with permission from Mensah et al.3
TABLE 3 A Framework for Action to Eliminate
Disparities in Cardiovascular Health
A. Strategic Imperatives
1. Accelerate health impact in disparate populations.
2. Advance policy and systems change.
3. Form strategic multidisciplinary partnerships.
4. Expand community-based participatory research and
research translation.
5. Collect healthcare data by race, ethnicity, and
disparate indicators.
6. Ensure a diverse clinical and public health workforce.
B. Focal Areas
1. Access to healthcare
2. Quality of healthcare delivered
3. Patient preferences, healthcare utilization, adherence
4. Culture, lifestyles, and personal behaviors
5. Regulations, policies, and systems of care
6. Geographic and environmental influences
7. Income and educational levels
8. Prejudice, discrimination, and bias
9. Psychosocial stressors
10. Biology, genomics, and gene-environment interactions
C. Major public health settings
1. Communities, cities, counties, regions, states
2. Schools and colleges
3. Worksites of small and large businesses
4. Hospitals, clinics, doctors’ offices, emergency

19. departments
5. Faith-based settings (eg, churches, synagogues,
mosques)
6. Centers for training health professionals
Reproduced with permission from Mensah.
4
454 Journal of Cardiovascular Nursing x November/December
2006
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reproduction of this article is prohibited.
relevant domains and elements. The pursuit of sys-
tems and policy changes to improve healthcare
access and quality; reduce risk factor prevalence;
increase minority participation in research; engage
in collaborative research-based practice networks;
develop programs to increase the cultural compe-
tence of the CVD workforce; foster patient-centered
care; and increasing community outreach programs
in schools, worksites, and faith-based settings are im-
portant approaches to eliminating these disparities.
Conclusions and Future Directions
Health disparities are pervasive in cardiovascular
healthcare, and they are demonstrable in access to care
as well as most domains of quality of care, including
treatment standards, effectiveness, prevention, and

20. patient-centered approaches. Multisectoral, transdisci-
plinary partnerships are essential to accelerate efforts
to eliminate these disparities in cardiovascular health.
Definitive evidence on the strategies likely to be
most effective in eliminating disparities is lacking;
however, emphasis on quality of care and access to
care for all regardless of race/ethnicity, sex, socio-
economic status, and geography are crucial first steps.
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