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Chapter 1: Introduction to the Study
Background
In the United States, heart disease is the leading cause of death among men and
women of all ethnic groups (Kochanek, Xu, Murphy, Minino, & Kung, 2011). Heart
disease is any affliction that impairs the structure or function of the heart (atherosclerotic
and hypertensive disease, congenital heart disease, rheumatic heart disease, and
cardiomyopathies). The word heart disease is often used interchangeable with
cardiovascular disease (United States Department of Health and Human Services
[USDHHS], 2003). The National Vital Statistics Report reported that over 616,000
deaths were attributed to heart disease (as cited in Kochanek et al., 2011). Heart disease
is commonly thought to be more fatal in men; however, women are twice as likely as
men to die within the first week after having a heart attack; 38% of women and 25% of
men die within 1 year of having a heart attack (Jones et al., 2010). Nearly every minute,
a woman in the United States dies from complications of heart disease (Jones et al.,
2006). Mosca et al. (2006) claimed that 36% of women did not perceive themselves to be
at risk for heart disease. Moreover, women perceived themselves to be at a greater risk of
being diagnosed with cancer than of heart disease (Mosca et al., 2006); yet, five times
more women (200,000) die each year from complications of heart disease (heart attacks)
when compared to breast cancer (Women’s Heart Foundation, 2007). Nearly 300,000
deaths have been attributed to heart disease in women in 2009 (Kochanek et al., 2011).
Over the past 15 years, awareness of heart disease as being the leading cause of death in
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women has nearly doubled from 30 % to 56% in women (Mosca et al., 2013); but,
minority women lack awareness of heart disease.
African American women are markedly more susceptible to developing heart
disease when compared to any other ethnicity group and are 35% more likely to die of
heart disease (Office of Minority Health [OMH], 2012). The rate of heart disease among
African American women is 48.9% compared to 32.4% in European American women
(American Heart Association [AHA], 2013a, 2013b). Although African American
women are at a greater risk for heart disease, they are less likely than European American
women to know the risk factors or know they have the risk factors for heart disease.
Approximately 68% of European American women know that heart disease is the leading
cause of death in women, compared to 31% of African American women (Christian,
Rosamond, White, & Mosca, 2007).
Women have been known to experience some of the traditional warning signs of
heart disease, but dismiss the red flags and delay seeking treatment (Sherrod, 2011). The
lack of awareness of heart disease by women has been the primary reason in delaying
treatment (Rosenfeld, 2006). The controllable risk factors of heart disease include high
blood pressure, high cholesterol, cigarette smoking, diabetes, poor diet, physical
inactivity, overweight, and obesity (Healthy People 2020, 2013). These risk factors, and
having a family history of heart disease, are prevalent in the African American
community. Sixty-four percent of African American women do not partake in any
physical activity, and 80% of African American women are overweight or obese as
compared to 60.2% of European American women (AHA, 2013a, 2013b). The rate of
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high blood pressure for non-Hispanic African American women 20 years and older is
47% (Rosamond et al., 2008). When compared to European American women, African
American women have an 85% higher rate of ambulatory medical care visits due to high
blood pressure (Rosamond et al., 2008).
In 1997, the American Heart Association began conducting national random
surveys of women’s awareness, knowledge, and perceptions related to heart disease
(Mosca, Mochari-Greenberger, Dolor, Newby, & Robb, 2010). Triennial surveys using a
different population of women were conducted every 3 years thereafter to determine and
follow the trend of awareness and perceptions of heart disease based on the age, race, and
ethnic background of the women (Mosca et al., 2010). Data were weighted to reflect the
U.S. population of women aged 25 and older. A sample weight is a measure of the
number of people in the population represented by that person. A sample weight is
created in three steps: (a) the base weight is calculated, (b) adjustments for nonresponses
are made, and (c) post stratification adjustments are made to match the U.S. Census
population (Centers for Disease Control and Prevention [CDC], 2013). The information
was gathered from the U.S. Census Bureau’s population survey overall and within ethnic
strata (Mosca, Hammond, Mochari-Greenberger, Towfighi, & Albert, 2013).
Women’s awareness of heart disease being the leading cause of death nearly
doubled from previous surveys from 30% in 1997 to 56% in 2012 (Mosca et al., 2013).
Even though there has been a trend of improvement in the past 15 years, there remains a
consistent gap in the overall awareness of heart disease risk factors, heart attack
symptoms, and heart disease being the leading cause of death among African American
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women (Mosca et al., 2013). The results of the Women’s Health Study revealed that the
awareness level among African American women had improved since 1997 (Mosca et al.,
2013) but, their awareness level in 2012 was equivalent to European American women’s
level of awareness in 1997 (Mosca et al., 2013). African American women are at an
increased risk of developing heart disease due to risk factors of higher rates of physical
inactivity, hypertension, diabetes, and obesity (Jones et al., 2010). It is important that
continued efforts are made to target this population. Increasing African American
women’s awareness of heart disease can have a positive effect on their decision to make
lifestyle changes in an effort to prevent heart disease (Mosca et al., 2006).
Problem Statement
Researchers have made progress in increasing awareness of heart disease in
women over the past 15 years (Mosca et al., 2013). Heart disease can be prevented if
there is an awareness of the risk factors involved. Most of the risk factors can be
controlled by making good lifestyle decisions (Healthy People 2020, 2013). Although
progress has been made, African American women’s awareness of heart disease being the
leading cause of death remains below the awareness level of European American women
(Mosca et al., 2013). African American women showed a 36% awareness level of heart
disease (Mosca et al., 2013). This is similar to European women’s 30% awareness level
in 1997 (Mosca et al., 2013). Further research was needed to evaluate the awareness and
perceptions of perceived risks for heart disease among African American women of all
ages. Because African American women are more susceptible to developing and dying
from heart disease compared to men or women of other races (Roger et al., 2012),
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surveying this population to determine their perceptions and perceived risks for heart
disease was important and will add more insight to heart disease awareness level among
African American women.
Nature of the Study
A descriptive, correlational, quantitative survey research design was used to
examine African American women’s awareness and perceptions of personal risks for
heart disease. Cost, time, convenience, and flexibility were the key factors that
determined an online survey to be the most beneficial approach in measuring the studied
population’s awareness, perceptions of personal risks for heart disease, and demographic
factors (age, income, education level, and family history) that may play a role in their
awareness of heart disease. Online-based surveys have become a new method for survey
research (Babbie, 2011). The advantages of an online survey consist of lower cost,
automation, time saving, convenience, and flexibility (Babbie, 2011). The survey was
administered using an online survey tool called Google docs.
Snowball sampling was used to recruit African American women aged 18 and
older in the United States to participate in the study by means of e-mail, LinkedIn, and
Facebook. LinkedIn and Facebook are social media websites that connect people. In
snowball sampling, I solicited women through an e-mail invitation to complete my
research survey who met the criteria (African American women, at least 18 years or
older) and asked them to forward the invitation to others they knew who also met the
criteria (Trochim & Donnelly, 2008). The criteria for participation were also included in
the e-mail invitation.
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The survey was administered through Google docs and was completed by the
participants. This method made distributing the survey quicker and easier than traditional
surveys. Participants were able to complete the survey in their own time and at their own
pace. The data were saved in a spreadsheet, and the data were loaded into SPSS for
statistical analysis.
In conducting a descriptive, correlational, quantitative study, it is important to
calculate the statistical power of the study prior to collecting data. A statistical power
assessment is used to determine how likely it is that a statistical significance test will
detect a significant difference between two or more groups (Olinksy, Quinn, &
Schumacher, 2008). The power analysis in this study was used to determine the number
of completed surveys (sample size) needed to accept the outcome of the statistical test
with a 95% confidence level. Based on the U.S. Census Bureau (2013a), there are an
estimated 15,302,276 African American women aged 18 and older in the United States.
Based on a sample size calculator from Creative Research Systems (2012), the
recommended sample size for a population of 15,302,276 was 384, with a 95%
confidence level and a confidence interval of 5.
All questions from the AHA Women’s Health Study were used in conducting the
study. Content and wording of the individual questions were not changed from the
original survey. The survey is divided into eight sections: (a) general awareness of
women’s health issues, (b) participants’ general health, (c) awareness of heart disease, (d)
specific understanding of heart attacks and stroke, (e) communicating about heart disease,
(f) behaviors associated with prevention, (g) motivation to change, and (h) custom
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demographics. There were 10 open-ended questions in which participants provided their
own answer to the questions. The remaining questions of the Women’s Health Study
were closed-ended questions where participants selected an answer from a list. I added
five questions in order to determine whether there was an association among participants
based on their age, education, income, state of residency, and family history of heart
disease.
Research Questions and Hypotheses
The research questions and hypotheses were developed based on the review of
existing research pertaining to the perceptions of heart disease among women. Statistical
analyses that were used to address the research questions will be discussed in Chapter 3.
1. Is there an association between African American women’s knowledge of
heart disease risk factors (diabetes, high blood pressure, high cholesterol,
cigarette smoking, poor diet, physical inactivity, and overweight) and
awareness of heart disease?
H11: There is a significant association between African American women’s
knowledge of heart disease risk factors (diabetes, high blood pressure, high cholesterol,
cigarette smoking, poor diet, physical inactivity, and overweight) and awareness of heart
disease.
H01: There is no significant association between African American women’s
knowledge of heart disease risk factors (diabetes, high blood pressure, high cholesterol,
cigarette smoking, poor diet, physical inactivity, and overweight) and awareness of heart
disease.
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2. Is there an association between African American women’s knowledge of
heart attack symptoms (chest pain, fatigue, nausea, pain in the shoulders,
neck, or arms, shortness of breath, and tightness of the chest) and
awareness of heart disease?
H12: There is a significant association between African American women’s
knowledge of heart attack symptoms (chest pain, fatigue, nausea, pain in the shoulders,
neck, or arms, shortness of breath, and tightness of the chest) and awareness of heart
disease.
H02: There is no significant association between African American women’s
knowledge of heart attack symptoms (chest pain, fatigue, nausea, pain in the shoulders,
neck, or arms, shortness of breath and tightness of the chest) and awareness of heart
disease.
3. Is there an association between African American women’s perceptions of
personal risks for heart disease and awareness of heart disease?
H13: There is a significant association between African American women’s
perceptions of personal risks for heart disease and awareness of heart disease.
H03: There is no significant association between African American women’s
perceptions of personal risks for heart disease and awareness of heart disease.
4. Is there an association between African American women’s demographic
background (age, income, education, state of residency, and family history
of heart disease) and awareness of heart disease?
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H14: There is a significant association between African American women’s
demographic background (age, income, education, state of residency, and family history
of heart disease) and awareness of heart disease.
H04: There is no significant association between African American women’s
demographic background (age, income, education, state of residency, and family history
of heart disease) and awareness of heart disease.
Purpose of the Study
The primary purpose of this descriptive, correlational, quantitative study was to
determine the relationship between the studied variables (knowledge of heart disease risk
factors, knowledge of heart attack symptoms, perceived risk for heart disease) as well as
what factors influenced participants’ awareness of heart disease. The secondary purpose
was to examine the participants’ perceptions of their personal risks for heart disease.
Individuals’ perceptions of heart disease risk factors often impact their behaviors related
to health maintenance (Hart, 2005). Through use of a self-reporting tool, individuals
provided their overall knowledge and beliefs about heart disease and indicated their
perceptions of personal risks for heart disease. A number of variables were investigated
in an effort to gain knowledge of African American women’s awareness and perceptions
of their personal risks for heart disease. The survey used in this study was the American
Heart Association’s (AHA) Women’s Health Study. This tool was used to measure the
awareness level and perceptions of personal risks of heart disease among African
American women. There were three sets of variables measured in this study: the
awareness of seven controllable risk factors of heart disease (diabetes, high blood
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pressure, high cholesterol, cigarette smoking, poor diet, physical inactivity, and
overweight), the awareness of six symptoms of a heart attack (chest pain, fatigue, nausea,
pain in the shoulders, neck, or arms, shortness of breath, and tightness of the chest), and
the perceptions of personal risk for heart disease. Participants’ awareness level was the
dependent variable for this study. Participants’ awareness level was measured by the
survey question: How informed are you about heart disease in women? Participants
chose very informed, well informed, moderately informed, or not at all informed. The
independent variables were the participants’ perceptions of personal risks for heart
disease, knowledge of heart disease risk factors, and knowledge of heart attack
symptoms. Age, income, education level, state of residency, and family history were the
covariate variables. African American women’s awareness and perceptions of personal
risks for heart disease were measured using the AHA Women’s Health Study.
Social Change
Heart disease among African American women continues to be the primary cause
of death. African American women are more likely to experience the risk factors of
diabetes, high blood pressure, high cholesterol, poor diet, physical inactivity, and
overweight when compared to any other ethnic group (Jones et al., 2010). A lack of
awareness of heart disease risk factors increases their risk of developing heart disease.
Gaining an understanding of their overall knowledge and health beliefs about heart
disease is important information to be added to research about heart disease.
The research study provides insight into African American women’s awareness
and perceptions of personal risks for heart disease. The research information can be used
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to create heart health dialogue within the studied population’s circle of people and bring
more awareness of heart disease among African American women, which is necessary for
the awareness of heart disease to increase.
Theoretical Base
Life decisions are made every day by people and are typically made according to
how they will affect their daily routine, family environment, or financial well-being. The
main concept of the health belief model (HBM) is that health behavior is influenced by
personal beliefs (Glanz, Rimer, & Viswanath, 2008). This model was the most
appropriate for this study because the constructs (perceived susceptibility, perceived
severity, perceived benefits, perceived barriers, and cues to action) can be used to
examine African American women’s perceptions of their personal risks for heart disease.
The construct perceived susceptibility in this study referred to an individual’s perceptions
of the risk of developing heart disease. Perceived severity was the individual’s
perception of the seriousness of the disease to cause complications of their lifestyle
(effects of the conditions on work and family life). An individual’s belief of the
effectiveness of various actions available in reducing the disease threat was considered
their perceived benefit. The perceived barriers were those actions that would make it
difficult to make a behavioral change. Events, people, or things that moved an individual
to make a behavioral change were considered cues to action. The constructs perceived
susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to
action were measured in this study using questions from the AHA Women’s Health
Study (see Table 1).
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Table 1
AHA Survey Questions that Address the HBM Constructs
Construct
Question(s) from AHA survey
Directions
Perceived
Susceptibil
ity
To what extent do you worry about getting each of the following health conditions?
Cancer, Heart disease, AIDS, Breast Cancer, Lung Cancer, Smoking, Drug Addiction or
alcoholism, Violent crime, Stroke, Alzheimer’s, Diabetes, Osteoporosis
Do you worry a lot
about this, worry a
little, do not worry at
all about it?
How much do you think your overall outlook on life impacts the following? Your
likelihood to develop a serious illness like heart disease
Not at all, some, very
much, a great deal?
Which of the following are the biggest barriers preventing you from leading a heart
healthy lifestyle? I don’t perceive myself to be at risk for heart disease, I don’t think
changing my behavior will reduce my risk of developing heart disease, None of these, I
lead a heart healthy lifestyle
Choose all that apply
Perceived Severity
Which of the following are the biggest barriers preventing you from leading a heart
healthy lifestyle? My family/friends have told me that I don’t need to change, My health
care professional doesn’t think I need to worry about heart disease, God or some higher
power ultimately determines my health
Choose all that apply
How much do you think your overall outlook on life impacts the following? Your
likelihood to successfully manage a serious illness like heart disease if you develop it
Not at all, some, very
much, a great deal?
Perceived Benefits
How likely are you to become involved with “heart health” as an issue if the following
kinds of programs existed? A medical research program to ensure that the ways in which
women experience heart disease are adequately addressed, A program to educate women
that heart health is an issue all women should pay attention to, A program to educate
women about how to navigate the health care system to get the best care possible, A
program to educate women about how to evaluate their health care provider’s ability to
treat them if they have heart disease
Definitely would not,
Probably would not,
Might or might not,
Probably would, or
Definitely would
Perceived Barriers
Which of the following are the biggest barriers preventing you from leading a heart
healthy lifestyle? I’m fearful of change, I’m not confident that I can successfully change
my behavior, I am too stressed to do the things that need to be done, I am too depressed to
do the things that need to be done, I am too ill/old to make changes, I don’t have the
money or insurance coverage to do what needs to be done, I have family obligations and
other people to take care of, I don’t’ have the time to take care of myself, My health care
professional doesn’t speak my language, I am confused by what I’m supposed to do to
change my lifestyle, I feel the changes required are too complicated I don’t know what I
should do, There is too much confusion in the media about what to do, My health care
professional doesn’t explain clearly what I should do
Choose all that apply
Cues to Action
Thinking about the things you have done to improve your health, please tell us if any of
the following prompted you to take action. I saw, heard, or read information related to
heart disease, My health care professional encouraged me to take action, A family
member or relative encouraged me to take action, A friend encouraged me to take action,
A family member/relative developed heart disease, got sick, or died, A friend developed
heart disease, to sick, or died, I experienced symptoms that I thought were related to heart
disease, I wanted to feel better, I wanted to avoid taking medications, I wanted to improve
my health, I wanted to live longer, I did it for my family, I was encouraged to take action
during an event or program at my place of worship (church, mosque, or temple), I was
encouraged to take action during an event or program at my community center,
Something else, I have not done anything to improve my health
Choose all that apply
Knowing that heart disease is the leading cause of death for women in the U.S. which of
the following are you likely to do? Go to the doctor to assess my risk for heart disease,
Get more information about heart disease, Research ways to improve my heart health,
Talk to my family about our medical history, Talk to my friends about heart disease, Get
involved with an organization to help raise awareness about heart disease, Make lifestyle
and behavior changes, Other, Nothing
Choose all that apply
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Operational Definitions
African American women: Women of any of the Black racial groups of African
that indicate their race as Black, African American, or Negro (U.S. Census Bureau,
2013b).
Covariate variables: Variables that influence the dependent variable (Creswell,
2009). The covariate variables in this study were the following:
• Age, income, education level, state of residency, and family history: Was
determined by participants’ responses to the demographic questions.
Dependent variables: Variables that depend on the independent variables; they
are the outcomes or results of the influence of the independent variable (Creswell, 2009).
The dependent variable of this study was the following:
• Participants’ awareness level: Was determined by participants’ response to
how informed they were about heart disease in women.
Heart attack: Occurs when the blood flow that brings oxygen to the heart muscle
is severely reduced or cut off completely (American Heart Association, 2013c).
Heart disease: Any affliction that impairs the structure or function of the heart
(USDHHS, 2003).
Independent variables: Variables that cause, influence, or affect outcomes
(Creswell, 2009). In this study, the independent variables were the following:
• Participants’ perceptions of personal risks for heart disease (PPRFHD):
Was determined by the participants’ response to the extent in which they
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worry about getting heart disease as well as whether they select as an
answer that they do not perceive themselves to be at risk for heart disease
• Knowledge of heart disease risk factors (HDRF): Was determined by
participants’ response to the major risk factors for heart disease.
• Knowledge of heart attack symptoms (HAS): Was determined by
participants’ response to the warning signs associated with having a heart
attack.
Assumptions
According to Creswell (2009), postpositivist assumptions represent the traditional
form of quantitative research. Problems studied by postpositivists “reflect the need to
identify and assess the causes that influence outcomes” (Creswell, 2009 p. 231). The
knowledge that develops through a postpositivist approach is “based on careful
observation and measurement of the objective reality that exists ‘out there’ in the world.
Thus, developing numeric measures of observations and studying the behavior of
individuals becomes paramount for a post-positivist” (Creswell, 2009, p. 7). The
scientific approach includes the following: the researcher begins with a theory, collects
the data that support or refute the theory, and then make the necessary revisions before
additional tests are conducted (Creswell, 2009). Using the HBM framework to examine
the overall knowledge and health beliefs about heart disease among African American
women was an important aspect of this study. For this study, I assumed that the
participants completed the survey accurately and honestly and to the best of their ability
to reflect their current health behavior and perceptions.
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Limitations
All research strategies and statistical procedures have limitations (Creswell,
2009). According to Simon (2011) and Creswell (2009), limitations of a study are
potential weaknesses and should be identified at the beginning of a study. Heart disease
is the primary cause of death among men and women of all ethnic groups in the United
States (Kochanek et al., 2011); but for the purpose of this study, men of all ethnic groups
and women of non-African American ethnic groups were not included as part of this
study. This study was limited in that I examined African American women’s overall
knowledge and perceptions for heart disease. Another limitation of this study was the
snowball sampling of participants. This study was limited to African American women
with access to the Internet; therefore, this study was not representative of all African
American women. In an effort to address this limitation, three methods of recruitment
were chosen. An e-mail, LinkedIn, or Facebook invitation was sent to all family, friends,
and associates who were African American women aged 18 and older, and they were
encouraged to forward the invitation to other African American women. The three
methods of recruitment targeted a diverse group of women who were both professionally
and socially driven. This process also allowed for the recruitment of participants from
different areas of the United States; a large population sample; and a wider diversity of
African American women of various ages, income levels, and educational backgrounds.
Scope and Delimitations
Delimitation is used to narrow the scope and define the boundaries of a study
(Creswell, 2009; Simon, 2011). A researcher’s objectives, research questions, variables
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of interest, theoretical framework, and the population chosen to examine are delimiting
factors (Creswell, 2009). This study was delimited to African American women 18 years
of age and older who lived in the United States because these women are at an increased
risk for developing heart disease due to risk factors of higher rates of physical inactivity,
hypertension, diabetes, and obesity (Jones et al., 2010). The study was also delimited to
seven risk factors: (a) diabetes, (b) high blood pressure, (c) high cholesterol, (d) cigarette
smoking, (e) poor diet, (f) physical inactivity, (g) and overweight. These are controllable
risk factors (National Heart, Lung, and Blood Institute [NHLBI], 2011).
Significance of the Study
Findings from this study will add to existing scholarly research and literature on
the awareness of heart disease among African American women aged 18 and older.
Heart disease is a major cause of death in women and specifically African American
women. African American women have higher heart disease mortality than any other
ethnic group (Jones et al., 2010). Heart disease can be prevented and/or controlled if
individuals are aware of the major risk factors (Ferris, Kline, & Bourdage, 2012).
African American women are less likely than European American women to know that
they may have major risk factors for heart disease (Jones et al., 2010). Christian et al.
(2007) showed the awareness level of heart disease has increased in women as a whole,
but little research has been conducted on the awareness of heart disease risk factors,
symptoms of heart attack, and perceptions of personal risks for heart disease among
African American women. Studies are needed to evaluate the perceived risks of heart
disease among African American women. This study provides insight on African
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American women’s perceptions and perceived risks of heart disease. Once participants
have completed the survey, a message at the end of the survey encouraged participants to
begin heart health dialogue among their peers, resulting in spreading awareness of heart
disease among African American women and initiating a positive social change.
Summary
In this chapter, information about the impact heart disease among Americans of
all races in the United States was presented. The awareness level of heart disease among
races and gender were noted. The little known knowledge of awareness level and
knowledge gap among African American women was demonstrated through the literature
provided in this chapter. The aim of this research study was to determine African
American women’s awareness level and perceptions of personal risks for heart disease, as
well as provide further insight of knowledge in an area of research that has been
understudied. In this chapter, the quantitative research design that was used with
justification of why it was chosen as well as the research questions that were used to
impact this study were presented. Words were defined in an effort to address any terms
that may not be understandable for readers of various backgrounds. The focus of the
study was the knowledge, awareness, and perceptions of personal risks for heart disease
specifically among African American women in the United States.
In Chapter 2, literature will be reviewed related to the findings of studies
completed concerning heart disease, heart disease risk factors, symptoms of heart attack,
heart disease perceptions, and perceived risks of heart disease among women and African
American women will be described. The use of a quantitative method design will also be
18
discussed. Chapter 3 will include details of the research design, hypotheses, subjects,
variables, reliability and validity of the survey instrument, data collection, and statistical
analysis. I used a survey design to determine the perceptions of heart disease among
African American women. Statistical analysis was computed at the completion of the
surveys. Chapter 4 will include data analysis from each research question, and in Chapter
5, an interpretation of the results and recommendations for further research will be
discussed.
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Chapter 2: Literature Review
Introduction
This literature review is organized in four sections: (a) heart disease risk factors,
(b) heart attack symptoms, (c) perceptions of heart disease, (d) and theoretical
framework. The sections on heart disease risk factors and symptoms of a heart attack
will include an exhaustive review of how these factors contribute to the development of
heart disease. In the review of prior research on the perceptions of heart disease among
women, I will identify their knowledge of the seriousness and perceived risks of heart
disease. The final section will include the theoretical framework. In this section,
individuals’ perceptions of heart disease and how it influences their health and lifestyle
choices will be discussed, as well as background information about the theory. In the
concluding portion of the chapter, I will connect the literature reviewed to the problem
statement and research questions.
In this chapter, a review of perceptions, perceived risks, and awareness level of
heart disease of women from all ethnic backgrounds is presented. The search engines
and databases used for the review were Google Scholar, ProQuest, CINAHL, Medline
Ovid, PubMed, EBSCO, and Sage. The search of articles was limited to original peer-
reviewed journal articles, electronic dissertations, scholarly books, and papers published
in English, between the years 2003-2013. Key search terms included heart disease,
women, African American women, black women, perceived risk, awareness, perception,
heart disease risk factors, and symptoms of a heart attack. The key search words were
20
used in various combinations. The search strategy was to identify studies whose main
purpose or goal was to explore women and their perceptions of heart disease.
Heart Disease
Heart disease continues to be the primary cause of death among both men and
women in the United States (Kochanek et al., 2011). Heidenreich et al. (2011) stated,
“By 2030, 40.8% of the U.S. population is projected to have some form of CVD” (p. 1).
For many years, heart disease was known as “a man’s disease;” but approximately the
same number of women and men die each year of heart disease in the United States
(Mosca et al., 2010). Women have a greater risk of developing heart disease; yet, they
perceive themselves to be at a greater risk of cancer (Mosca et al., 2006). There are more
African American women dying from heart disease than any other ethnic group; yet, they
are less likely than European American women to know that they may have major risk
factors (Jones et al., 2010). High blood pressure, high cholesterol, cigarette smoking,
diabetes poor diet, physical inactivity, overweight, and obesity are dominant in the
African American community and are also the major risk factors for heart disease
(Healthy People 2020, 2013).
Heart disease in women can be prevented if women are aware of the risk factors
(Ferris et al., 2012). According to Homko et al. (2008), knowledge of heart disease risk
factors is important for a person to make an informed decision about engaging in or
continuing certain behaviors that may increase disease risk. If a person has an increased
awareness of the risk factors involved in developing heart disease, his or her chances of
developing heart disease decreases (Crouch &Wilson, 2010). There is little known about
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African American women’s perceptions of the seriousness of heart disease, and further
research is needed in order to get a better understanding of their knowledge, especially
with the high prevalence of heart disease among this group.
Risk Factors
Individuals’ behaviors including food choices, sedentary lifestyle, physical
inactivity, smoking, and drinking alcohol may have a negative impact on the heart and
can increase heart disease risk. There are two categories of risk factors for heart disease:
controllable and uncontrollable. The risk factors that cannot be controlled are age,
gender, and family history of heart disease (NIH, 2011). Preventive practices can be
implemented in order to decrease the chances of developing heart disease with theses
uncontrollable risk factors. Most risk factors such as smoking, unhealthy diet, physical
inactivity, obesity and overweight, high blood pressure, high blood cholesterol, and
diabetes are controllable. Many scholars have confirmed that the controllable risk factors
account for the majority of heart disease cases in the United States (Vasan et al., 2005).
According to the CDC (2011a), 49% of people in the United States have at least one of
the three controllable risk factors for heart disease: high blood pressure, high blood
cholesterol, or smoking. Smoking and diabetes put an individual at a greater risk of heart
disease and experiencing a heart attack compared to any of the other risk factors (NIH,
2011). African American women have more heart disease risk factors than European
American women, higher rate of physical inactivity, hypertension, diabetes, and obesity
(Heidenreich et al. 2011); and yet they are unaware of their risk (Christian et al., 2008).
22
Smoking
Smoking has contributed to 50% of all avoidable deaths and half of those deaths
were due to heart disease (Agewall, 2012). There is no safe level of smoking; even
smoking one cigarette increases an individual’s risk of developing heart disease
(Agewall, 2012). Smoking is the single most preventable cause of death and disease in
the United States (Healthy People 2020, 2012). Smoking is also the most common
modifiable risk factor for heart disease in women (Lefler & Nuss, 2009).
African American women have shown a pattern of smoking similar to European
American women. Overall, the prevalence of smoking is lower among African American
women (Adams & Schoenborn, 2006); yet, they tend to smoke brands with higher
nicotine levels, which makes them more susceptible to developing heart disease (CDC,
2006). Nicotine increases the body’s heart rate and blood pressure (Benuck, 2006). In
2010, 23.4% of African Americans aged 18 and older smoked; of that percentage, 16.7%
were women (CDC, 2011a). People who smoked were less likely to use health care
services (Adab, Hedley, Lam, & McGhee, 2005).
High Blood Pressure/High Blood Cholesterol
Consistent high blood pressure is a risk factor for both heart disease and stroke.
Agewall (2012) claimed that increased cholesterol is a contributing factor to heart disease
mortality. High blood pressure and high cholesterol often occur concurrently (Feresu,
Zhang, Puumala, Ulrich, & Anderson, 2008). As cholesterol levels increase, the chance
of having heart disease and stroke also increases. In 2006, approximately 38.8 million
women (44.8% African American women) had high blood pressure, and 54.5 million
23
women (41.8% African American women) had high cholesterol in the United States
(Jones et al., 2010).
African Americans have a higher rate of high blood pressure and lower control
rates when compared to other ethnic groups in the United States (Yoon, Burt, Louis, &
Carroll, 2012). African American women have a higher percentage (45%) of
hypertension and death due to hypertension when compared to European American
women (Egan, Zhao, & Axon, 2010). Poor knowledge of high blood pressure and its
complications of having heart failure, heart disease, or heart attack, false health beliefs
that taking medication can cure having high blood pressure, beliefs that nothing can be
done to prevent high blood pressure, beliefs that a person can feel when their blood
pressure is high and a lack of lifestyle modifications such as weight control and a lack of
aerobic exercise have been linked to the high prevalence of hypertension among African
American women (Peters, Aroian, & Flack, 2006; Viera, Cohen, Mitchell, & Sloan,
2008; Watt et al., 2008). Guo, He, and Zhang (2012) revealed that there has been an
increase in awareness of hypertension overall, but not a significant increase in awareness
of hypertension among African American women from 1999 to 2010.
Ford, Kim, and Dancy (2009) conducted a study that consisted of seven talking
circles (TC), similar to focus groups, with 25 African American women aged 40-74. The
participants’ perceptions of hypertension were examined according to their personal and
environmental factors that would affect their hypertension. All of the participants felt
that hypertension was a common occurrence within the African American community.
The women in four of the groups considered hypertension to be a serious disease (Ford et
24
al., 2009). In four of the groups, the women felt that it was difficult to identify
hypertension because it did not have symptoms. Some of the barriers mentioned by the
women to following a treatment plan were being of low income, medical expenses, a lack
of insurance, or being too tired to exercise or take medication. African American
women’s personal environmental factors affect their hypertensive status, and educators
should focus on these factors when targeting this group of women (Ford et al., 2009).
Diabetes
Diabetes is also associated with an increased risk of heart disease; with lifestyle
changes, diabetes can be prevented (Agewall, 2012). According to national survey data
from 2007 to 2009, 12.6% of African Americans were diabetics compared to 7.1% of
European Americans, 8.4% of Asian Americans, and 11.8 % of Hispanic Americans
(CDC, 2011b; Go et al., 2012). The risk of being diagnosed with diabetes in the United
States is higher among African Americans (CDC, 2011b; Go et al., 2012). The 2009
overall underlying-cause of death rate attributable to diabetes was 20.9 (CDC, 2011b; Go
et al., 2012). Death rates per 100,000 people were 23.3 for European American men and
44.2 for African American men and 15.7 for European American women and 35.9% for
African American women (CDC, 2011b; Go et al., 2012). The incidence of diabetes was
projected to more than double from 2005 to 2050 in all age, sex, and ethnic groups (CDC,
2011b; Go et al., 2012). The increase is projected to be largest for African Americans
and Hispanic Americans (CDC, 2011b; Go et al., 2012).
Diabetes is a major health issue for African Americans, especially African
American women (Office of Women’s Health [OWH], 2010). African Americans are
25
disproportionately affected by diabetes (American Diabetes Association, 2013) and are
twice as likely to be diagnosed with diabetes when compared to European Americans
(OMH, 2012). One in four African American women older than 55 has diabetes (OWH,
2010).
Baptiste-Roberts et al. (2007) conducted a cross-sectional study of 1,122 African
American adults without diabetes aged 50 and older who participated in Project Diabetes
Interventions Reaching and Educating Communities Together (DIRECT). The majority
of the participants were women. Sixty-three percent of the participants had a high school
education or less, 63% were employed, and 61% had an annual income below $25,000.
The study was conducted to examine the role family history of diabetes had on the
participants’ awareness of diabetes risk factors and their likelihood of practicing healthier
lifestyle behaviors (Baptiste-Roberts et al., 2007). The scholars revealed that having a
family member with diabetes was associated with a better awareness of diabetes risk
factors, healthier eating habits, and more willingness to participate in diabetic screening
than those participants without a family history of diabetes (Baptiste-Roberts et al.,
2007). Participants with a family history of diabetes were also more likely than those
without a family history to partake five or more servings of fruits and vegetables per day
(Baptiste-Roberts et al., 2007). Women were more likely than men to report having a
family history of diabetes (Baptiste-Roberts et al., 2007).
Diet, Physical Activity, & Overweight
Excess body weight and physical inactivity are often coexisting risk factors that
increase a person’s chance of developing heart disease (Li et al., 2006). Eating a diet full
26
of fruits and vegetables has been shown to be a protection against heart disease (Agewall,
2012). Scholars of a cohort study of 380,296 United States men and women revealed that
adherence to a specified diet of higher intakes of vegetables, legumes, nuts, fruits, whole
grains, fish, and unsaturated fat and lower intakes of red and processed meat, was
associated with a 22% lower heart disease mortality (Mitrou et al., 2007). A similar
dietary pattern of increased vegetables, fruits, legumes, fish, poultry, and whole grains
study was conducted with women nurses in the United States with results of a 28% lower
heart disease mortality; however, a dietary pattern of higher intakes of processed meat,
red meat, refined grains, french fries, and sweets/desserts was associated with a 22%
higher heart disease mortality (Heidmann et al., 2008).
Scholars in recent studies have also shown that exercising regularly can have a
stronger effect on reducing an individual’s risk for heart disease when compared to other
traditional risk factors for heart disease (Joyner & Green, 2009). A higher BMI and lack
of physical activity are strong and independent risk factors for heart disease (Weinstein et
al., 2008). Results from the 2011 national health interview survey showed that 32% of
adults 18 and older do not participate in leisure activities (Schiller, Lucas, & Peregoy,
2012). Inactivity was higher among women than men; African American women were
more likely to be inactive when compared to European American women (Schiller et al.,
2012).
Obesity has been associated with the development of heart disease (Brown,
Fujioka, Wilson, and Woodworth, 2009). According to data from the 2011 national
health survey, African Americans aged 18 and older were less likely to be at a healthy
27
weight; they were more likely to be obese when compared to American Indians, Alaska
Natives, European Americans, and Asian Americans (Schiller et al., 2012). Overall,
African Americans are at a higher rate of obesity (36.8%) when compared to European
Americans (25.2%), and Hispanic Americans (30.7%). African American women are
80% more likely to be overweight or obese than any other ethnic group of women
(Schiller et al., 2012).
Diet, weight, physical inactivity, high blood pressure, and high cholesterol
contributes to the development of heart disease or having a heart attack. According to a
recent study known as the Jackson Study, those participants that are physically inactive,
obese, have diabetes and high cholesterol were more likely to have high blood pressure
(Wyatt et al., 2008). A lifestyle change to a healthier diet and exercise can improve
weight, blood pressure, and blood cholesterol levels. Typically controlling for two or
more risk factors will decrease the chance for the development of heart disease (Godfrey
& Manson, 2008).
Awareness of Heart Disease Risk Factors
Scholars revealed a lack of awareness of heart disease risk factors among
participants in a number of studies reviewed. In 2008, a sample of 50 Middle Eastern
women living in Australia were recruited through a snowball method from community
groups in metropolitan Sydney, Australia to determine their awareness and causal
attributions of risk factors for heart disease. Body weight and blood pressure were
assessed; a questionnaire, and depression, anxiety, and stress scale were administered
(Gholizadeh, Salamonson, Worrall-Carter, DiGiacomo, & Davidson, 2009). Although
28
participants were knowledgeable about the risk factors for heart disease, their awareness
of the seriousness of heart disease was low. More than half of the women possessed at
least two of the risk factors for heart disease (Gholizadeh et al., 2009).
A randomized trial of 128 African American women from an urban community
clinic over a four-month period was conducted (DeSalvo et al., 2005). The participants
completed a multipart survey that included demographic information, socioeconomic
variables, and self-reported history of chronic conditions and the major heart disease risk
factors. Most of the women were middle aged, poorly educated, and below poverty level
income. Two-thirds of the women did not perceive themselves to be at risk for heart
disease nor did they recognize their risk of heart disease when symptoms occurred
(DeSalvo et al., 2005). Seventy-nine percent of the participants had three or more heart
disease risk factors; of these, 63% did not perceive themselves to be a risk for heart
disease (DeSalvo et al., 2005). The underestimation of heart disease risk factors was
associated with those participants who were less educated (DeSalvo et al., 2005).
The awareness of lifestyle risk factors for cancer and heart disease in a single UK
representative sample of men and women was conducted by Sanderson, Waller, Jarvis,
Humphries, and Wardle (2009). The sample consisted of 1,643 White British, 51 Black
British, and 49 Asian British participants between the ages of 16-75 years. Each
participant completed the Omnibus Survey, a monthly multipurpose survey for use by
government and non-profit making organizations. Age, gender, ethnic group, and
education attainment were measured by each participant. A low awareness of lifestyle
risk factors for both cancer and heart disease was shown among the participants. Those
29
individuals with a degree were more aware of the lifestyle risk factors of both cancer and
heart disease when compared to those without a degree. Participants under the age of 31
and over 60 years of age knew fewer lifestyle risk factors for heart disease than those
middle aged individuals. Men identified more lifestyle risk factors for heart disease than
women (Sanderson et al., 2009). Those individuals with a family history of heart disease
were able to identify more lifestyle risk factors for heart disease than those without a
family history of heart disease. Current smokers knew fewer risk factors for heart disease
when compared to nonsmokers. Smoking was identified more as a risk factor for cancer
than heart disease (Sanderson et al., 2009).
Lange et al. (2009) conducted a study to assess Puerto Rican women’s knowledge
of heart disease and the risk factors associated with heart disease. Twelve women aged
36-53 were recruited from two community centers in southern New England. A 16-
question interview guide was developed for the two focus groups. Participants believed
that stress was the main risk factor for heart disease. The women failed to connect high
cholesterol, high blood pressure, smoking, and diabetes as risk factors (Lange et al.,
2009).
A cross sectional study of 127 African American men and women aged 21-75
years was conducted to determine the relationship of demographics to opinions and
knowledge of heart disease, and their knowledge of a selected number of heart disease
risk factors (hypertension, obesity, and dietary intake). These participants completed a
79-item questionnaire about their knowledge of diet, chronic disease associations,
perceptions of the impact of chronic disease, and eating behaviors (Pace, Dawkins,
30
Wang, Person, & Shikany, 2008). Demographic variables (sex, age, race/ethnicity,
education, income, employment status, marital status, and number of children) were
measured. Of the 127 participants, 82% were women and 18% were men. Over half of
the participants had at least some college or a college degree. More women than men
were able to correctly agree that heart disease is the leading cause of death in the United
States (Pace et al., 2008). Older participants were more aware that high blood pressure
and high cholesterol causes heart disease. Most participants believed that overweight
increases individuals’ chances of high blood pressure, diabetes, and heart disease.
Heart Attack Symptoms
Symptoms of a heart attack among women consists of neck, shoulder, upper back,
or abdominal discomfort, fatigue, shortness of breath, weakness, nausea, sweating/hot
sensation, and dizziness (AHA, 2012). Women with heart disease have stated that, prior
to being diagnosed they had experienced some of these symptoms but often delayed
seeking medical attention due to not experiencing the typical symptoms of heart attack
such as arm and/or chest pain (Albarran et al., 2007; Gallagher, Marshall, & Fisher, 2010;
Godfrey & Manson, 2008). Sometimes symptoms women experience appear to them to
be common and less serious health problems such as acid reflux issues, the flu, or normal
aging, and they attempted to self medicate themselves without seeking medical attention
(Almond, Salisbury, & Ziebland, 2012). Some symptoms of a heart attack experienced
by women have been difficult to determine as a cardiac cause. Sweating, for example, is
typically associated with menopause for women; but it is also one of the symptoms of a
heart attack (Almond, et al., 2012).
31
Recently a study was conducted with ten women between the ages of 44 and 82 to
determine their knowledge of heart attack symptoms (Gallagher et al., 2010). These
women were from diverse backgrounds, but majority spoke English and were Australian
born. Four of the women were married, four were divorced or separated, and two were
widows. The majority of the women were either employed or retired. Most of the
women that were interviewed did not recognize the symptoms, mild breathlessness or
perceived indigestion during exercise being symptoms of a heart attack until the
symptoms progressed into more typical symptoms that they were familiar with like chest
pain. A 2005 qualitative study of African American women that were hospitalized for
cardiac symptoms revealed that half of the women did not recognize their symptoms as
cardiac in nature even when typical symptoms of chest pain or arm pains were included
(Banks & Malone, 2005). Women that were interviewed after a cardiac event reported
that symptoms were different from what they expected (King & McGuire, 2007).
Scholars of previous studies have confirmed that cardiac symptoms have been confused
with gastrointestinal causes, respiratory conditions, panic attacks, or stress (Turris &
Finamore, 2008; Turris & Johnson, 2008). If women are unaware of all of the symptoms
of heart disease, it is a strong possibility that they may be less likely to perceive
themselves at risk for heart disease (Almond et al., 2012).
Awareness of Heart Attack Symptoms
Lutfiyya, Cumba, McCullough, Barlow, and Lipsky (2008) conducted a study to
examine the knowledge of heart attack and stroke symptoms among African American
women. Data from the 2003, 2004, and 2005 Behavioral Risk Factor Surveillance
32
System (BRFSS) optional module questionnaire on heart attack and stroke were used for
analyses. The module included 13 questions focused on ascertaining knowledge on early
symptoms of heart attack and stroke. Age, education, and annual household income were
recoded for this analysis. All African American women 18 years of age or older were
included in the analysis. Well over half of the participants did not recognize some of the
attack symptoms (pain or discomfort in the jaw, neck, lightheadedness, or back pain).
The women’s scores were higher in stroke knowledge than heart attack knowledge. The
participants also noted that if they reached out for emergency service help and it turned
out to be not serious, they would appear foolish (Lutfiyya et al., 2008).
Albarran et al. (2007), Gallagher et al. (2010), Godfrey and Manson (2008), and Lutfiyya
et al. (2008) all suggested that women do not recognize heart attack symptoms, therefore
they delay treatment and do not perceive their symptoms to be serious.
Perceptions of Heart Disease
Heart Disease Awareness
Beginning in 1997 and every three years after, the American Heart Association
conducted national random surveys of United States women aged 25 years and older to
determine and follow the trend of awareness and perceptions of heart disease based on
the participants’ age, race, and ethnic background (Christian et al., 2007; Mosca et al.,
2004; Mosca et al., 2013; Mosca et al., 2000; and Mosca et al., 2010). The most recent
results from the Women’s Health Study of 2012 were compared with results from similar
past triennial surveys conducted in 1997, 2000, 2003, 2006, and 2009 (Christian et al.,
2007; Mosca et al., 2004; Mosca et al., 2013; Mosca et al., 2000; and Mosca et al., 2010).
33
The awareness of heart disease as the leading cause of death in women doubled from
1997 to 2012 (Mosca et al., 2013). Even so, the overall awareness of heart disease had
not changed significantly in the past 6 years. “Although the level of awareness among
black women has also doubled since 1997, their level of awareness in 2012 is similar to
that of white women in 1997” (Mosca et al., 2013, p. 7). Over the past 15 years,
improvement of knowledge was noted, but there still remained a gap in awareness among
racial/ethnic minority women. European American women were more likely to identify
heart disease being the leading cause of death (Mosca et al., 2013). Women between the
ages of 25 and 34 had the lowest awareness rate of any age group (Mosca et al., 2013).
European American women represented the majority (more than half) of participants in
each of the Women's Health Study research (Christian et al., 2007; Mosca et al., 2004;
Mosca et al., 2013; Mosca et al., 2000; and Mosca et al., 2010). Mosca et al (2013)
concluded that there needs to be more heart disease awareness research conducted in
minority women.
Crouch and Wilson (2010) conducted an awareness study among Australian
women aged 25-65 years of age. The study evaluated the perceptions of heart disease
using an explorative descriptive design (questionnaire). The majority of the participants
viewed breast cancer as the greatest health risk and leading cause of death among
women. Among the participants only 27% percent of the women noted that heart disease
was the most common cause of death in women in Australia (Crouch & Wilson, 2010).
One of the potential reasons for this perception provided by Crouch and Wilson (2010)
34
was the fact that women underestimate the importance of coronary heart disease and it is
not discussed as much as breast cancer.
A cross sectional study similar to the AHA Women’s Health Study was conducted
using college women aged 25-34 from a private university by Munoz et al. (2010). The
majority of the 320 women were Hispanic American and only 20 were African American.
Each woman completed a 13-item survey on demographic information and awareness of
cardiovascular disease. Scholars revealed that slightly more than half of the total sample
of students reported heart disease and heart attack as the leading cause of death, and less
than one third recognized heart disease as the greatest health problem facing women
(Munoz et al., 2010). This scholar as well as Christian et al. (2007), and Mosca et al.
(2004 and 2000) revealed very similar results of the perceptions of the leading cause of
death and greatest health problem among women. Older African American women had a
significantly lower awareness level than European American women in the study (Munoz
et al., 2010).
Unlike the other previous mentioned studies conducted evaluating the awareness
of heart disease, Winham and Jones (2011) conducted a study to evaluate the knowledge,
attitudes, and practices about heart disease among young African American men and
women aged 18-29 years. Among the participants, 36% were men and 64% were women
and more than half of the participants had some college education. There were more
women than men who had completed college. The researchers used the health belief
model constructs to guide the study design. Participants completed a questionnaire
adapted from the AHA national surveys. Descriptive statistics were used to compare
35
results by age, gender, education level, and health status variables (body mass index,
smoking status, and physical activity). Nearly 40% of the participants had two or more
heart disease risk factors. Obesity (27%) was considered the leading cause of death
followed by heart disease (16%) according to the participants. Participants’ with college
degrees and older individuals were more aware of heart disease being the leading cause
of death in the United States. Of the participants studied, 24% felt that they were not
informed about heart disease. Over 50% of the participants assessed their risk for a heart
attack as low to somewhat at risk (Winham &Jones, 2011). The participants were
knowledgeable of some risk factors of heart disease. The awareness of many of the heart
disease risk factors was higher among men than women. Those individuals with a
college education were more aware of the risk factors when compared to those without a
college education (Winham & Jones, 2011).
A qualitative descriptive study by Arslanian-Engoren (2007) was conducted
among African American, Hispanic American, and European American women from
churches and local community centers. The researcher recruited ten participants between
24 and 63 years old (Arslanian-Engoren, 2007). The scholars found that both European
American and African American women associated heart disease to be a “man’s” disease
even with the awareness efforts made by the American Heart Association. Hispanic
women associated heart disease to death or dying. In contrast to previous studies
reviewed, women from all three races were able to provide the researcher with the risk
factors for heart disease (Arslanian-Engoren 2007).
36
Sadler et al. (2005) conducted a study to determine perceptions of the most
serious health threats for African American women. The participants consisted of 1,055
African American women, who were between 20 and 94 years old. The majority of the
participants were employed and worked outside of their homes. The majority of the
women (80.9%) noted one or more cancers among their top four health problems, while
only 31.4% listed heart disease as one of their top four health problems. Heart disease
was listed first by less than a fifth of the participants. The women aged 50 and older
were more likely to list heart disease as a health problem when compared to women
younger than 50 years of age (Sadler et al., 2005). Education attainment was determined
to have an impact on how women rated health threats. Women with a higher education
were more likely to describe themselves as being well-informed about breast cancer and
diabetes (Sandler et al., 2005). Participants were asked their perceptions of their ability
to influence their own health. The women perceived themselves to be aware of things
they could do to influence their health. Contrary to prior studies conducted by Mosca et
al. (2004, 2000, and 2006), more information about a health issue does not cause
confusion, worry or disinterest. The women believed that early detection of a disease can
make a positive difference in the outcome of a disease (Sandler et al., 2005). Women
were also asked to list their sources of information for health information; the majority of
the women listed the media as a key source of information for breast cancer. Although
the women’s list of the top four most serious health problems facing African American
women matched the CDC’s four most common causes of death report (heart disease,
cancer, cerebrovascular disease, and diabetes), the women’s level of awareness of the
37
seriousness of each was low. The women were unaware that heart disease is the number
one cause of death among African American women. Only 31% of the women listed
heart disease as one of the four most serious health problems (Sandler et al., 2005).
Walter and Emery (2006) conducted a study in which semi-structured interviews
were conducted with thirty participants, fourteen men and sixteen women. The
participants were recruited from two Cambridgeshire, UK general practices. An
electronic search of medical records was used to identify patients 18 years and older, with
at least one first degree relative with cancer, diabetes, or heart disease. All but one of the
participants was European American. The purpose of the study was to compare and
contrast the perceptions of family history across common diseases among patients within
a primary care center. Based on what the participants witnessed from their family
members living with cancer, their perception of cancer was based on what they
experienced with their family members; they perceived cancer as a threat, a serious
disease that inevitably leads to death. Heart disease was also perceived to be serious by
many of the participants, but not as threatening as cancer. Diabetes was perceived to be a
general illness that can be treated with medication management. The cause of cancer was
perceived to be genetic; participants with a family history of cancer noted environmental
or lifestyle causes a trigger. Some participants felt that there was no way to control for
cancer, while others believed that lifestyle and behavioral changes could reduce their risk
for cancer. Lifestyle factors were perceived to be the cause of heart disease among those
participants with a family history of heart disease. Participants believed that if they
modified their lifestyle, they would reduce their risk for heart disease. Participants
38
viewed family history of cancer to be more serious than a family history of heart disease.
Some viewed deaths from heart disease as “a good way to go” (Walter & Emery, 2006, p.
477) and not viewed as a premature death.
Perceived Risks for heart disease
Of the reviewed literature, there were some studies that evaluated the perceived
risks of heart disease among participants. Christian, Mochari, and Mosca (2005)
evaluated the perceived versus the calculated risk of heart disease among 125 women
(45% Hispanic American, 30% European American, 19% African American, and 6%
other) aged 38-86 who underwent screening mammography at the Columbia University
Medical Center. The scholars revealed that the younger aged women underestimated
their risk of heart disease. Half of the women at low risk and two thirds at moderate or
high risk of heart disease perceived themselves to be at a high-risk level (Christian, et al.,
2005). Similar to the study conducted by Christian et al. (2005), another study was
conducted by Smith, Dickerson, Sosa, McKyer, and Ory (2012) to compare 625 college
students’ perceived risk and actual prevalence rate of heart disease. These students
completed a 60-item Internet based survey. The results from the study by Smith et al.
(2012) were consistent with prior findings of Christian et al. (2007) and Mosca et al.
(2010) in that the participants estimated their risk of developing heart disease as low.
Participants perceived themselves to be at a higher risk for breast cancer (Smith et al.,
2012). Wendt (2005) also revealed that participants’ perceived risk of heart disease was
low in a study completed by 133 undergraduate college women students aged 17-46
(49% European American, 19% Hispanic American, 14% African American, 5% Asian
39
American, 1% NA, 12% other). Participants were more worried about getting breast
cancer than heart disease. The findings from the previously mentioned studies are
consistent with the findings of the triennial AHA studies conducted (Christian et al.,
2007; Mosca et al., 2004; Mosca et al., 2013; & Mosca et al., 2010).
Knowledge of heart disease and risk perceptions of heart disease risk was
assessed in a sample of underserved African American men (56%) and women (45%)
patients with high heart disease risk at an inner city rural hospital (Homko et al., 2008).
There were 465 participants aged 18-85. A 29-item questionnaire was created and used
for this study. All participants rated their perception of risk compared with individuals of
their sex and age. The scholars found that the participants had limited heart disease risk
factor knowledge and a low perceived risk of heart disease (Homko et al., 2008).
The perceived risks for diabetes and heart disease among overweight and obese
women was studied by Darlow, Goodman, Stafford, Lachance, and Kaphingst (2012).
The sample consisted of 170 African American, 118 Hispanic American, and 109
European American women (Darlow et al., 2012). Participants completed a survey to
assess their disease risk perception and weight perceptions, as well as risk perceptions of
diabetes and heart disease. There was an overall belief that perceiving oneself
overweight, with the belief that overweight is a health problem, and having a family
history of diabetes is associated with a greater perceived risk for diabetes. Perceived risk
for heart disease was associated with those individuals that perceived themselves to be
overweight.
40
Allen, Purcell, Szanton, and Dennison (2010) conducted a cross-sectional study to
determine the perceptions of cardiac risk among 143 low-income predominantly middle-
aged diabetic African American women at urban community clinics. In order to
participate in the study, the women had to have at least one uncontrolled cardiovascular
disease (CVD) risk factor. Age, sex, race, income, years of formal education, medical
history, health behavior, depressive symptoms, perception of risk for CVD, physical
activity, smoking status, and intake of dietary fat were measured (Allen et al., 2010). The
majority of the women had a high school diploma or General Education Diploma (GED);
29% possessed some technical, college or graduate school education and fewer than 5%
had less than a high school education. The risk factors for CVD were high among all
participants. Almost three-quarters of the participants had three or more out of control
CVD risk factors. The self-rated perception of overall health was relatively good. The
women perceived that they were at risk for developing heart disease within the next five
years (Allen et al., 2010). Those women with poor overall health, greater depressive
symptoms, younger in age, and who had a higher intake of dietary fat and higher body
mass index were associated with increased level of perceived risk for the development of
heart disease (Allen et al., 2010).
In a study by Lefler, Hartford, and Fagan (2009), the perceived risks of heart
disease among older high-risk African American and European American women was
determined using two self-reported instruments. There were 48 African American
women and 48 European American women between the ages of 60-86 in this study.
Participants were chosen if a health expert considered them “high risk” as defined by
41
multiple risk factors for heart disease. Women who experienced histories of previous
cardiac events were excluded. Hypertension, high cholesterol, family history of heart
disease, and diabetes were the most frequent risk factors presented by the participants
(Lefler et al., 2009). African American women had higher body mass index, were less
likely to follow a heart smart diet, had lower incomes, and lower education levels
compared to European American women (Lefler et al., 2009). European American
women perceived themselves to be more at risk for experiencing a heart attack when
compared to African American women. Older high-risk women in this study
underestimated their risk of a heart attack. Overall, these women did not perceive
themselves at high-risk for heart disease and they were more than likely not going to
change their lifestyle behaviors (Lefler et al., 2009).
McKenzie and Skelly (2010) conducted semi-structured interviews with African
American women aged 30-65 with type 2 diabetes from nine counties in the southeastern
United States. The study was conducted in order to determine the participants’
perceptions of their risk for heart disease. The participants revealed in the interviews that
they did not perceive themselves to be at risk for heart disease. The women were
unaware that diabetes enhanced the risk for heart disease. Even when the women were
diagnosed with hypertension and medication was prescribed, they still did not perceive
themselves to being at risk for heart disease; they thought that if they took the
medication, their hypertension would go away and they would be without risk (McKenzie
& Skelly, 2010).
42
Health Belief Model
Theories are used to explain behavior as well as to examine ways to achieve a
behavioral change (Glanz, Rimer, &Viswanath, 2008; Hochbaum, 1958; Rosenstock,
1974). Life decisions are made everyday by people and are typically made according to
how the decisions will affect their daily routine, family environment, or financial well-
being. The main concept of the health belief model (HBM) is that health behavior is
influenced by personal beliefs (Glanz et al., 2008; Hochbaum, 1958; Rosenstock, 1974).
The HBM consist of six constructs: perceived susceptibility, perceived severity,
perceived benefits, perceived barriers, cues to action, and self efficacy.
In previous research, the HBM has been used to determine individuals’
perceptions of heart disease and its impact on their life (Ford et al., 2009; Jones et al.,
2006; & Wang et al., 2009). African American women’s perceptions of susceptibility
and the seriousness of heart disease were studied by Jones et al. (2006). The association
between the women’s perceptions of heart disease and their socioeconomic status, age,
and knowledge of heart disease risk factors were also examined (Jones et al., 2006). The
HBM was used in another study to examine African American women’s perceptions of
personal and environmental factors of hypertension (Ford et al., 2009). The HBM has
shown also to be effective when comparing risk perceptions and beliefs across common
chronic diseases among healthy adults from primary care practices (Wang et al., 2009).
I used the HBM constructs: perceived susceptibility, perceived severity, perceived
benefits, perceived barriers, and cues to action to examine African American women’s
43
perceptions of their personal risk for heart disease and their awareness of the seriousness
of heart disease (see Table 1). The construct perceived susceptibility in this study
referred to an individual’s perceptions of the risk of developing heart disease. Three
questions from the AHA Women’s Health Study were used to measure participants’
perceived susceptibility for heart disease. Participants’ perceived severity was measured
by their perceptions of the seriousness of heart disease to cause complications of their
lifestyle (see Table 1). Both perceived susceptibility and perceived severity have strong
cognitive components and are partly dependent on knowledge (Rosenstock, 1974;
Gautam, 2012).
An individual’s belief of the effectiveness of various actions available in reducing
the disease threat were measured as their perceived benefits. People tend to make
decisions and changes in life based on how they will benefit them. Perceived benefits
were measured by the answers received from the participants’ feedback on how likely
they would be to becoming involved with heart health as an issue if programs existed.
Perceived barriers are considered the things or actions that would make it difficult to
make a behavior change. Perceived barrier is considered to be the most significant
construct in determining behavior change (Janz & Becker, 1984; Champion & Skinner,
2008). Participants were asked what barriers they thought prevented them from leading a
heart healthy lifestyle.
Lastly, events, people, or things that will move an individual to make a behavioral
change were considered cues to action. This construct was measured by asking
44
participants what they have done to improve their own health that prompted them to take
action. At the end of the survey, participants were told that heart disease is the leading
cause of death and were asked what they would likely do next to become better aware of
heart disease.
Gap in Research
Researchers have made a great deal of progress in increasing awareness of heart
disease in women over the past 15 years (Christian et al., 2007). Heart disease can be
prevented if there is an awareness of the risk factors involved. Most of the risk factors
can be controlled by making good lifestyle decisions (Healthy People 2020, 2012).
Although progress has been made, there is little known about the awareness level of heart
disease among African American women of all ages. Based on the population samples of
the previous studies reviewed, the majority of the participants was European American
women even though, according to Sherrod (2011), African American women are
disproportionately at risk for developing heart disease.
Although the existing research results have shown an enhancement of the
awareness of heart disease among women, little research has been conducted on the
awareness of heart disease risk factors, symptoms of heart attack, and perceptions of
personal risks for heart disease as it may relate to the studied variables (age, income,
education, state of residency, and family history) among African American women.
Further research is needed to determine the relationship between the studied variables and
what factors influence the awareness and perceptions of perceived risk for heart disease
among African American women of all ages. This study will add to previous research
45
studies conducted. An online survey potentially attracted larger participation due to
convenience of not having to set a time or place to complete the questionnaire. Because
African American women are more susceptible to developing and dying from heart
disease compared to men or women of other races (AHA, 2012), surveying this
population to determine their perceptions/perceived risks of heart disease was important
and adds more insight to heart disease awareness level among African American women.
Summary
In this literature review, I explored research on heart disease risk factors, heart
attack symptoms, perceptions, perceived risks, and awareness level of heart disease. I
also explored studies involving women specifically African American women and their
perceptions of heart disease. Heart disease is the number one cause of death among
United States women. There have been a number studies conducted on the perceptions of
heart disease among women since the AHA Women’s Health Study started in 1997. Over
the past 15 years, heart disease knowledge has improved among women overall, but there
remains a gap of awareness among racial/ ethnic minority women (Christian et al., 2007;
Mosca et al., 2004; Mosca et al., 2013; & Mosca et al., 2010).
Although there have been a number of studies conducted examining heart disease
knowledge and awareness, what seems to be missing from the literature were studies
conducted specifically with African American women. African American women have
more heart disease risk factors than European American women (Heidenreich et al.,
2011) and are at a greater risk for developing and dying from heart disease (OMH, 2012).
The majority of the participants of the previously reviewed studies were European
46
American women. According to Mosca et al. (2013) there needs to be more heart disease
awareness conducted in minority women.
The perceptions of heart disease among African American women were examined
in this study. In this study snowball sampling through emails, LinkedIn, and Facebook
were chosen to recruit African American women aged 18 and older in an effort to have a:
(a) sample of participants from different places of residence and regions, (b) large
number of participants, and (c) wider diversity of African American women of various
ages, income levels, and education backgrounds. Because there is little known about the
awareness level of heart disease among African American women of all ages, it was
important to target this group of individuals. I discuss the research design and rationale,
setting and sample, instrumentation and materials, data collection, and data analysis in
detail in Chapter 3.
47
Chapter 3: Research Method
Introduction
The perceptions of heart disease among African American women as it pertains to
risk factors and heart attack symptoms were examined in this research study. The
increased morbidity and mortality rate of heart disease among African American women
justified the need for more focus on this population. In this chapter, I provide a
description of the research design and justification for why the design was chosen. Next,
I provide a description of the sample, with selection criteria of the study participants. I
also provide an overview of the instrument chosen, as well as a detailed description of
each variable in the study. Lastly, the data collection process, data analysis, and ethical
consideration are discussed.
Research Design and Rationale
A descriptive, correlational, quantitative, survey research design was used for this
study. Data were collected using a self-administered online survey. According to Babbie
(2011), surveys are used for collecting original data and measuring orientations of a
population. Quantitative studies have been consistently used to examine awareness of
heart disease among women (Adams et al., 2010; Christian et al., 2005; Christian et al.,
2007; Crouch & Wilson, 2010; Guo, He, Walton, & Zhang, 2012; Jones & Winham,
2011; Mosca et al., 2004; Mosca et al., 2013; Mosca et al., 2000; Mosca et al., 2010;
Wendt, 2005).
A quantitative survey design was chosen based on the research problem, the
purpose, and research questions of this study. The purpose of this research was to
48
determine the overall knowledge and health beliefs about heart disease among African
American women. A quantitative survey research study is the most appropriate approach
to use when characteristics, opinions, attitudes, or behaviors of a population are being
studied. Quantitative survey research is also used when descriptive information is being
gathered in a survey/questionnaire format (Babbie, 2011). A quantitative design is also
generally chosen when a researcher wants to do a correlational study to examine
relationship/associations between variables (Babbie, 2011). The independent variables
heart disease risk factors, heart attack symptoms, and perceived risk for heart disease
were tested to determine whether there was an association with the dependent variable of
heart disease awareness among the participants. The covariate variables age, income,
education, and family history of heart disease are descriptive information that allowed me
to gain more information about the association each may have on the awareness of heart
disease among the participants. The advantages of a descriptive correlational quantitative
survey design is that researchers can collect large amounts of data and this method
provides an evaluation of strength and direction of association between the variables
being studied (Babbie, 2011). Additionally, this design provided the advantage of low
cost, convenience for participants, and flexibility of completion time.
A quantitative questionnaire was used to collect data regarding African American
women’s overall knowledge and perceptions of heart disease. Descriptive data analysis
was calculated to determine participants’ knowledge of risk factors for heart disease,
symptoms of a heart attack, awareness of heart disease, and demographics. Data analysis
49
was also calculated to determine a correlation coefficient that may exist between the
variables of the study.
Setting and Sample
Snowball sampling was used to recruit participants for this study. Snowball
sampling is defined as “a sampling method in which you sample participants based upon
referral from prior participants” (Trochim & Donnelly, 2008, p. G-8). Snowball
sampling is a method of recruiting that is usually used when the researcher is trying to
reach a population that is hard to find (Trochim & Donnelly, 2008). I chose snowball
sampling to connect to participants through the use of online tools alone. These women
were African American, English speaking, 18 years and older, had an e-mail address, and
had access to an electronic device with Internet connection. This sample was chosen
because (a) African American women are more susceptible to developing heart disease
when compared to any other ethnic group, (b) African American women have a higher
prevalence of heart disease, (c) African American women are less likely to be aware of
the risk factors for heart disease and symptoms of a heart attack, and (d) there is little
known about African American women’s awareness and perceptions of their personal
risk for heart disease.
According to the U.S. Census Bureau (2013), there are an estimated 15,302,276
African American women 18 years of age or older residing in the United States. A power
analysis was conducted to determine the sample size needed for this study. Probability
level alpha confidence interval was set at 0.05 level of significance with a confidence
level of 95%. This means that there is a 5% chance of making a Type I error or rejecting
50
a null hypothesis when it is in fact true. The power of a statistical test (1-β) was set at
0.80. This means there is a 20% chance of making a Type II error or incorrectly
accepting a null hypothesis when in fact it is false. The effect size (degree of association
between two variables (population and sample) was set between 0.2 – 0.4. A sample size
calculator from Creative Research Systems (2012) indicated that the sample size for a
population of 15,302,276 was 384.
The recruiting process of participants consisted of using e-mail, LinkedIn, and
Facebook to connect with potential women participants in the United States who met the
inclusion criteria. E-mail, LinkedIn, and Facebook invitations were sent to all of my
family, friends, and associates who meet the criteria for participation in the study. This e-
mail contained the Google docs web link. I included my study on my LinkedIn and
Facebook page and encouraged eligible participants to respond to the online survey, as
well as forward my invitation to other potential eligible participants.
Instrumentation and Materials
The American Heart Association 2012 Women’s Health Study survey (see
Appendix B) was used to determine participants’ overall knowledge and beliefs about
heart disease. Permission to use this survey was obtained from the author (K. Robb,
personal communication, June 9, 2013; see Appendix A). The survey addressed the four
research questions. Participants’ knowledge of heart disease risk factors and heart attack
symptoms was measured by the participants’ answers to questions in Section 3 of the
survey. Their perceptions of personal risks for heart disease were measured by the
participants’ answers to questions in Section 6 of the survey. The awareness level of
51
heart disease was measured by participants’ answers to questions in Section 3 of the
survey. Each variable was measured by separate survey questions (see Table 2; see
Appendix B).
Table 2
Summary of Survey Questions that Address Variables
RQ Variables
Question(s) from AHA survey
Directions
Independent
Variable:
Knowledge of
heart disease
risk factors
Based on what you know, what are the major causes of heart
disease?
List your answer.
Independent
Variable:
Knowledge of
heart attack
symptoms
Based on what you know what warning signs do you associate
with having a heart attack?
List your answer.
Independent
Variable:
Participants’
perceptions of
personal risks
for heart
disease
Please tell me the extent to which you worry about getting
heart disease. Do you worry a lot, worry a little, or do you not
worry at all about it
Do you worry a lot, worry a
little, or do you not worry at
all about it?
Which of the following are the biggest barriers preventing you
from leading a heart healthy lifestyle? (If participants select
this answer)
Select if apply: I don’t
perceive myself to be at risk
for heart disease.
Dependent
Variable:
Participants’
awareness level
How informed are you about heart disease in women?
Very well informed, well-
informed, moderately
informed, not at all
informed.
Covariate
Variables:
Age, income,
Education level,
state of
residency, and
family history
What is your age? What is the highest level of education you
have completed? Which of the following best clarify the
income of your family household? Do you have a family
history of heart disease?
List your answer.
52
The AHA Women’s Health Study has been used in previous studies from the
AHA and other researchers. Although the reliability and validity has not been reported in
the literature, the survey has been repeated with consistent results over a 15-year time
span with the majority of the studies conducted using only women as participants (Adams
et al., 2010; Albert et al., 2013; Christian, Mochari, & Mosca, 2005; Christian, Mosca,
Rosamond, & White, 2007; Crouch & Wilson, 2010; Dolor, Mochari-Greenberger,
Mosca, Newby, & Robb, 2010; Fabunmi et al., 2012; Jones & Winham, 2011;
Thanavaro, 2005; Wendt, 2005). Stability and consistency of results can be considered
measures of reliability (Donnelly & Trochim, 2008). The survey has substantial content
and face validity of awareness, perceptions, and knowledge of heart disease in women
(McCoy, 2008).
Data Collection
An online survey of 44 questions from the Women’s Health Study was conducted
using Google docs to collect the data. Participants’ awareness of heart disease was the
dependent variable and was collected in this study. Participants’ knowledge of heart
disease risk factors (diabetes, high blood pressure, high cholesterol, cigarette smoking,
poor diet, physical inactivity, and overweight), heart attack symptoms (chest pain,
fatigue, nausea, pain in the shoulders, neck, or arms, shortness of breath, and tightness of
the chest), and the perceptions of their personal risks for heart disease were the
independent variables that were collected in this study. The demographic variables that
were collected were age, income, education, state of residency, and family history. These
variables were the covariate variables of this study.
53
Participants completed the survey at a computer and location of their choice. This
method of distribution was chosen to make it more convenient for women to complete on
their own time. An introductory page was included in my e-mail, LinkedIn, and
Facebook page that, explained my study, informed individuals that their participation was
voluntary, included the online survey, and included my contact information (see
Appendix C).
The responses were anonymous and kept securely. The completion and return of
the survey indicated consent to participate in the study and acknowledgement that the
participant met the inclusion criteria. On the concluding page of the survey, there were
links to relevant information on the American Heart Association, Centers for Disease
Control and Prevention, and National Heart, Lung, and Blood Institute web pages to
encourage participants to increase their awareness of heart disease. Google docs stored
the data and the results were transferred to SPSS for data analysis.
Data Analysis
Participants inputted their responses using the online survey developed in Google
docs. The data results collected from Google docs were exported to an Excel spreadsheet
and coded by each survey item and then transferred into the Statistical Package for the
Social Science (SPSS) software for data cleaning. Statistical analysis was completed
using version 21 of SPSS (SPSS, Inc., 2010). Descriptive statistics was calculated for
mean, standard error, and minimum and maximum values for each item of the survey and
for all demographic and personal variables. Each of the HBM constructs was calculated
using descriptive statistics as well. The linear multiple regression test was used because:
54
(a) it is often used when association between variables are needed to be determined, (b)
there are more than two independent variables (heart disease risk factors, heart attack
symptoms, and perceptions of personal risks for heart disease), (c) the independent
variables were considered either nominal or interval data, (d) the dependent variable
(heart disease awareness) was interval (Triola, 2008). The importance of interval data is
that the numbers have real meaning, the numbers have a real order, and the difference
between the numbers are measurable (Triola, 2008). Self reported awareness of heart
disease was scored on a four point Likert scale (very well informed, well informed,
moderately informed, not at all informed). This was meaningful for the determination of
the awareness level of participants and in analyzing the association between the
independent and dependent variables.
Table 3
A List of Criterion and Predictor Variables with Level of Measurement
Dependent variable
Independent variables
Level of Measurements
Self- reported awareness of
heart disease
(Interval)
Knowledge of heart disease
risk factors
Nominal
Knowledge of heart
attack symptoms
Nominal
Perceptions of personal
risks for heart disease
Interval
Age
Interval
Income
Interval
Education
Interval
State of residency
Nominal
Family history
Nominal
I used linear multiple regression to analyze the association linking the
independent variables heart disease risk factors, heart attack symptoms, and perceptions
55
of personal risks for heart disease, and the dependent variable heart disease awareness.
For coding purposes, the AHA provided a list of risk factors and heart attack symptoms;
this is how I knew that the selected items were indicators of the variables. I determined
the mean average of the dependent variable scores from the four point Likert scale in the
statistical analysis based on the range of scores. Then I determined low, medium, or high
level of awareness of heart disease. An alpha level of 0.05 was set to determine the level
of statistical significance. The general formula for linear multiple regression is as
follows:
Awareness of heart disease = a + b1HDRF + b2HAS + b3PPRFHD + b4age + b5income +
b6education + b7family history
Research Question 1
Is there an association between African American women’s knowledge of heart
disease risk factors (diabetes, high blood pressure, high cholesterol, cigarette smoking,
poor diet, physical inactivity, and overweight) and awareness of heart disease? This
question was measured by item 23 of the Women’s Health Study survey, which measures
the participant’s knowledge of heart disease risk factors. Participant’s awareness of heart
disease was measured by item 15 of the survey. A linear multiple regression test was
performed to determine the association between knowledge of risk factors and awareness
of heart disease.
56
Research Question 2
Is there an association between African American women’s knowledge of heart
attack symptoms (chest pain, fatigue, nausea, pain in the shoulders, neck, or arms,
shortness of breath, and tightness of the chest) awareness of heart disease? This question
was measured by item 17 of the Women’s Health Study survey, which measures the
participant’s knowledge of heart attack symptoms. Participant’s awareness of heart
disease was measured by item 15 of the survey. A linear multiple regression test was
performed to determine the association between knowledge of heart attack symptoms and
awareness of heart disease.
Research Question 3
Is there an association between African American women’s perceptions of
personal risks for heart disease and awareness of heart disease? This question was
measured by items 3 and 31 of the Women’s Health Study survey, which measures the
participant’s perceptions of personal risks for heart disease. Participant’s awareness of
heart disease was measured by item 15 of the survey. A linear multiple regression test
was performed to determine the association between perceptions of personal risks for
heart disease and awareness of heart disease.
Research Question 4
Is there an association between African American women’s demographic
background (age, income, education, state of residency, and family history of heart
disease) and awareness of heart disease? Items 40-44 from the Women’s Health Study
57
measured this research question. Participant’s awareness of heart disease was measured
by item 15 of the survey. A linear multiple regression was performed to determine the
association between covariate variables and awareness of heart disease.
Threats to Validity
The lack of randomly selecting the sample of participants was a potential threat
to external validity; there was no guarantee that the sample would draw a fair
representative sample of African American women aged 18 and older. The need for
participants to have access to electronic devices and Internet availability to complete the
survey was potentially a threat to external validity because this method eliminates
women without access to electronic devices and Internet availability from participating
in the study. Therefore the results could not be generalized to all African American
women. According to Trochim and Donnelly (2008), one way to improve external
validity is to conduct the study in a variety of places, with different people, and at
different times. In an effort improve external validity, snowball sampling through
e-mails, LinkedIn, and Facebook were chosen to recruit participants from different
places of residence and regions, to recruit a large number of participants, and to recruit a
wider diversity of African American women of various ages, income levels, and
education backgrounds.
Protection of Human Participants
In this study, the responses from each participant were kept confidential. Each
participant received a link to the survey either through an e-mail, LinkedIn, or Facebook
58
invitation. The survey did not record the participants’ names or any other personal
information to ensure that privacy was maintained. Participation was voluntary;
participants could stop participating at any time. The completion and return of the survey
online indicated acknowledgement from the participants that they were consenting to
participate in the study. Google docs maintained the data drawn from the survey. The
link to the data from Google docs was limited to my access only. The e-mail link with
the survey was available for completion for four weeks or until a sample size of 384 was
reached. Once the desired sample size was obtained, the e-mail link with the survey was
removed. I obtained Walden Institutional Review Board approval prior to conducting
this research to ensure that all ethical issues had been addressed. It is recommended that
analyzed data be kept between five to ten years (Creswell, 2009; Sieber, 1998). I will
shred and destroy the data after six years. A copy of the approval notification is included
in the appendices (see Appendix F).
Summary
In this quantitative study, I used a descriptive correlational survey design. The
AHA Women’s Health Study was the survey instrument used to examine the awareness,
perceived risk, and perceptions of heart disease among African American women. A
snowball sampling of African American women aged 18 and older were recruited for this
study. The target sample number was 384. After receiving approval from the Walden
Institutional Review Board; data collection for this study began. For data analysis,
descriptive statistics was conducted for all of the variables. To answer the first research
question (Is there an association between African American women’s knowledge of heart
59
disease risk factors [diabetes, high blood pressure, high cholesterol, cigarette smoking,
poor diet, physical inactivity, and overweight] and awareness of heart disease?); a linear
multiple regression test was conducted to analyze the association between participants
knowledge of heart disease risk factors and awareness of heart disease. To answer the
second research question (Is there an association between African American women’s
knowledge of heart attack symptoms [chest pain, fatigue, nausea, pain in the shoulders,
neck, or arms, shortness of breath, and tightness of the chest] and awareness of heart
disease) linear multiple regression test was conducted to analyze the association between
participants knowledge of heart attacks symptoms and awareness of heart disease. A
linear multiple regression test was also conducted to analyze the association between
participant’s perceptions of personal risks for heart disease and awareness of heart
disease, in order to address research question three (Is there an association between
African American women’s perceptions of personal risks for heart disease and awareness
of heart disease?). Lastly, to answer research question four (Is there an association
between African American women’s demographic background [age, income, education,
state of residency, and family history of heart disease] and awareness of heart disease?) a
linear multiple regression test was conducted to analyze the association between the
covariate variables (age, income, education, state of residency, and family history of heart
disease) and awareness of heart disease. In the next chapter, the results of the data
analysis are presented.
60
Chapter 4: Data Analysis
Introduction
The purpose of this study was to determine the overall knowledge and health
beliefs about heart disease among African American women within the United States. In
this chapter, I will provide the data results from the participants’ completion of the
Women’s Health Study survey. First, I will describe the data collection process and
provide descriptive data of the participants. Next, I will provide the results of
participants’ knowledge of heart disease risk factors, heart attack symptoms, perceptions
of personal risks for heart disease, and awareness of heart disease based on the AHA
Women’s Health Study survey. I will also provide an overview of how the HBM
constructs perceived susceptibility, perceived severity, perceived benefits, perceived
barriers, and cues to action) were measured in this study. Lastly, I will describe how the
statistical test linear multiple regression was used to answer the research questions: Is
there an association between African American women’s knowledge of heart disease risk
factors (diabetes, high blood pressure, high cholesterol, cigarette smoking, poor diet,
physical inactivity, and overweight) and awareness of heart disease? Is there an
association between African American women’s knowledge of heart attack symptoms
(chest pain, fatigue, nausea, pain in the shoulders, neck, or arms, shortness of breath, and
tightness of the chest) and awareness of heart disease? Is there an association between
African American women’s perceptions of personal risks for heart disease and awareness
of heart disease? Is there an association between African American women’s
61
demographic background (age, income, education, and family history of heart disease)
and awareness of heart disease?
Data Collection
On December 1, 2013, e-mail, Facebook, and LinkedIn invitations of the survey
were sent to female family, friends, and associates who were African American, English
speaking, 18 years of age or older, had an e-mail address, and had access to an electronic
device with Internet connection. The invitation also encouraged invitees to forward the
invitation to other potential eligible family, friends, and associates. The snowball
sampling helped in recruiting participants. On February 5, 2014, the survey link was
deactivated due to reaching the target sample size of 384. The data collection process
took 8 weeks and 2 days with a final number of 389 survey responses (see Figure 1). The
data results were exported to an Excel spreadsheet, coded by each survey item, and
transferred into version 21 of SPSS software for data cleaning.
Figure 1. Number of Daily Completed Responses
0!
5!
10!
15!
20!
25!
12/1/13!
12/8/13!
12/15/13!
12/22/13!
12/29/13!
1/5/14!
1/12/14!
1/19/14!
1/26/14!
2/2/14!
Number!
of!
Response
62
Descriptive Data of Participants
There are approximately 15,302,276 African American women 18 years of age or
older residing in the United States (U.S. Census of Bureau, 2013a). A power analysis
was conducted, and I determined the sample size needed for this study was 384
participants, in order to accept the outcome of the statistical test with a 95% confidence
level and confidence interval of 5. The demographic variables in the study were age (18-
29, 30-49, 50-69, and 70 and older), education (some high school, high school graduate,
trade/technical/vocational/training, college graduate, some postgraduate work, and
postgraduate degree), income (less than $10,000, $10,000-$29,000, $30,000-$49,000,
$50,000-$69,000, and $70,000 and greater), family history (yes or no), and state of
residency within the United States.
The age group between 30- and 49-years-old represented the majority of the
participants (63%). There were 23.4% of the women between the age of 50-69, 11.3% of
the women were between the age of 18-29, and only 2.3% of the women were aged 79
and older (see Table 4). Over 80% of the participants were highly educated with 50% of
the women obtaining a postgraduate degree and 20.8 % of the women obtaining a college
degree (see Table 5). The range of income of the women was less than $10,000 to
$70,000 or greater, with 39.8% of the women’ household being $70,000 or greater (see
Table 6). There was at least one representative from 33 states within the United States
that completed the survey. Nearly 60% of the women were residents of Georgia (see
Table 7). There were 211 (54.2%) women who reported having a family history of heart
disease (see Table 8).
63
Table 4
Age
Age
Frequency
Percent
18-29
44
11.3
30-49
245
63.0
50-69
91
23.4
79 and older
9
2.3
Total
389
100.0
Table 5
Educational Level
Education Level
Frequency
Percent
some high school
2
.5
high school graduate
31
8.0
trade/technical/vocational/training
40
10.3
college graduate
81
20.8
some post graduate work
39
10.0
post graduate degree
196
50.4
Total
389
100.0
Table 6
Household Income
Household Income
Frequency
Percent
less than $10,000
8
2.1
$10,000-$29,000
45
11.6
$30,000-$49,000
87
22.4
$50,000-$69,000
94
24.2
$70,000 and greater
155
39.8
Total
389
100.0
64
Table 7
State of Residency
State of Residency of Participants
Frequency
Percent
Alabama
28
7.2
Arizona
2
.5
Arkansas
1
.3
California
7
1.8
Colorado
4
1.0
Connecticut
1
.3
Delaware
1
.3
District of Columbia
5
1.3
Florida
8
2.1
Georgia
232
59.6
Illinois
6
1.5
Indiana
6
1.5
Iowa
1
.3
Kentucky
5
1.3
Louisiana
5
1.3
Maryland
9
2.3
Massachusetts
3
.8
Michigan
8
2.1
Mississippi
7
1.8
Missouri
3
.8
New Hampshire
1
.3
New Jersey
1
.3
New York
5
1.3
North Carolina
7
1.8
Ohio
13
3.3
Oregon
2
.5
Pennsylvania
3
.8
South Carolina
4
1.0
Texas
3
.8
Virginia
4
1.0
Virgin Island
2
.5
Washington
1
.3
New Mexico
1
.3
Total
389
100.0
65
Table 8
Family History of Heart Disease
Family History of HD
Frequency
Percent
Yes
211
54.2
No
178
45.8
Total
389
100.0
Results of Knowledge, Perceptions, and Awareness of Heart Disease
The American Heart Association Women’s Health study survey was developed
for the purpose of determining U.S. women’s awareness, knowledge, and perceptions of
heart disease. In this study, survey questions from Sections 3 and 6 (see Appendix B)
were used to evaluate participants’ knowledge of heart disease risk factors, knowledge of
heart attack symptoms, perceptions of personal risks for heart disease, and awareness of
heart disease. The seven controllable risk factors identified in this study (diabetes, high
blood pressure, high cholesterol, smoking, poor diet, physical inactivity, and overweight)
were used to measure the participants’ knowledge of the risk factors for heart disease
Knowledge of Heart Disease Risk Factors
The results showed that 24% of the women listed either diabetes, high blood
pressure, high cholesterol, smoking, poor diet, physical inactivity, or overweight as a risk
factor for heart disease. Almost 39% of the women listed at least two of the risk factors
for heart disease, 14.9% of the women listed three of the risk factors, 6.2% of the women
listed four of the risk factors, and 4.1% of the women listed five of the risk factors for
heart disease. Less than 1% of the women were able to list all seven of the controllable
heart disease risk factors. Over 10% of the women either did not know any risk factors or
66
listed other factors for heart disease. Some of the factors that were mentioned by less
than 5.7% of the women were hereditary, drinking alcohol, stress, blockage, clogged
arteries, and depression (see Table 9).
Table 9
Knowledge of Risk Factors for Heart Disease
Risk Factors
Frequency
Percent
Diabetes
2
.5
High Blood Pressure
7
1.8
High Cholesterol
14
3.6
Smoking
5
1.3
Poor Diet
38
9.8
Physical Inactivity
5
1.3
Overweight
22
5.7
Listed 2 of the Risk factors
151
38.8
Listed 3 of the Risk factors
58
14.9
Listed 4 of the Risk factors
24
6.2
Listed 5 of the Risk factors
16
4.1
Listed 6 of the Risk factors
1
.3
Listed 7 of the Risk Factors
1
.3
Listed other Risk Factors
22
5.7
Don't Know
23
5.9
Total
389
100.0
Knowledge of Heart Attack Symptoms
The knowledge of six symptoms of a heart attack (chest pain, fatigue, nausea,
pain in the shoulder, neck, or arm, shortness of breath, and tightness of chest) was
measured by the identified heart attack symptoms on the original AHA Women’s Health
Study. Chest pain, fatigue, nausea, pain in the shoulder, neck, or arm, shortness of
breath, or either tightness of chest were listed among 32.6% of the women. Most of the
women (34%) listed two of the heart attack symptoms, 16.3% of the women listed three
of the heart attack symptoms, 2.8% listed four of the heart attack symptoms, and less than
1% (1) of the women listed all six of the heart attack symptoms. Only 4.1% of the
67
women didn’t know any of the heart attack symptoms. Some of the women (9.5%)
referenced other symptoms to having a heart attack (see Table 10).
Table 10
Knowledge of Heart Attack Symptoms
Heart Attack Symptoms
Frequency
Percent
Chest Pain
61
15.7
Fatigue
7
1.8
Nausea
4
1.0
Pain in shoulder, neck, or arm
21
5.4
Shortness of breath
21
5.4
Tightness of chest
13
3.3
Listed 2 of the HA symptoms
134
34.4
Listed 3 of the HA symptoms
63
16.2
Listed 4 of the HA symptoms
11
2.8
Listed 5 of the HA symptoms
1
.3
Listed other HA symptoms
37
9.5
Don't Know
16
4.1
Total
389
100.0
Perceptions of Personal Risks for Heart Disease
The women’s perceptions of personal risks for heart disease was measured by the
survey question: tell me the extent to which you worry about getting heart disease. The
women selected worry a lot, worry a little, or do not worry at all. Nearly half of the
women (46.5%) worry a little about getting heart disease, 29.6% worry a lot about getting
heart disease, and 23.9% of the women do not worry at all about getting heart disease
(see Table 11).
68
Table 11
Perceptions of Personal Risks for Heart Disease
Perceptions of Personal Risks for Heart Disease
Frequency
Percent
Worry a lot
115
29.6
Worry a little
181
46.5
Do not worry at all
93
23.9
Total
389
100.0
Awareness of Heart Disease
The awareness of heart disease among the women was measured by their answer
to the survey question: how informed are you about heart disease in women? The
variables for this question were recoded as very/well informed to be considered high
level of heart disease awareness, moderately informed to medium level of awareness, and
not at all informed to low level of heart disease awareness. Half (50.6%) of the women
have a medium level of heart disease awareness. Slightly under half of the women have a
high level (32.1%) compared to 17.2% of the women with a low level of heart disease
awareness (see Table 12).
Table 12
Awareness of Heart Disease
Awareness of Heart Disease
Frequency
Percent
1.00
125
32.1
2.00
197
50.6
3.00
67
17.2
Total
389
100.0
69
Health Belief Model Constructs
Generally, people make life decisions according to how they impact their daily
routine, family environment, or financial wellbeing. The main concept of the HBM is
that health behavior is influenced by personal beliefs (Glanz et al., 2008); for this reason
the HBM constructs perceived susceptibility, perceived severity, perceived benefits,
perceived barriers, and cues to action were measured in this study. The five constructs
were evaluated using questions from Sections 1, 2, 6, and 8 of the survey (see Appendix
B). A more in depth discussion of each construct will be discussed in Chapter 5.
Perceived Susceptibility
The women’s perceptions of their risks of developing heart disease was measured
by participants’ responses from three of the survey questions and was considered their
perceived susceptibility. Only about 30% of the women worried a lot about getting heart
disease indicating that most of the participants were not seriously concerned about their
risk (see Table 13).
70
Table 13
HBM Perceived Susceptibility Construct
Please tell me the extent to which you worry about getting
each of the following health conditions: Heart Disease
Frequency
Percent
Worry a lot
115
29.6%
A little
181
46.5%
Not at all
93
23.9%
Total
389
100.0
How much do you think your overall outlook on life impacts
the following: your likelihood to develop a serious illness
like heart disease
Frequency
Percent
A great deal
30
7.7
Very much
53
13.6
Some
194
49.9
Not at all
112
28.8
Total
389
100.0
Which of the following are the biggest barriers preventing
you from leading a heart healthy lifestyle? Please only select
up to 5 barriers
Frequency
Percent
I don’t perceive myself be at risk for heart disease
56
14.4
I don’t think I need to changing my behavior will reduce my
risk of developing heart disease
6
1.5
None of these, I lead a heart healthy lifestyle
123
31.6
Perceived Severity
Perceived severity was considered the women’s perception of the seriousness of
heart disease to cause complications of their lifestyle. The construct was measured by the
women’s answers to two questions (see Table 14). Overall 60% of the women thought
either a great deal or very much of how successfully managing heart disease would
impact their overall outlook on life if they developed heart disease. This is an indication
that the majority of the women thought that heart disease would have an altering impact
on their lifestyles.
71
Table 14
HBM Perceived Severity Construct
How much do you think your overall outlook on life impacts
the following: your likelihood to successfully manage a
serious illness like heart disease if you develop it
Frequency
Percent
A great deal
98
25.2
Very much
138
35.5
Some
111
28.5
Not at all
42
10.8
Total
389
100.0
Which of the following are the biggest barriers preventing
you from leading a heart healthy lifestyle? Please only select
up to 5 barriers
Frequency
Percent
My family/friends have told me that I don’t need to change
3
.8
My health care professional doesn’t think I need to worry
about heart disease
13
3.3
God or some higher power ultimately determines my health
26
6.7
Perceived Benefits
The women’s perceived benefits of reducing the threat of heart disease was
measured by the answers received on how likely they would become involved with heart
health as an issue if programs existed. Over 50% of the women chose the response that if
a medical research program existed, they would become involved. Even more women
(60%) said they would become involved in a program that educated women about heart
disease. A program that educated women on how to get the best care possible from the
healthcare system appeared to be more important than a medical research or heart disease
education program among 70% of the participants (see Table 15). Overall, more than
half of the women felt that they would become involved with heart health programs if
they existed as a way to reduce the threat of heart disease.
72
Table 15
HBM Perceived Benefit Construct
How likely are you to become involved with “heart health” as
an issue if the following kinds of programs existed: A medical
research program to ensure that the ways in which women
experience heart disease are adequately addressed
Frequency
Percent
Definitely would
73
19.0
Probably would
154
40.0
Might or might not
102
26.3
Probably would not
47
12.1
Definitely would not
10
2.6
Total
389
100.0
How likely are you to become involved with “heart health” as
an issue if the following kinds of programs existed: A program
to educate women that heart health is an issue all women
should pay attention to
Frequency
Percent
Definitely would
90
23.2
Probably would
154
40.0
Might or might not
98
25.2
Probably would not
40
10.3
Definitely would not
5
1.3
Total
389
100.0
How likely are you to become involved with “heart health” as
an issue if the following kinds of programs existed: A program
to educate women about how to navigate the health care system
to get the best care possible
Frequency
Percent
Definitely would
120
31.8
Probably would
142
36.7
Might or might not
77
19.9
Probably would not
38
10.1
Definitely would not
6
1.5
Total
389
100.0
Perceived Barriers
The women were asked a question regarding barriers they thought prevented them
from leading a heart healthy lifestyle. Over 60 % of the participants selected monetary
reasons, personal confidence, available time, or other obligations as their barriers. Nearly
32% of the women selected that they already lead a heart healthy lifestyle. This indicates
that less than half of the women felt there were no barriers to preventing them from living
a heart healthy lifestyle while the majority of the women have other obstacles that
hindered them from a healthy lifestyle (see Table 16).
73
Table 16
HBM Perceived Barriers Construct
Which of the following are the biggest barriers preventing you from
leading a heart healthy lifestyle? Please only select up to 5 barriers
Frequency
Percent
I’m fearful of change
11
2.8
I’m not confident that I can successfully change
my behavior
46
11.8
I am too stressed to do the things that need to be
done
47
12.1
I am too depressed to do the things that need to
be done
12
3.1
I am too ill/old to make changes
2
.5
I don’t have the money or insurance coverage to
do what needs to be done
47
12.1
I have family obligations and other people to
take care of
47
12.1
I don’t have the time to take care of myself
50
12.9
I am confused by what I’m supposed to do to
change my lifestyle
24
6.2
I feel the changes required are too complicated
18
4.6
I don’t know what I should do
44
11.3
There is too much confusion in the media about
what to do
30
7.7
None of these, I lead a heart healthy lifestyle
123
31.6
Total
389
Cues to Action
Lastly, participants were asked to think about things they have done to improve
their own health. They were then asked to select the reason(s) they took action. This
question was used to measure their cues to action. Nearly 30% of the women selected I
saw, heard, or read information related to heart disease or my healthcare professional
encouraged me to take action. Participants were also asked “what would you likely do
after knowing that heart disease is the leading cause of death.” After finding out that
heart disease was the leading cause of death, 92% of the participants selected that they
would make lifestyle and behavior changes in their lives (see Table 17). Overall the
majority of the women chose to make a positive behavioral change so that they could live
a longer and healthy life.
74
Table 17
HBM Cues to Action Construct
Thinking about things you have done to improve your own health,
please tell us if any of the following prompted you to take action.
Please select all that apply
Frequency
Percent
I saw, heard, or read information related to heart
disease
94
24.2
My health care professional encouraged me to take
action
114
29.3
A family member or relative encouraged me to
take action
74
19.0
A friend encouraged me to take action
49
12.6
A family member/relative developed heart disease,
got sick, or died
75
19.3
I experienced symptoms that I thought were
related to heart disease
31
8.0
I wanted to feel better
235
60.4
I wanted to avoid taking medications
138
35.5
I wanted to improve my health
291
74.8
I wanted to live longer
262
67.4
I did it for my family
102
26.2
I was encouraged to take action during an event or
program at my place of worship (church, mosque,
or temple)
22
56.6
I was encouraged to take action during an event or
program at my community center
12
30.8
Something else
29
74.6
I have not done anything to improve my health
10
25.7
Total
389
The leading cause of death for all women in the U.S. is heart disease. Knowing
that information, which of the following are you likely to do?
Frequency
Percent
Go to the doctor to assess my risk for heart disease
52
13.4
Get more information about heart disease
64
16.5
Research ways to improve my heart health
71
18.3
Talk to my family about our medical history
14
3.6
Talk to my friends about heart disease
7
1.8
Get involved with an organization to help to raise
awareness about heart disease
6
1.5
Make lifestyle and behavior changes
144
37.0
Other
11
2.8
Nothing
20
5.1
Total
389
100.0
Statistical Testing of Hypotheses
Frequency, crosstab, mean, standard error, standard deviation, minimum, and
maximum scores were calculated for each variable in this study. Linear multiple
regression was used to determine the association between the independent variables
knowledge of heart disease risk factors, knowledge of heart attack symptoms, perceptions
of personal risks for heart disease, and demographic backgrounds (age, income,
75
education, family history, and state of residency) and the dependent variable awareness of
heart disease. Descriptive statistics for all the measures in the study are presented in
Table 18. Each of the hypotheses was tested at the 0.05 level of confidence and a
confidence interval of 5. The power of the statistical test (1- β) was set at 0.80. The
effect size (degree of association between two variables, population and sample) was set
between 0.2 – 0.4.
Correlation Analyses: Pearson R
Pearson R was also run when selecting multiple regressions. Pearson R measured
the strength of the linear relationship between each of the independent variables
individually (heart disease risk factors, heart attack symptoms, perceptions of personal
risks for heart), and demographic background (age, education, income, state of residency,
and family history of heart disease) and the dependent variable (awareness of heart
disease). The Pearson R analysis revealed a weak linear relationship between the
independent variables and the dependent variable.
When the independent variables were measured collectively (R), the result was
0.385. This means that only 14.8% (R2) of the awareness of heart disease was attributed
to each of the independent variables collectively; the women’s knowledge of heart
disease risk factors, heart attack symptoms, perceptions of personal risks for heart
disease, and their demographic backgrounds. The variables have a very low correlation
collectively. Even still, for the purpose of this study’s focus on the variables participants’
knowledge of heart disease risk factors, knowledge of heart attack symptoms, perceptions
of personal risks for heart, and demographic backgrounds were slightly dependent upon
76
their awareness of heart disease. Of the independent variables, perceptions of personal
risks for heart disease, participant’s age, and family history of heart disease were mostly
associated with awareness of heart disease.
Table 18
Descriptive Statistics for the Variables in the Study
N
Range
Minimum
Maximum
Mean
Std. Deviation
Statistic
Statistic
Statistic
Statistic
Statistic
Std. Error
Statistic
Knowledge of Risk factors
389
14.00
.00
14.00
7.4216
.14904
2.93962
Knowledge of Heart Attack
Symptoms
389
12.00
.00
12.00
5.5733
.16814
3.31630
Perceptions of Personal Risks
for Heart Disease
389
2.00
.00
2.00
.9434
.03701
.72998
Awareness
389
2.00
1.00
3.00
1.8509
.03485
.68743
Age of participants
389
3.00
.00
3.00
1.1671
.03257
.64244
Education of participants
389
5.00
.00
5.00
3.8303
.06987
1.37803
Income of participants
389
4.00
.00
4.00
2.8817
.05689
1.12213
Family history of HD
389
1.00
.00
1.00
.4576
.02529
.49884
State of Residency
389
32.00
.00
32.00
10.7892
.32922
6.49320
Valid N
389
(Age code: 18-29 was coded 0; 30-49 was coded 1; 50-69 was coded 2; 70 and older was coded 3)
(Education level code: some high school was coded 0; high school diploma was coded 1; trade/technical/vocational training was coded 2; College graduate was coded 3; Some post graduate work
was coded 4; Post graduate degree was coded 5)
(Income code: less than $10,000 was coded 0; $10,000-$29,000 was coded 1; $30,000-$ 49,000 was coded 2; $50,000-$69,000 was coded 3; $70,000 and greater was coded 4)
(States code: the states were coded from 0-31 alphabetical Alabama –Washington; and New Mexico is coded 32)
(Family History of HD code: Yes was coded 0; No was coded 1)
77
Table 19
Regression Coefficient to Explain Awareness of Heart Disease from the Independent
Variables
Independent Variables
Unstandardized
Coefficients
Standardiz
ed
Coefficient
s
t
Sig.
95.0% Confidence
Interval for B
B
Std. Error
Beta
Lower
Bound
Upper
Bound
Knowledge of risk
factors
.021
.011
.092
1.922
.055
.000
.043
Knowledge of
heart attack
symptoms
-.015
.010
-.071
-1.486
.138
-.034
.005
Perceptions of
Personal Risks for
Heart Disease
reported
.215
.048
.228
4.462
.000
.120
.309
Age
-.184
.053
-.172
-3.450
.001
-.289
-.079
Education
.009
.025
.019
.374
.708
-.040
.058
Income
-.043
.031
-.071
-1.400
.162
-.105
.018
Family history of
HD
.167
.070
.121
2.404
.017
.030
.304
State of Residency
-.007
.005
-.065
-1.333
.183
-.017
.003
Research Question 1
The first research question was: is there an association between African American
women’s knowledge of heart disease risk factors (diabetes, high blood pressure, high
cholesterol, cigarette smoking, poor diet, physical inactivity, and overweight) and their
awareness of heart disease. Approximately 30% of the women knew at least one risk
factor, 23.9% knew two or more, 12.6% knew three or more, 5.4% knew four or more,
and 2.1% knew five risk factors for heart disease and also displayed a high level of
awareness of heart disease. Nearly half (45.2%) of the women knew at least one risk
factor for heart disease and had a medium level of awareness of heart disease. Among
78
those women, 31.9% knew two or more risk factors, 10.8% knew three or more risk
factors, 4.6% knew four or more risk factors, and 2.1% knew five risk factors for heart
disease. Women with a low level of awareness and a little knowledge of heart disease
risk factors represented approximately 10% of the studied population. Hypothesis 1 was
that there is an association between African American women’s knowledge of heart
disease risk factors (diabetes, high blood pressure, high cholesterol, cigarette smoking,
poor diet, physical inactivity, and overweight) and their awareness of heart disease. This
hypothesis is supported by the data. The linear multiple regression analysis computed a
significance level of 0.055 (see Table 19). This value indicates strong evidence against
the null hypothesis; therefore the null hypothesis is rejected meaning that there is
statistically a significant association between African American women’s knowledge of
heart disease risk factors (diabetes, high blood pressure, high cholesterol, cigarette
smoking, poor diet, physical inactivity, and overweight) and their awareness of heart
disease.
Research Question 2
The second research question was: is there was an association between African
American women’s knowledge of heart attack symptoms (chest pain, fatigue, nausea,
pain in the shoulders, neck, or arms, shortness of breath, and tightness of the chest) and
their awareness of heart disease. Women with a high level of awareness for heart disease
and knowledge of at least one symptom of a heart attack represented 29.0% of the women
in the study. Within that group of women, 20.1 % knew two or more heart attack
symptoms, 8.2% knew three or more heart attack symptoms, 1.9% knew four or more
79
heart attack symptoms, and less than 1% knew five heart attack symptoms. Women with
a medium level of awareness of heart disease as well as their knowledge of at least two
heart attack symptoms made up 25.2% of the studied population. Less than 15% of the
women with a low level of awareness knew more than one symptom of a heart attack.
Hypothesis 2 was that there is an association between African American women’s
knowledge of heart attack symptoms (chest pain, fatigue, nausea, pain in the shoulders,
neck, or arms, shortness of breath, and tightness of the chest) and their awareness of heart
disease. This hypothesis was not supported by the data. The linear multiple regression
analysis computed a significance level of 0.138 (see Table 19). The data supports the
null hypothesis, indicating that there is no statistically significant association between
African American women’s knowledge of heart attack symptoms (chest pain, fatigue,
nausea, pain in the shoulders, neck, or arms, shortness of breath, and tightness of the
chest) and their awareness of heart disease.
Research Question 3
The third research question was: is there was an association between African
American women’s perceptions of personal risks for heart disease and their awareness of
heart disease. Among 389 women, 28.0% of the women worry about their risk for heart
disease and showed a high level of awareness for heart disease. Less than 5 % of the
surveyed women do not worry about their risk for heart disease and showed that they
have a high level of awareness for heart disease. Women with a medium level of
awareness and worry about their risk for heart disease represented 38.3% of the studied
population. Hypothesis 3 was that there is association between African American
80
women’s perceptions of personal risks for heart disease and their awareness of heart
disease. This hypothesis was supported by the data. The linear multiple regression
analysis computed a significance level of 0.000 (see Table 19). This value indicates
strong evidence against the null hypothesis; therefore, the null hypothesis is rejected
showing that there is statistically a significant association between African American
women’s perceptions of personal risks for heart disease and awareness of heart disease.
Research Question 4
The fourth and final research question consisted of 5 variables and the question
was: is there an association between African American women’s demographic (age,
education, income, family history of heart disease, and state of residency) and their
awareness of heart disease. Women in the age group 30-49 represented majority of the
sample size (63.1%) and 20.3 % of them showed a high level of awareness of heart
disease. This age group of women also represented 31.6% of the studied population who
had a medium level of awareness for heart disease. Among the women with a low level
of heart disease awareness, 4.6% are between the age of 18-29, 11.1% between the age of
30-49, 1.5% between the age of 50-69, and no woman in the age group of 79 and older
showed a low level of awareness of heart disease. Hypothesis 4 was that there is an
association between African American women’s demographic: (a) age, (b) education, (c)
income, (d) family history of heart disease, (e) state of residency, and their awareness of
heart disease. Hypothesis 4(a) was supported by the data. The linear multiple regression
analysis computed a significance level of 0.001 as it pertains to the variable age (see
81
Table 19). Therefore the null hypothesis 4(a) is rejected; there is statistically a significant
association between African American women’s age and their awareness of heart disease.
More women with a postgraduate degree had either a medium level (26.2%) or
high level (15.9%) of awareness of heart disease. Regardless of educational background,
women were more likely to have a medium level of awareness (50.7%) compared to high
(31.6%) and low (17.2%) levels of awareness of heart disease. Hypothesis 4 (b) was not
supported by the data. The linear multiple regression analysis computed a significance
level of 0.708 as it pertains to the variable education (see Table 19). Therefore the null
hypothesis 4(b) is supported; there is no statistically significant association between
African American women’s education and their awareness of heart disease.
As the income of the studied population increased, so did their awareness level of
heart disease. The percentage of women with a high level of awareness of heart disease
in the income range of $70,000 and more doubled when compared to those making
$30,000-$49,0000 and $50,000-$69,0000 (14.7% vs. 7.2% and 7.2%). Among the
women that earned between $10,000-$29,000, 2.8% had a high level of awareness of
heart disease and only one person (less than 1%) that earned less than $10,000 had a high
level of awareness of heart disease. Less than 20% of the women showed a low level of
awareness for heart disease. Hypothesis 4 (c) was not supported by the data. The linear
multiple regression analysis computed a significance level of 0.162 as it pertains to the
variable income (see Table 19). Therefore the null hypothesis 4(c) is supported; there is
no statistically significant association between African American women’s income and
their awareness of heart disease.
82
More women with a medium level of awareness (24.9%) had a family history of
heart disease compared to women with a high level of awareness (22.1%). Slightly more
women without a family history of heart disease (25.7%) showed a medium level of
awareness of heart disease compared to those with a family history of heart disease
(24.9%). Less than 10% of women with a family history of heart disease had a low level
of awareness of heart disease. Hypothesis 4 (d) was supported by the data. The multiple
regression analysis computed a significance level of 0.017 as it pertains to the variable
family history (see Table 19). Therefore the null hypothesis 4(d) is rejected; there is
statistically a significant association between African American women’s family history
of heart disease and their awareness of heart disease.
Among the thirty-three states the women reside within, 32.1% have a high level,
50.9% have a medium level, and 17.2% have a low level of awareness of heart disease.
More than half of the women were from Georgia (59.6%) and most of these women
displayed a medium awareness of heart disease. Alabama and Ohio had the next highest
representation (7.2% and 3.3% respectively) and the majority of them showed a medium
level of awareness of heart disease as well. Hypothesis 4 (e) was not supported by the
data. The linear multiple regression analysis computed a significance level of 0.183 as it
pertains to the variable state of residency (see Table 19). Therefore the null hypothesis
4(e) is supported; there is no statistically significant association between African
American women’s state of residency and their awareness of heart disease.
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Summary
In this chapter, I presented the results of the study. This included descriptive
statistics of the variables heart disease risk factors, heart attack symptoms, perceptions of
personal risks for heart disease, demographic background, and awareness of heart
disease. The majority of the women was between the ages of 30 and 49, highly educated,
and earned $70,000 or more a year. Participation was represented from 33 states within
the United States. Almost 60% of the women resided in Georgia. Over half of the
women had a family history of heart disease. The majority of the women listed two risk
factors for heart disease and two symptoms of a heart attack. More women worried about
their personal risk for heart disease than those that do not worry at all about their personal
risk for heart disease. Half of the women showed a medium level of awareness of heart
disease.
Descriptive statistics were also calculated for the HBM constructs used in this
study. Most of the women thought that their overall outlook on life impacts their
likelihood for developing and managing heart disease (perceived susceptibility and
severity). The majority of the participants selected that they would participate in
programs to educate women about heart health and how to navigate the healthcare system
to get the best care possible if the programs existed (perceived benefits). Less than half
of the women feel that that lead a healthy lifestyle (perceived barrier). Most of the
women would get regular exercise, lose weight, reduce stress, pray or meditate, or visit a
doctor to monitor or improve their health. Nearly almost all the women participants
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chose to make lifestyle and behavior changes once they were told that heart disease was
the leading cause of death in the U.S. (cues to action).
I conducted correlation analysis among the women’s knowledge of risk factors for
heart disease, knowledge of heart attack symptoms, perceptions of personal risks for heart
disease, and demographic background to evaluate the association with their awareness of
heart disease. Results showed that African American women’s knowledge of heart
disease risk factors, perceptions of personal risks for heart disease, age, and family
history of heart disease are statistically associated with awareness of heart disease.
In the next chapter, results and the connection to the review of literature will be
discussed. The association of the health belief model will be discussed as well as the
positive social change and implications of the study. The conclusion of Chapter 5 will
include limitations and recommendations of the study.
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Chapter 5: Summary, Conclusion, and Recommendations
Introduction
The objective of this study was to examine the association, if any, between
knowledge of heart disease risk factors and awareness of heart disease, knowledge of
heart attack symptoms, perceptions of personal risks for heart disease, and demographic
background and awareness of heart disease among African American women within the
United States. I examined the participants’ knowledge of seven controllable heart disease
risk factors (diabetes, high blood pressure, high cholesterol, cigarette smoking, poor diet,
physical inactivity, and overweight), knowledge of six heart attack symptoms (chest pain,
fatigue, nausea, pain in the shoulders, necks, or arms, shortness of breath, and tightness of
the chest), yes or no perceptions of personal risks for heart disease, and five demographic
background qualities (age, income, education, family history, and state of residency), as
well as key predictor variables of awareness of heart disease. Linear multiple regression
analysis was used to address the research questions and hypotheses. Five of the health
belief model constructs (perceived susceptibility, perceived severity, perceived benefits,
perceived barriers, and cues to action) were also measured in this study using descriptive
statistics. In this chapter, I will provide an interpretation of the findings, limitations of
the study, recommendations, implications for social change, and conclusion.
The Women’s Health Study survey was used in developing the Internet survey
using Google docs. I recruited participants who met the inclusion criteria through e-mail,
LinkedIn, and Facebook invitations. The invitation encouraged invitees to forward the
invitation to other potential eligible family, friends, and associates. Snowball sampling
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was used to recruit participants for 8 weeks and 2 days with a final number of 389
completed surveys.
The data results were exported to an Excel spreadsheet, coded by each survey
item, and transferred into SPSS software for data cleaning. A Pearson correlation was
used to evaluate the strength of the linear relationship between each of the independent
variables individually and collectively with the dependent variable. Descriptive statistics
were calculated for each survey variable in the study. I addressed the research questions
using multiple regression analysis to determine the association between independent
variables (knowledge of heart disease risk factors, knowledge of heart attack symptoms,
perceptions of personal risks for heart disease, and demographic background qualities)
and the dependent variable of heart disease awareness.
Interpretation of Findings
Knowledge of Heart Disease Risk Factors
Poor diet (31%), physical inactivity (22.6%), and overweight (21.9%) were listed
the most as risk factors for heart disease among the women. These results are consistent
with previous findings by Pace et al. (2008) in which most of the studied population of
African American women listed over eating and a lack of physical activity as a
contributing factor for heart disease. Less than 10% of my studied participants
considered stress a risk factor for heart disease; yet, in a previous study, stress was
consistently noted as a risk factor for heart disease (Delsalvo et al., 2005). High blood
pressure was considered one of the risk factors for heart disease by less than 15% of the
women in my study. This finding is consistent with prior literature where researchers
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revealed a low awareness of high blood pressure being a risk factor for heart disease
among African American women (Guo et al., 2012).
Knowledge of Heart Attack Symptoms
Chest pain (25%) and pain in the shoulder, neck, or arms (24%) were the two
most common symptoms of a heart attack that were noted by the participants. These
findings are consistent with the women in the study by Gallagher et al. (2010) in which
most of the women recognized chest pain as a symptom of a heart attack. However,
Lutfiyya et al. (2008) found that participants did not think that pain or discomfort in the
neck was a symptom of a heart attack. Nausea and fatigue were acknowledged by less
than 5% of the participants in my study as symptoms of having a heart attack. Most
women, according to Gallagher et al. (2010) and Banks and Malone (2005), do not
recognize or associate nausea, shortness of breath, or tightness of the chest as a symptom
of a heart attack.
Perceptions of Personal Risks for Heart Disease
Nearly half of the participants worried just a little about getting heart disease, and
14.9% of the women selected that they did not perceive themselves to be at risk for heart
disease. This is consistent with previous literature where most of the women considered
themselves to be low to no risk for heart disease (Christian et al., 2007; DeSalvo et al.,
2005; Gallagher et al., 2010; Homko et al., 2008; Lefler et al., 2009; Lutfiyya et al., 2008;
McKenzie & Skelly, 2010; Mosca et al., 2010). Christian et al. (2005) found that women
were calculated to be at moderate to high risk for heart disease perceived themselves to
be at a low risk for heart disease. When breast cancer and heart disease were compared,
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women were more concerned with developing breast cancer than heart disease. This is
consistent with previous findings in which participants perceived themselves to be at a
higher risk for breast cancer than heart disease (Christian et al., 2007; Mosca et al.,
2004;Mosca et al., 2013; Mosca et al., 2010; Smith et al., 2012, Wendt, 2005; Winham &
Jones, 2011). Women in the study by Homko et al. (2008) showed a limited knowledge
of risk factors for heart disease, and they also perceived themselves to be at low risk for
heart disease. Yet, in the study conducted by Allen et al. (2010), women perceived
themselves to be at higher risk for developing heart disease.
Awareness of Heart Disease
Heart problems, including heart attacks and heart disease, were reported the most
by participants (43.1%) as the leading cause of death among women, with cancer
including breast, lung, and ovarian cancer being reported by 18.1% of the women as the
leading cause of death. Based on the results, this means that 56.9% of the women did not
know that heart disease is the leading cause of death among women. These findings are
similar to the most recent AHA Women’s Health study (2012). The AHA Women’s
Health study showed that, among the African American women, heart disease was
considered the leading cause of death among women by 36% of the women and cancer
was thought to be the leading cause of death among women by 38% of the women
(Mosca et al., 2013). In each of the triennial AHA Women’s Health Study, more African
American women chose cancer as opposed to heart disease to be the leading cause of
death (Christian et al., 2007; Mosca et al., 2004; Mosca et al., 2013; Mosca et al., 2000;
Mosca et al., 2010); yet, in my study, heart disease was reported more than cancer.
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I found that knowledge of heart disease risk factors and perceptions of personal
risk for heart disease, age, and family history were statistically associated with the
women’s awareness of heart disease. Knowledge of heart attack symptoms, education,
income, and state of residence findings, however, were not statistically associated with
the women’s awareness of heart disease. The variables collectively yielded weak linear
correlation (14.8%). DeSalvo et al. (2005), Homko et al. (2008), Lefler et al. (2009), and
Winham and Jones (2011) examined similar variables and similar sample sizes between
128 - 465 and also yielded weak linear correlation. More investigation is needed beyond
the studied variables in order to improve African American women’s awareness of heart
disease.
Health Belief Model
Perceived susceptibility. Perceived susceptibility is described as an individual’s
perceptions of the risks of developing a health disease (Glanz et al., 2008). The
probability that individuals will participate or engage in preventive measures for heart
disease depends on their perception of being at risk for heart disease. People tend to
underestimate their own susceptibility to heart disease (Christian et al., 2005). Only
about 30% of the women worried a lot about getting heart disease, indicating that most of
the participants were not seriously concerned about their risk for heart disease. This
finding is consistent with previous literature that most participants estimated their risk for
developing heart disease as low (Christian et al., 2007; Mosca et al., 2010; Smith et al.,
2012; Wendt, 2005). Yet, approximately 88% of the women in my study experienced
one or more of the risk factors for heart disease. In order for individuals to make an
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accurate perception of their risk for heart disease, it is important to know the risk factors
and symptoms of a heart attack that contribute to the development of heart disease (Lefler
et al., 2009). More research is needed to determine why women with one or more risk
factors for heart disease do not perceive themselves to be susceptible to the disease.
More education is needed to explain how specific health issues (high blood pressure, high
cholesterol, smoking, overweight, and physical inactivity) can serve as a catalyst to the
development of heart disease.
Perceived severity. Perceived severity is described as individuals’ perceptions of
the seriousness of a disease to cause complications of their lifestyles (Glanz et al., 2008).
Life decisions are made everyday by people and typically made according to how they
will affect their daily routine, family environment, or family well-being. The majority of
the women in my study thought that heart disease would have a negative impact on their
lifestyles. According to Glanz et al. (2008), if individuals perceive a health condition to
have negative and serious consequences to their lifestyle, they are more likely to change
their health behavior in order to reduce their risk for the disease. The women’s perception
that heart disease would have a negative impact on their life is a potential indicator that
the women would possibly consider improving their personal behavior.
Perceived benefits. Perceived benefits are described as an individual’s belief of
the effectiveness of various actions available in reducing the disease threat (Glanz et al.,
2008). More than half of the women indicated that they would participate in heart health
programs if they existed. This confirms that the women consider heart health programs
effective; and, the majority of the women in this study felt that there was a need for
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further education in improving their knowledge of heart disease. In analyzing these
results, further research should be conducted to determine what exact measures women
are willing to consider or take to prevent heart disease in their own lives.
Perceived barriers. Perceived barriers are those issues that would make it
difficult to make a behavioral change (Glanz et al., 2008). My study showed that over
60% of the women felt that there were barriers in their life that hindered them from
leading a heart healthy lifestyle. Family obligations, lack of money or lack of insurance,
low self-confidence, and stress were noted the most. Further research should be
conducted to determine procedures and techniques that will enhance African American
women in areas that often hinder them from leading a heart healthy lifestyle.
Cues to action. Cues to action are described as events, people, or things that
move an individual to make a behavioral change (Glanz, et al., 2008). Over 60% of the
women chose to make a behavioral change in order to feel better, to improve their health,
or to live longer. An event or program at the women’s place of worship was selected by
over 50% of the women as a reason that encouraged them to take action; as well as, over
20% saw, heard, or read information related to heart disease that prompted them to make
a behavioral change. Over 35% of the participants chose to make lifestyle and behavioral
changes after learning that heart disease was the leading cause of death for all women in
the U.S. In knowing this, continued empowerment of these women is needed to ensure
that increased heart health knowledge and behavioral changes are taking place.
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Limitations of the Study
There were a number of limitations noted in this study that impacted the findings
and the ability to generalize the results to all African American women. The first
limitation is the data collected were self-reported and only reported by African American
women with email and Internet access. Second, the majority of the participants were
residents of the state of Georgia. Third, over half of the participants were middle aged
(30-49 years of age) with a very small percentage of participants being between the ages
of 18-29 and 79 and older. Fourth, over half of the participants were educated with a
postgraduate degree. Nearly half of the participants had an income greater than $70,000.
Because of the small percentage of representation of women within the 33 states in the
U.S., the 18-29 age group, the less than $30,000 group, and the some high school and
high school graduate groups, the results cannot be generalized to all African American
women in the United States.
Despite these limitations, the study yielded valuable findings. The information
from the study is valuable because it demonstrated the level of heart disease knowledge
among the women. When answers from each age, education, and income groups of heart
disease awareness were compared more women in the age group of 18-29 showed a low
level of heart disease awareness (40%) when compared to any other age group (age group
30-49: 17.6%; age group 50-69: 6.6%; age group 79 and older: 0%). More high school
graduates showed a low level of awareness of heart disease (29%) when compared to any
other level of education among the women (trade/technical/vocational/training, 10%;
college graduate, 18.5%; some post graduate work, 17%; post graduate degree, 16%).
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More women with an income of $10,000 and less showed a low level of awareness of
heart disease (22%) when compared to any other income level among the women
($10,000-$29,000, 15.5%; $30,000-$49,000, 21%; $50,000-$69,000, 20%; $70,000 and
more, 14%). Statistically these findings suggest further research should be conducted
with a focus on reaching the younger age, less educated, and low-income group of
African American women.
A low correlation of the African American women’s awareness of heart disease
was displayed. A larger sample size, a longer recruitment period, or even providing other
methods of completing the survey may have yielded a stronger linear correlation.
Suggesting that the strength of the linear relationship between the variables (heart disease
risk factors, heart attack symptoms, perception of personal risk for heart disease, and
demographic backgrounds) is affected by the sample size and recruitment period were
consistent with prior studies conducted. Similar to my study, Homko et al. (2008)
examined similar variables and sample size in order to determine heart disease
knowledge and risk perceptions among underserved individuals. A low correlation
between the variables heart disease risk factors, age, income, and education (Homko et
al., 2008) were shown. Lefler et al. (2009) also conducted a study to determine the
perceived risk of heart disease among older high risk African American and European
women. The sample size and variables were similar. In comparison to my study, Lefler
et al. (2009) found that the variables (age, educational level, and income, family history
of heart disease, and risk factors for heart disease) yielded a weak linear relationship.
Winham and Jones (2011) also yielded a low correlation with similar variables (age,
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education, risk factors for heart disease, and household income) with a sample size of 172
when determining the knowledge of heart disease among young African Americans.
Yet Wang et al. (2009) conducted a study with a larger sample size (2,362) and
longer recruitment period (2 years) with similar variables (age, education, income, family
history of heart disease, and perceived risk for heart disease) to evaluate participants’ risk
perception of heart disease and other chronic diseases. Strong linear relationships
between the variables were shown (Wang et al., 2009). Lutfiyya et al. (2008) also
conducted a study with a larger sample size (11,269), similar variables (age, education,
and income), and longer recruitment period (2 years) that resulted in a strong correlation.
Consistent with the previously mentioned studies, studies by Christian et al. (2007),
Mosca et al. (2013), and Mosca et al. (2010) yielded a stronger linear relationship
between the variables than in my study. Each of the previous scholars conducted their
study with a larger sample size (greater than 1,000), similar variables (age, race,
education, income, and history of heart disease), and different methods for survey
completion (telephone and online survey). My sample size of 389 could be the cause of
the weak linear relationship between the variables. According to Goodwin and Leech
(2006), a low correlation between variables can be affected by a small sample size.
Additionally, in determining why a correlation might be lower than expected to
be, Goodwin and Leech (2006) recommended examining the variability of the research
data. According to Glass and Hopkins (1996) and Goodwin and Leech (2006), the
correlation between the variables will be stronger if there is more variability among the
data. As in my study for example, a different format to my survey may have yielded
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different results. Providing the participants with a range of choices to select for heart
disease risk factors and heart attack symptoms may have resulted in a different
relationship among the variables. Changing the demographic background questions to be
more specific to the participants may have been helpful. For example with the education
variable, if I had asked the participants to provide the type of degree they had, this may
have provided more range of variability and may have had an impact on the correlation.
This would suggest that further research should be conducted building upon what was
revealed in this study.
Recommendations for Dissemination
As heart disease awareness among women continues to be observed yearly,
incorporating public health awareness that links key indicators of heart disease
knowledge (heart disease risk factors, perceptions of personal risks for heart disease, age,
and family history) with women’s individual awareness of heart disease would be helpful
in improving heart disease knowledge among African American women. Enhancing
education among African American women by presenting this information in various
settings would be helpful. For example, presenting this information at undergraduate and
graduate level African American sorority meetings are good venues to reach women of
various ages and economic backgrounds. Other potential avenues to reach this
population of women would be to present this information to African American women’s
civic and church groups; as well as, providing this information on individual Facebook
pages.
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I would disseminate these findings by sharing with my Facebook, LinkedIn, and
email contacts. Dissertation results will be disseminated through publications in peer
reviewed journal articles and poster presentations at health conferences. These results
will also be made public knowledge through access to the Google docs result link that
was provided to the participants after they completed the survey. Dissemination of the
information and results would increase awareness and educate women on the importance
of leading a heart healthy lifestyle.
Recommendations for Further Study
Based on the barriers (family obligations, lack of money or lack of insurance, low
self confidence, and stress) that were selected by the women as reasons they do not lead
heart healthy lifestyles, there is a need for African American women to learn to prioritize
rest and relaxation into their schedule. Over 60% of the women agreed to the statement
“I don’t get enough sleep on a regular basis” and nearly half of the women (47%) agreed
to the statement “I’m so busy taking care of everyone else, I don’t take care of myself.”
Twenty four percent of the women selected that half of the time to all of the time “my life
is chaotic,” 27% of the women selected that half of the time to all of the time “I feel like I
am running on empty,” 29% of the women selected that half of the time to all of the time
“I feel overwhelmed,” and 36% of the women selected that half of the time to all of the
time “I have too many responsibilities.” There is also a need for
motivational/inspirational sessions and healthcare availability education seminars that
will enhance African American women’s health knowledge, time management, and self-
confidence. Further research is needed to determine the best methods in reaching African
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American women, especially the younger age group in order to gain better knowledge of
heart disease. Some potential ideas would be the development and implementation of
prerecorded messages sent over the phone, text message, email, or even daily heart health
information on individuals’ Facebook page.
Implications for Social Change
The purpose of this study was to determine the overall knowledge and health
beliefs about heart disease among African American women within the United States.
Through analyzing participants’ responses to the Women’s Health Study questions, the
women’s overall knowledge and perceptions of heart disease were determined. By
utilizing the results from this study with regard to, a) the women’s knowledge of heart
disease risk factors; b) the women’s knowledge of heart attack symptoms; c) the
women’s perception of the leading cause of death among women; d) the women’s
perceptions of their personal risks for heart disease; e) issues that prompted women to
improve their health; f) barriers the women felt prevented them from leading a heart
healthy lifestyle; g) what the women felt they needed to know or learn to believe that
heart health is an issue for all women, creating social change within the African
American women community should be possible. Although the awareness of heart
disease has increased in African American women, the young age group (18-29), less
educated (high school and less), and low income (less than $30,000) women were poorly
represented in the study. There is a need to strategize ways to reach these groups of
women. In addition to providing prerecorded heart health messages to social media links
(email, Facebook, and LinkedIn), other potential ways to reach these groups of women
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would be to provide heart health education at nontraditional places that are potentially
frequently visited by the women such as their place of worship, place of employment,
their child(ren)’s school, hair salons, grocery stores, pharmacies, and nail salons.
The information gained in this study can be used for future studies that will have a
positive impact on heart disease knowledge among African American women. The
women were told that heart disease was the leading cause of death for all women in the
U.S. at the end of the survey, thus bringing more awareness of heart disease among at
least 389 African American women. Also some of these women selected to talk to their
family and friends about heart disease, thus creating heart health dialogue within their
circle of people as well as bringing more awareness of heart disease among African
American women, in this I accomplished my social change goal set for this study.
Conclusion
Heart disease awareness among African American women has improved
significantly since the initial study in 1997 was conducted to determine women’s
awareness of heart disease. In previous years, most women that were studied considered
cancer to be the leading cause of death; yet, more women (43.1%) in my study believed
that heart disease as opposed to cancer was the leading cause of death among women in
the United States. The least amount of responses was from the young, low income, and
less educated African American women. These findings suggest that future educational
efforts should target these groups of women to determine their overall knowledge of heart
disease. More than half of the women reported that they were prompted to take
preventive measures for heart disease at their place of worship. This supports the
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recommendation from AHA (Mosca et al., 2012), that more faith-based interventions are
also needed to increase awareness among African American women.
The participants provided suggestions of things that they need to know or learn in
order to believe that heart health is an issue of all women, a) hearing or reading personal
stories from African American women who live with heart disease; b) simple detailed
information of heart disease; c) statistics on the prevalence of heart disease among
African American women; d) more research and surveys; e) education classes; f)
community based programs that promote women wellness in rural areas; g) ways to
become healthy and stay healthy; h) how to incorporate maintaining good health into
your busy daily schedule; i) ways to control your weight; j) stress management; k) ways
to motivate yourself; and l) daily reminders. Researchers can use these suggestions to
design future studies and programs that will encourage women to make heart health a
priority and enhance their heart disease knowledge. Despite the variables yielding a
weak correlation to awareness of heart disease, the variables in this study provided
valuable insight to the participant’s awareness of heart disease among African American
women based on their current knowledge of heart disease risk factors, knowledge of heart
attack symptoms, perception of personal risk for heart disease, and demographic
backgrounds. These variables in my opinion could be used as a building block
foundation to furthering the study of African American women and potentially conduct
Heart Health focus groups among the younger age, less educated, and low- income group
of women in order to determine what the other key variables are that may play an
important role in increasing African American women’s awareness of heart disease.
