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Dissertation Literature Review Sample

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A Quantitative Analysis of Perceptions of Health, Family History, and Health Outcome Associations in African American Men at risk for CVD

Chapter 2: Literature Review


While extensive public and clinical research on CHD exists, scholarly information on the public policy system mechanisms, which help in creating awareness and preventing CHD in AAM, is non-existent. The problem revolves around the fact that even though earlier investigators have indicated a rise in CHD awareness among AAW, highest numbers of deaths attributed to the silent killer are reported in AAM (CDC, 2011). Because of this, the literature review will explore factors that contribute to the CHD epidemic affecting AAM from the socio-ecological perspective. Secondly, the negative health effects emanating from the cultural values and beliefs, socio-economic status, and environmental conditions that affect AAM’s health jointly will be evaluated. Finally, a discussion of findings from previous literature examining correlation between how AAM perceive health and its effect on attitude and behavior towards lifestyle choices and health is presented.

Public policy within the literature may be considered understandings, informal or formal rules, regulations, and laws, which are employed collectively for directing collective and individual behaviors among people (Schmid, Pratt, & Howze, 1995). The literature review is aimed at examining past literature from the socio-ecological viewpoint to provide an insight into how the health status of AAMs have been affected by cultural beliefs, socio-economic status, and environmental conditions, which jointly contribute to negative lifestyle decisions as well as the awareness, and adoption of existing resources required for better health outcomes.

Because of this, better life quality and policy prevention mechanisms formed the focal point in the current study. With regard to the literature review, three extensive relationships involving different effects were captured they include social cultural effects and CHD, socio-economic condition and CHD, as well as environmental conditions and CHD. In the current review, over 100 sources containing the three aforementioned topics were investigated. Because of the key terms, the literature review was intentionally designed around the three thematic concerns identified. The literature review featured a set of different quantitative and qualitative studies, which examined cultural aspects, socio-economic status, and environmental conditions that prevent CHD individuals from attaining better life quality and health.

Literature Search Strategies

In Chapter 2, a discussion pertaining to selection of articles, literature evaluation and comparison of appropriate quantitative and qualitative studies, coupled with abstract and title review is undertaken to ascertain the suitability of the research topic. To identify current gaps within the empirical literature, past studies are reviewed to create the base for conducting further investigations on CHD prevention as well as the factors, which contribute to racial /ethnic health disparities. The selection process for the literature review alongside the technique for gathering and analyzing data involved evaluation of peer –reviewed journals as well as statistical analysis of data. The inclusion of peer –reviewed articles was determined with articles in the past 10 years of publication. The researched databases included Pro Quest Central, SocIndex, PubMed, Web of Knowledge, Academic Search Complete, and Health and Medical Complete. The search on the databases involved use of several search terms namely health equity, culturally effective healthcare system, health disparities, health perception, CHD screening, health literacy, social support, and Afro-American Men. Other search terms were culture, environmental characteristics, built environment, food dessert, tobacco, physical inactivity, health-care access, healthcare unitization, barriers, motivation, literacy level, and low income. Many peer-reviewed articles exploring the topic were obtained from the Academic Search Complete database. In conclusion, chapter 2 explains previous research and summarizes existing literature regarding CHD conditions among AAM.

Overview of CHD and Related Research

Despite the ongoing decline of CHD mortality and cases in the past 10 years, CHD is still the top cause of death among American men (CDC, 2010). Although people across ethnic groups, genders, and age groups are affected by CHD, those at higher risk are Native Alaskans, Native Americans, Afro-Americans, and octogenarians (Villablanca et al., 2010). However, with regard to race, AAM are more vulnerable with many CHD reported deaths compared to other racial groups (DHHS, 2010). Notably, AAM are not accorded the same attention and care for CHD as their White counterparts; AAM are accorded different treatments and tests, which aggravate mortality (DHHS, 2010). CHD emerges as the most prevalent type of CVD within the United States, thus medical procedures, medicines, and lifestyle changes may help in treating or preventing the illness and may minimize the risk posed by other related health issues (NLBI, 2012). However, minority men in general face more health problems, which are related directly to accessing healthcare services, genetics, and personal behavior compared to White men or high-income men (NLBI, 2012). This is vividly illustrated by the disparity that exists between the care accorded to Whites and that for AAM regarding CVD diagnosis and access to health facilities (Villablanca et al., 2010). AAM have been found to have the greatest age-adjusted CVD death rate than other male ethnicity/race groups within the United States (Villablanca et al., 2010). Estimates indicate that around 33% (81.1 million) of American adults within the United States are diagnosed with one or multiple CVD diseases (CDC, 2010). Additionally, CHD is a severe disease and disability, widely considered a silent killer and which reduces life expectancy of people (CDC, 2010). In 2008, estimates indicated that around 600, 000 individuals had encountered a cardiovascular –related condition within the United States, and about 53% (320,000) individuals were estimated to have experienced a recurrent attack (Rosamond et al., 2008). As illustrated by the CDC (2011), CVD has emerged as a severe health issue within the United States for several years. For example, in the late 1940s, half of US citizens succumbed to CHD; this compelled the Inter-university Consortium for Political and Social Research (ICPSR) to finance the Charleston Heart Study to. The findings of the Charles Heart study assisted in highlighting the CVD risk factors, thus redirecting public health focus. Although CHD is still ranked as the major cause of mortality in the United States, a 60% reduction in CVD deaths has been reported annually (NIH, 2011). CHD refers to a condition where a plaque blocks or fills the coronary arteries of a person. Plaque comprises calcium, cholesterol, fatty tissues, alongside other substances dissolved within blood, preventing arteries from supplying blood to heart muscles. The coronary arteries become narrow and hard as the plaque increases (NHLBL, 2012). Because of this, the condition limits blood flow towards the heart muscle and might trigger clotting of blood on the plaque’s surface. In some instances, the situation leads to blood flow blockage via the coronary artery triggering a heart attack (NHLBL, 2012). When there is no circulation of blood for a prolonged period, the victim might experience a brain or heart damage or succumb to the condition (Austin, Hutter, Zimmerman, & Humphries, 2004). Wolff, Miller, and Ko (2009) discovered that about 58% of mortalities reported within the United States were attributed to CVD. There are different modifiable risk factors for CHD, which are categorized under cultural, socioeconomic, and environmental factors. Such modifiable CHD risk factors aggravate CHD prevalence within low-income marginalized populations (CDC, 2011). Additionally, based on a CDC (2011) report, many individuals diagnosed with high blood pressure (HBP) controlled the disease. One out of three Americans with high cholesterol accesses better care, and less than a quarter of the people who smoke access some physician assistance to help them quit the vice (CDC, 2011). Such statistical findings show that even though CHD awareness has increased in the recent years, less than half of the individuals at greater risk sought and used relevant medical treatment. An approximated nine in 10 patients having CHD possess at least one risk factor (CDC, 2010). Women are particularly at a greater risk compared to men because of lifestyle choices as well as medical conditions including physical inactivity, cholesterol, HBP, diabetes, smoking, poor nutrition, and obesity (CDC, 2010). According to the Illinois Department of Public Health (IDPH, 2011), 1.1 million people in America encounter a cardiovascular condition annually and an estimated 42% (460,000) of the cases are severe.

Health Disparities

Disparities in health outcomes emerged in the 1980s after the U.S. Surgeon General’s report on disease prevention and health promotion was published (Mullins et al., 2005). The report mentioned two groups with significant rates of potentially preventable mortality. The initial group was low birth weight and premature infants. The second cohort consisted of younger Afro-American adults whose mortality rates because of stroke emanating from hypertension were 2.5 times greater compared to that for Caucasians. The report Promoting Health/Preventing Disease: Objectives for the Nation, released in 1980, was an extension of the Surgeon General’s report. The target of Promoting Health was 15 strategic areas requiring improvement, spanning the consumers’ and physicians’ health behaviors, public health issues, and healthcare access, and delivery.

The 1980 report was used for modeling Healthy People 2000 alongside its successors that advocated for 2010 and 2020 health objectives (Mullins et al., 2005). Eliminating health disparities constituted the main goal of Healthy People 2010. Although investigators and other experts have made considerable inroads, health inequalities remain an incessant issue. Integrating data from the National Health and Nutrition Examination Survey (NHANES) as well as the Behavioral Risk Factor Surveillance System (BRFSS), Danaei (2010) located four main risk factors, which explained the considerable level of disparities in deaths attributed to cancers and CVD, alongside some life expectancy disparities among Americans. The factors included excessive body fat, blood glucose, blood pressure, and cigarette smoking examined using the body mass index (BMI). Such risk factors have a significant effect on deaths from CVD compared to those from cancer; individually, hypertension and smoking have a considerable impact on disparities in life expectancy. Due to widespread public health campaigns, many Americans understand some CVD risk factors, especially obesity and smoking. Afro-American men are sharply aware of the catastrophic effects associated with hypertension from witnessing neighbors, friends, and family develops severe medical conditions linked to hypertension (Webb & Gonzalez, 2006). Indeed, Webb and Gonzalez advocated incorporating Afro- American men’s perspectives regarding hypertension into a model for enhancing health promotion programs. The systematic revelation that men underestimate the CVD risk shows an urgent necessity for health –promotion mechanisms, which personalize risk while offering men with practical means on ways of reducing the risk. The next section delves into the issue of CVD risk among men including men’s awareness of the risks.

Theoretical Foundation

Schroeder and Peck (2008) presented an adapted Health Belief Model for Men and Heart Disease but derived from Rosenstock’s 1966 model (Kirscht, Haefner, Stephens and Rosenstock, 1966). At the core of the model was Perceived Threat of Heart Disease. The model located CVD risk factors as non-modifiable and modifiable. Cues to action included many channels for potential effects on men’s health perceptions and habits associated with CVD: magazine and newspaper articles, reminder postcards from the providers of healthcare, the illness of a relative or friend, advice of others, TV commercials, and mass media campaigns. The theoretical framework for the current research pertains to respondents as their self-health perception measurements were obtained over a 10-year period to determine its improvement or not caused by age, education, treatment, or health behavior. Although not incorporated into the model, Schroeder and Peck also cited several Internet resources where men might seek social support and information. As cases of successful public health initiatives, they mentioned the American Heart Association to bring men together in the war against heart disease.

Cardiovascular Disease Risk Factors

Cardiovascular Disease Risk and Manifestation

For many years, health promotion initiatives for decreasing CVD focused on women. So comprehensively ingrained was the female model of CVD that health experts and the public, in general, were unaware of the gender variations in symptom manifestations and disease risk (Gleeson & Crabbe, 2009; Shirato & Swan, 2010; Williams, 2009). For instance, Coronary artery disease (CAD) occurs 10 years later on among men than it does in women. Although the absence of knowledge might be attributed to the protective impact of hormones among men, a delayed diagnosis could count as another cause. While women encounter chest pains that could be confused with fatigue, nausea, and abdominal pain, men experience breath shortage, chest pains, which indicate the classic signs of heart attack. Moreover, while women with CAD are likely than men to experience angina pectoris (47% against 26%), men have a greater likelihood of developing heart attack (49% against 29%). Both Hypertriglyceridemia and diabetes place men at greater risk than women for CAD (Williams, 2009). Gleeson and Crabbe (2009) suggested that the extensively utilized Framingham Risk Assessment Tool could not be relied upon as a precise measure for CVD risk within certain male groups, particularly octogenarian and minority men. A 2004 version adapted for men categorized men based on optimal, intermediate, and high-risk levels, and 2007 versions featured evidence –based guidelines for CVD prevention. The revised criteria for men at high risk included a 10-year Framingham global risk >20%, chronic or end stage disease, abdominal aortic aneurysm, peripheral artery disease, cerebrovascular disease, and CHD. Men at intermediate risk had multiple key risk factors for CVD, which included obesity, hypertension, low exercise capacity, subclinical vascular disease, premature CAD family history, physical inactivity, dyslipidemia, metabolic syndrome, poor diet, and cigarette smoking. Men designated at high risk of CVD had a Framingham global risk <10% as well as a healthy lifestyle without risk factors.

Recommended Strategies for Reducing Risk Aligned to Risk Levels and Common Risk Factors.

Hypertension Risk

Using data from Black Men’s Health Study (BMHS), follow-up towards a countrywide study of 59,000 men unveiled in 1995, Cozier et al. (2007) examined the correlation between neighborhood median hypertension risk and housing value among Afro-American men. Neighborhood characteristics affect personal health via such aspects as recreational and safety areas, which can promote social coherence, and offer a good climate for physical exercises, the existence of stores that provide affordable and healthy food choices, nearness to possible environmental hazards, employment and educational opportunities, and housing conditions. Cozier et al. (2007) reported significant levels of CVD within low-income neighborhoods. Recruitment of respondents within the BMHS was via different areas across the country and the 36, 099 men incorporated in Cozier et al. (2007) analysis represented 20,192 census tracts. The study included data from 1997, 1999, and 2001 surveys. The basis of classifying men as hypersensitive was whether they reported taking medication for hypertension or took diuretics due to a diagnosis of hypertension. Cozier et al. (2007) observed that the study was the initial one to suggest the examination of hypertension and median housing value and to incorporate a bigger sample of middle-class Afro-American men. As the investigators expected, a considerable inverse correlation existed between hypertension and median housing value even after modifying the individual risk factors. Indeed, the effect of median housing values was seen in men at all education attainment levels, including men of all income categories, including those with income exceeding 50,000 dollars and those with advanced baccalaureate degrees. The same trend influenced young, physically active and lean men. In effect, neighborhood characteristics were capable of affecting the risk of hypertension even in men who would be at low risk. Cozier et al. (2007) considered their results as evidence of residential segregation legacy as well as continued discrimination in lending and housing practices (p. 721), leading to considerable distinctions within the characteristics of White and Black neighborhoods. Even with equal income and education levels, Black men were likely than White men to reside in inferior learning institutions, undervalued real estates, and crime –infested neighborhoods. Based on BMHS data, significant portions of Black men with family incomes of more than 50,000 dollars still resided in low-median housing value neighborhoods. Residents of such neighborhoods were unlikely to access resources, for instance, full-service shopping malls with recreational areas and fair prices, which promoted healthy lifestyles. The stresses of living in unfavorable neighborhood condition might negate the protective impacts of health promoting habits, education, and personal income.

Gender Variations in Stroke Risk

The Afro-American Antiplatelet Stroke Prevention Study (AAASPS) is a random, multicenter, clinical controlled trial for prevention of recurrent stroke that provides a suitable source of data on risk profiles for both Afro-American women and men. Between late 1995 and mid-1999, the AAASPS enlisted 574 women and 513 men within the trial (Worrall, Johnston, Konable, Hung, Richardson, & Gorelick, 2002). Using information from the project, Worrall et al. examined potential gender variations within vascular risk factors alongside subtypes of stroke, treatments, medical conditions, and other critical data within the respondents’ medical histories. The analysis showed that heavy consumption of alcohol and cigarette smoking was common in men whereas obesity, diabetes, and hypertension were prevalent among women. A large proportion of men and women (95% and 95% respectively) had numerous stroke risk factors, thus escalating their personal risks. Worrall et al. (2002) asserted that respondents of the two genders had no treatment of antiplatelet agents for secondary stroke prevention. However, many men received treatment at the commencement of the study compared to women. Gender variations in subtypes of stroke among respondents were non-existent. Finally, the gender variations in the risk profiles of stroke were an indication of variations that required improvement.

Men’s Knowledge and Awareness

National Surveys

In 1997, the American Heart Association unveiled a countrywide campaign to increase men awareness regarding CVD with numerous follow-up studies since the inception of the project. Christian, et al., (2007) investigated patterns in men’s perceptions, knowledge, and awareness of CVD in nine years. The investigators contrasted data from a nationally –representative sample consisting of 1005 women investigated in 2006 to results of previous surveys in 1997, 2000, and 2003. The men in the 2006 survey comprised 71% White with a mean age of 50 years. According to Christian et al. (2007), the trend data indicated a considerable rise in men understanding of CVD as the major cause of mortality; however, there was the persistence of CVD knowledge and awareness. Recognition of cardiovascular disease as the main cause of mortality in men rose across all socio-demographic groups. Afro-American men had significant CVD awareness compared to Hispanics, but Caucasian men had greater CVD awareness than AAM despite being at intensified risk. For men in general, the results indicated a definite necessity for improvement since less than half the men investigated considered they understood heart disease. Virtually, all men (95%) said they were comfortable discussing treatment options and preventive care with the doctors, but only 46% had taken part in heart disease discussions. Additionally, the men lacked awareness regarding typical cardiac symptoms. Many said they would make an emergency call in the event of a heart attack or stroke; however, the individual might exhibit symptoms that the victim or the observer understands. Christian et al. stressed the importance of improving symptom recognition, particularly among minority men with the greatest risk of heart attack or stroke. Confusion on messages pertaining to stress, nutrition, and diet effect on CVD were prevalent, thus Christian et al. (2007) found that other men studies reported a similar confusion. Frequently, the media, relatives, friends, and health experts offer contradicting information. To overcome confusion, the investigators proposed testing and designing public health messages tailored to particular audiences. Focus groups might offer an efficient channel for soliciting feedback and input in developing easy and attractive informational materials (Goldman et al., 2006; Parra-Medina et al., 2004).

Socio-demographic Gap

Employing the 2005 AHA data set, Mochari-Greenberger Mills, Simpson, and Mosca (2010) found that Afro-American men were likely to lose weight, avert fatty foods, and change diet than were men from other racial groups. In most instances, advice from health professionals motivated their choices. However, while some Afro-American men reported working towards changing their habits based on encouragement from health care providers, others mentioned an absence of health insurance as an obstacle towards preventing CVD. Afro-American men and Hispanic men were likely than Caucasian men to say that changing lifestyle decrease the risk of CVD was complicated or were apprehensive regarding the change. Culturally sensitive initiatives, which support behavioral change might reduce fears and ease efforts of lowering CVD risk.

Knowledge Gap

Mosca, Mochari-Greenberger, Dolor, Newby, and Robb (2010) reported on 12-year follow-up to the AHA survey of CVD and Afro-Americans. The study of 1142 Afro-Americans took place in 2009.The findings revealed that the rate of awareness was nearly similar as it was three years back. While twice as most men knew CVD as the major cause of mortality in Afro-Americans as they did in 1997, the knowledge gap between Whites and Afro-Americans was still clear. The 2009 survey featured questions associated with mechanisms of preventing CVD as well as heart health barriers. Mosca et al. asserted that many participants noted utilizing numerous supplements to decrease the risk of CVD even though there was no proof for efficiency. The supplements comprised of individual vitamins, multi-vitamins, and antioxidants, for instance, vitamin C. Latest randomized clinical trials did not find empirical evidence regarding the antioxidant efficiency in CVD prevention. Moreover, many participants felt consuming aspirin will have protective impacts on the heart. However, the AHA 2007 Evidence Based Guidelines encouraged young participants to take aspirin to decrease heart disease risk. Participants in the survey supported environmental mechanisms of reducing CVD risks; this included improvement of nutritional labeling, increasing the presence of healthy food in the neighborhood, and expanding access towards recreational sites (Mosca et al., 2010). Among women, caregiving roles emerged as an impediment to a prevention of risks for some women, mainly because it prevented the use of healthy lifestyle habits or created a barrier via psychosocial mechanisms. Care giving might aggravate stress, which in return, escalates the risk of CVD. Mosca et al. quoted the WISEWOMAN initiatives as evidence regarding how well –designed interventions might assist Afro-Americans to take advantage of local community resources in making positive changes in lifestyle in exercise and diet areas (Finkelstein, Khavjou, Mobley, Haney, & Will 2004; Jilcott et al., 2006; Khare et al., 2009; Will et al., 2004).

Exploring ethnic and racial disparities in CVD risk constituted a project undertaken under the WISEWOMAN program (Finkelstein et al., 2004). The analysis utilized baseline data from 5595 women enlisted in WISEWOMAN from January 2001 to December 2002 and denoting seven geographically different states. Generally, the respondents in WISEWOMAN were at increased CVD risk. Similar to other studies, Afro-American women had the greatest risk profiles. Averagely, the Afro-Americans had a greater Framingham CHD score, greater diabetes prevalence, hypertension, and obesity. Unlike Caucasians, Afro- Americans with high blood pressure alongside Native Alaskans with high cholesterol and high blood pressure appeared to understand the conditions. Afro-Americans with high blood pressure had a higher likelihood of receiving treatment.

Based on the data from the 2003 BRFSS, Li, Ford, Mokdad, Balluz, Brown et al. (2008) discovered that adults with several CVD risk factors (diabetes, smoking, obesity, high cholesterol, and high blood pressure) appear to have minimal health-related quality of factors as was apparent in various WISEWOMAN respondents. Improving community resources may assist Afro-Americans to reduce many risk factors concurrently. Indeed, Finkelstein et al. (2004) discovered that community features accounted for a significant level of ethnic and racial disparities in the risk of CVD. Therefore, they recommended community mechanisms to have a balanced playing field (p. 515). Just as the greater level of knowledge regarding high blood pressure in Afro-Americans WISEWOMAN respondents reported by Finkelstein et al. (2004), Lutfiyya, Cumba, McCullough, Barlow, and Lipsky (2008) discovered a high level of knowledge regarding stroke in Afro-American men based on the 2003-2005 BRFSS data. The Afro- American men exhibited greater awareness of stroke symptoms than heart attack symptoms, that compared with the findings of Christian et al. (2007) that men generally had a greater understanding of heart attack symptoms. Based on the BRFSSS data, many Afro- American men’s awareness scores for heart attack and stroke symptoms fell within the moderate – high range (Lutfiyya et al., 2008). About 20% posted low scores on the known range. Age and SES variations were major aspects differentiating Afro-American men with lower and greater knowledge levels. Among Afro-American participants, younger men, men with low-household incomes, as well as uninsured men were 40% likely to experience minimal levels of stroke and heart attack symptom knowledge.

The respondents featured 112 men that completed the risk and knowledge score evaluations. Ranging in ages 35-85 years with an average age of 58.3 years, the men were 36.6% Afro-American and 62.5% Caucasian. As the foundation for life (HRQOL) for psychosocial and physical health, the existence of several CVD risk evaluation, Hamner, and Wilder (2008) turned to the Coronary Heart Disease Knowledge Test, using 20-items derived from the test, and to the Framingham CHD prediction points to evaluate the risk of heart disease. Almost all respondents possessed a health insurance cover; comparable proportions formed part of received Medicare and managed care plan (30.8% and 33.5% respectively). The findings indicated that both Caucasian and Afro-American men had scant knowledge regarding CVD risk (Hamner & Wilder, 2008). Knowledge was considerably greater in men that were under health insurance cover and full-time men. Older, single, underpaid, and employed on a full-time basis were at a greater CVD risk. Those having insurance via a managed or traditional care plan were at minimal CVD risk compared to those on Medicare or Medicaid cover, highlighting the effect of income and age evident within the trend. The Economic disadvantage was especially high CVD risk factor. In evaluating their individual CVD risk, many men only cited a single risk factor, while Hamner and Wilder (2008) asserted that, averagely, the respondents featured three risk factors. None of the men identified taking contraceptives, type A personality, and race as a risk factor, even though they understood other identifiable risks. Hamner and Wilder (2008) observed that men may have misunderstood questions and thought they were required to enumerate their greatest risk factor or the one they were concerned with most. Ironically, while men underestimated their individual CVD risk, they were pessimistic regarding the possibility of developing CVD within the future. Over 90% of the respondents approximated their personal risk of developing CVD in the next decade as ranging from 41%-80%. According to age estimates within the Framingham CHD evaluation, respondents ranging from 40 – 54 years possessed a slightly increased CVD risk, while those with 55 years and above had a slightly minimal risk. Noting that the probable risk for the older men in the study appeared paradoxical with regard to the elevated CVD rates in Alabama County alongside the increased older age risk, Hamner and Wilder proposed that older men might understand their mortality and work actively to reduce the risk. Hamner and Wilder (2008) perceived NPs as the leading advocates in efforts of promoting men education regarding CVD. All men considered smoking and obesity as CVD risk factors, this was not a surprise given the extensive publicity accorded to the factors within national health initiatives. They were not aware of the influence that family history, hyperlipidemia, age, diabetes, high blood pressure, personality types, and race had on CVD risk. The authors suggested the use of multi-disciplinary teams such as NPs in providing rural men with healthcare and education that reduced risk and enhanced knowledge simultaneously. Many community environments might serve as health education sites; these include workplaces, churches, universities, colleges, and schools. Additionally, they suggested collaborative partnerships between local health divisions and AHA.

Regional Surveys

The focus of Hamner and Wilder (2008) was in men residing in the rural areas of Alabama in the exploration of men’s awareness and actual CVD risk. The investigators observed that death rates in men and women in Alabama surpassed the national level; in 2004, the mortality rate among Alabamans was 292.2 for every 100,000 against 241.7 for the whole country. For the county wherein Hamner and Wilder undertook their study the 2005 CVD death rate for men was 406.7, exceeding the state average. The research study was conducted in a primary care clinic within a county of 41,474 residents. The biggest city in the county had 14,971 people. The clinic, located near a small hospital, had two full-time doctors, six receptionists, one unlicensed nursing assistant, one licensed practical nurse (LPN), and three part-time registered nurses (RNs), and one part-time nurse practitioner (NP). Open six days every week, the facility saw 2,100 clients every month, all residents of the local rural communities. Roughly 65% (two-thirds) of the clients receive Medicaid or Medicare. Women represented half of the patients in clinics.

Perception of CVD Risk

The framework that Hamner and Wilder used was the common sense illness model based on an individual’s perception regarding their susceptibility to illness and their health. Using the model as a guideline, Hamner and Wilder proposed a three-pronged method for designing interventions to decrease CVD in men. Firstly, men required being sensitized on the risk CVD risk factors. Secondly, investigators ought to design psycho-educational interventions for men to acquire input into the personal management and understanding of risk factors. Thirdly, men required interventions that increased their knowledge of means for controlling their individual risk factors as well as the negative effects of not controlling their CVD risks. DeSalvo et al. (2005) examined awareness of risk factors in Afro-American men interviewed for inclusion in a random, controlled test undertaken at an urbanized New Orleans internal medicine clinic. The findings obtained from the baseline evaluations of 128 men in the 199 trial respondents. The clinic affiliated with a big public hospital system, catered for the needs of an economically disadvantaged clientele mainly comprising Afro-Americans and middle-aged men (75% each). The site of the study was a federal Health Manpower Shortage Area, a designation symbolizing that the facility served an underserved population with regard to care services.

Socio-demographic Gap

In-depth interviews and focus group discussions supported the survey data, which included self-reported and socio-demographic medical histories (DeSalvo et al., 2005). The analysis featured object risk evaluations based upon identified CVD indicators to contrast perceived against objective risk and personal CVD risk calculations. Socio-demographically, most men had low income and education levels far below the levels of poverty. A large proportion of men were not employed during the study period, thus stress, an aggravator of CVD risk was an overarching issue within their lives. Obesity integrated with high blood pressure existed in 61% of the men and denoted the most common combination of risk factor. The next combination in terms of prevalence was heart disease family history and blood pressure. The combination of heart disease family history and obesity emerged as the third most prevalent risk combination. After adjustments for age and incorporating conventional cardiac risk factors, stress and income emerged as the only considerable factors in the men’s underestimation of the individual CVD risk. DeSalvo et al. (2005) observed that, overall, a very minimal concordance level existed between the respondents’ objective and perceived risk. Two thirds of the men did not consider themselves at individual risk of heart disease in spite of their real multiple factor prevalence. The investigators did not ask men whether they considered stress a CVD risk factor but instead asked the respondents whether they experienced any stress and incorporated stress in the risk factor analysis. In contrast, stress emerged as a major problem among Afro-American men engaged within a focus group study examining individual hypertension perceptions (Webb & Gonzalez, 2006). Across five focal groups, the men considered stressing the major risk factor for hypertension. Some Afro-American men cited racism within the society and at workplace as the main trigger of stress. The men in Webb and Gonzalez’s (2006) study were employed and educated, and all had acute knowledge of the damaging impact of hypertension among Afro-Americans. 20 of the 47 men had been subjected to diagnoses of high blood pressure and their relatives had high blood pressure. From the socio-demographic perspective, they were different from the men within the study undertaken in New Orleans who experienced daily stresses triggered by urban poverty and inner city conditions (DeSalvo et al., 2005, p. 1130). The juxtaposed perceptions of both groups of men underscored the devastating effect that stress posed on the Afro-American men’s cardiovascular health, alongside the diverse economic and social categories. DeSalvo et al. (2005) argued that stress possessed an insidious impact on health as experiencing stress might block women from caring about their cardiovascular health. Additionally, the men in the study did not attribute cardiac risk to stress and underestimated their individual risk, thus making it less likely they would shift their habit via smoking cessation, diet, or exercise. As observed by DeSalvo et al., “men who experience stress may be unable [initial emphasis] to take care of cardiovascular health, thus unwilling to take into account” (p. 1129). They advocated for interventions directed to the target group health beliefs that would involve future research examining how at-risk Afro-American men defined stress. Moreover, they suggested that innovative educational initiatives, which included stress reduction mechanisms might be efficient compared to traditional mechanisms for CVD risk reduction.

Liewer, Mains, Lykens, and Rene (2008) examined barriers towards CVD risk knowledge in men living within Tarrant County, Texas. Designed to produce insightful information for expounding community resources for men, the qualitative study featured interviewing directors and managers from 10 community organizations namely a provider-related advocacy group, a general heart health organization, two local public health agencies, four hospital-based cardiac rehabilitation facilities, and two ethnic heart health organizations. Only one institution had initiatives tailor-made specifically for men’s CVD problems. Many patients at Cardiac rehabilitation facilities were men. The AHA provided several initiatives, including “Choose to Move” and “Simple Solutions” designed specifically for men. Many participants in Texas confirmed the findings of Mosca et al. (2010) that care giving practices posed impediments to health prevention for several men.

Other issues, which appeared as barriers to the men’s cardiovascular health care included the necessity for cultural awareness in delivering health education messages as well as the need for men to advocate for heart disease that constituted a major concern for one ethnic organization (Liewer et al., 2008, p. 28). Barriers associated with healthcare delivery system featured perceptions that physicians did not speak to men in the same manner they did to women as well as the dependence of several men on doctors as their main health care provider. Compared to doctors in family practice or internal medicine, specialists might not be aware of the CVD risk factors and men who do not understand the CVD symptoms may misinterpret or downplay their symptoms while consulting the doctor. One respondent on cardiac rehabilitation explicitly considered an impediment towards receiving early better care a lack of awareness on the doctors’ and patient’s part regarding the atypical symptoms of a cardiac disease that men experience. One thematic concern that was dominant was that men accustomed to catering for their next of kin should be able to serve as advocates in not only learning their symptoms and signs but by posing appropriate questions and remaining interactive during communication with their favorite healthcare expert (Liewer et al., 2008, p. 34). Need for sensitization, routinely considered a critical issue, including offering me information on existing tests, creating awareness regarding the cardiac history of the family, and providing guidance and information on exercise and nutrition. Liewer et al. (2008) identified a regional program, the Healthy Tarrant County Collaboration (HTCC) educational and hypertension program that provided psycho-educational initiatives. The study formed part of the effort for expanding the program to include cardiac health. As an illustration of the manner in which community groups may rely on domestic resources, the authors observed that the site had running, biking, hiking and walking trails. For residents without transport, they stressed the need of maintaining the safety for local parks to facilitate outdoor activities. Within their region, the Salud Su Corazon initiative and cultural health tackled heart health in the large Latino population. Frank and Grubbs (2008) examined the popular nature of church-driven programs using Afro-American residents. Indeed, local churches offered an ideal venue for promoting healthy activities for Afro-American rural communities. Barbershops and hair salons in Afro-American communities also emerged as efficient sites for supplying health educational materials (Kleindorfer, 2009).

Liewer et al. (2008) observed that tackling the men’s cardiovascular health awareness needed a coordinated method with collaborative partnerships in programs and agencies. The authors observed that consumers had a preference for a program, which suited their needs. Tarrant County represents different locales with current programs that require adaptation or expansion to offer cardiovascular health services and education to men.

Cardiovascular Health Communication

Schmittdiel, Taylor, Uratsu, Mangione, Ferrara et al. (2009) investigated variations between patient and doctor communication styles and its relation to medication regimens. No considerable gender variations were identified for communication that involved patients adhering to the medication regimen. Bryant, Lande, and Moshavi (2012) investigated long-term interactions involving patients and doctors. Personality traits, empathy, and listening skills were areas examined for improving quality. Increasing uncertainty or knowledge might be undermined by the compliance likelihood, aggressiveness level, and physician or patient’s interpersonal styles. Thus, patients were urged to take part in the health management via self-management. This constituted tri-fold communication strategy implemented as ongoing or preventative care. Self-reported patient details gathered before office visits promoted doctor-patient dialogue, which targeted communication after and during visits. Patients were urged to play a leading role in the health or participation, which created empowerment to increase their awareness about the symptoms for purposes of treatment. The process enabled the doctor after and during visits to come up with sound decisions regarding treatment plans. The patients were not passive listeners, but active participants with the doctors concerning any treatment (Bryant, Lande, Moshavi, 2012). This was referred to as the knowledge model that cardiologists used in a research study to ask patients to keep track of their levels of blood pressure, cholesterol, and stress. Doctors gave the self-management and knowledge power to the patients in tracking the health of their hearts. During the visits to the doctor, both the doctor and physician deliberated upon current prevention methods, possible treatment plans, compliant treatment plans for future diseases with the view of decreased uncertainty on the part of the physician for proper treatment. Bryant, Lande, Moshavi (2012) discovered a modified doctor –patient interaction that utilized knowledge model modified communication regarding cardiovascular health alongside other health outcomes. Written materials play an important role in sensitizing the public on mechanisms of decreasing their chronic disease risk factors’ and initiate healthy lifestyle decisions. Significant evidence indicates the most efficient materials include those designed to the targeted group; however, in spite of the greater prevalence of chronic illnesses in minority populations, there is no existence of culturally appropriate health education materials (Parra-Medina et al., 2004). Moreover, many educational pamphlets and brochures have reading levels, which surpass the levels of average Americans (Sellers et al., 2003). Even graphic images are usually designed poorly and are either unduly or bland, thus undermining the potential of inspiring positive behavioral changes (Goldman et al., 2006). Eliciting consumer input via focal groups is possibly the ideal means of designing materials for optimum effect. Assessing current materials might provide the beginning point for enhancing the quality of materials used in health sensitization.

According to Sellers et al. (2003), many healthcare instructions are above or at 9th –grade reading threshold despite the notion that the reading level for average American adults ranges from 8th -9th grade. For instance, a single study revealed that, with a single exception, the educational brochures that the Arthritis Foundation distributed required one to have a reading level of a 10th grade, far surpassing the reading levels nearly a third of the customers with a 7th-grade reading level. Other studies revealed similar trends concerning educational handouts on HIV/AIDS and cancer. The study by Sellers et al. focused on the reduction of CVD risk among ethnic minorities and men. Because of this, the investigators studied printed educational materials on physical exercise and diet. The study featured 174 pamphlets, handouts, and brochures as well as other materials, with 80 targeting both diet and exercise risk factors, 42 focusing on diet, and 42 focusing on exercise. Seven kinds of printed were targeted at Afro-Americans with 16 created specifically for men. The reading materials included lower levels of reading than cited in other studies; however, Sellers et al. (2003) still discovered that many materials surpassed what they considered acceptable level (5th to 9th grade). There was a consistent link between redundant health outcomes and education even those not dependent on SES. While some investigators considered low education levels an impediment to understanding healthcare guidelines and health promotion information, few investigated the problem directly. Sellers et al. observed that, while the featured materials were not conclusive, they emanated from different sources. They requested health experts to lead the advocacy campaigns by designing and distributing reader-friendly and culturally proper materials (pp. 193-194) to fulfill the demands of the population groups. The Sellers et al. (2003) study incorporated the WISEWOMAN research team. Expounding on their work, Parra-Medina et al. (2004) presented procedures for tailoring and redesigning educational materials on exercise and diet for Afro-American men residing in the South. The authors stressed their mechanism might be adapted and replicated to other racial groups. Creating evidence-based teaching materials for convenient use within busy clinic facilities constitute an intrinsic aspect of the WISEWOMAN project. Parra-Medina et al. (2004) utilized the Heart Healthy and Ethnically Relevant Tools (HHER Tools), which utilized seven phases: a) creating a materials’ inventory based on physical activity, or diet or both; b) designing an assessment form for the cultural significance of each material, efficiency in passing health awareness messages, suitability of clinical environments c) selecting a material subset for review by professional panels; d) undertaking consumer focal groups to determine the cultural relevance, clarity, and appeal for the eight materials ranked highly e)redesigning both materials; f) soliciting additional feedback from the focus group; and g) finalizing the redesigning. 214 materials were catalogued for first analysis. Many books on health communication provided deriving assessment guidelines to the panel of experts comprised professionals drawn from Alabama and South Carolina. The study was undertaken at one urban and one rural South Carolina clinic and featured four focal groups with each having two topics on exercise and diet. All focal groups’ respondents included Afro-Americans. The expert panel emerged efficient in locating materials that were attractive to members of the focus group (Parra-Medina et al., 2004). There was significant preference for eye catching (visually appealing), useful, and concise materials. Within the redesign, an older and younger Afro-American represented the major characters. Four physician frameworks were incorporated: Two Caucasian, one Afro-American, three Afro-American women and one man.

When the focal groups reconvened, the materials that had been redesigned generated favorable responses. Particularly, the respondents were satisfied that the research team considered their views (p. 586). Bright colors looked attractive with respondents praising the conciseness and graphics, as well as written material. As one respondent within the physical exercise group asserted, one assumes that he is the one (p. 586). There were additional proposals for modifying the nutritional components based on the knowledge that eating behaviors were deeply entrenched, thus cumbersome to change particularly for men with families. While confirming that the components should allow men to perceive they are important, many women proposed the materials need to have a family focus. Many respondents in the focal group preferred the male doctors’ images. Indeed, many men stated emphatically “Get that woman out of there” (Parra-Medina et al., 2004, p. 586). The men preferred men preferred pictures indicating the doctors involved in active listening and constructive communication. They considered the ideal doctor compassionate, a person one relates to (p. 586). The sole preference pertained to gender; the men were amenable equally to pictures depicting a Caucasian or Afro-American male doctor. The men preferred younger male patient, considering her exciting, vibrant, energetic not too fat and thin –a good-looking person but with something to improve upon. Tags on final components included HHER Walking Low-Fat Living and HHER Walking Program. Parra-Medina et al. (2004) tested the themes at two community health facilities in South Carolina, and the pamphlets formed part of HHER Lifestyle Program intervention packages. The initial response from participating health experts was significantly favorable, describing materials culturally practical and relevant for the settings. Goldman et al. (2006) were affiliated to a multidisciplinary study team having the collective objective of enhancing CVD risk and cholesterol awareness. The investigators recruited the respondents for a focal group survey undertaken in a community in Northeastern. 50 adults took part in seven focal groups where they discussed and viewed presentations for two standard risk information messages as well as HeartAge, the risk information instrument the research team developed. The components’ revolved around CHD risk based on the Framingham Heart Score. The main character within the three visual exhibitions was a man aged 42 years. The initial involved a crowd chart involving 100 stick figures having shadings denoting the anticipated proportion, which may develop CHD in the next decade alongside a comparison to the hypothetical middle –aged man without risk factors. The second exhibition utilized vertical bar graphs to indicate a relative reduction of risk. The final exhibition was HeartAge, which showed the 42-year old man with a similar CHD risk probability as the average 70-year old. The focal group respondents included different educational levels, income, and age groups. Goldman et al. (2006) observed that all respondents understood the dangers associated with cholesterol, thus respondents within the two literate groups understood their levels of cholesterol; however, in other groups, the only respondents who understood their levels of cholesterol had severe issues or a family history linked to high levels of cholesterol. The respondents assumed generally that testing of cholesterol constituted a routine element of frequent physical examination and whether their physician did not provide a discussion of their level of cholesterol, it should be normal. Many respondents did not prioritize control of cholesterol level compared to their blood pressure, thinking that the mortality rate from cholesterol is not comparable to blood pressure (p. 209). While the respondents understood the significant link between CHD and high blood pressure, they considered the correlation between CHD and cholesterol difficult and distant for relating to personally. Many studies revealed high awareness levels regarding the hazards of high blood pressure because of many years’ health awareness campaigns. On the other hand, many respondents had heard about cholesterol in the recent years. The focal group rejected the crowd universally terming it busy and confusing (Goldman et al., 2006). Conversely, they considered the graph too dry, too statistical, and boring (p. 209). The graph attracted the few respondents that understand statistics. However, many considered Heart Age engaging as it conveyed a strong visual message. A few respondents observed personal alarm by the notion that their heart attack risk might be equivalent to that of an octogenarian.To overcome the fear numerous respondents proposed that the graphics need to incorporate information for decreasing cardiovascular risk. Numerous respondents suggested that it was easier to recall and associate age figures with cholesterol percentages or numbers. To Goldman et al. (2006), the most significant finding pertained to the low knowledge level regarding cholesterol cited by respondents that underscored needs for efficient methods for conveying risk messages. The study explained the efficiency of certain visuals used commonly in health tutorial materials. Perhaps, it indicated that the research team selected a man as a representative of heart attack risk even though their intention entailed creating generic figures for the focal group exploration instead of a completed product. The basic Heart Age model might be adapted easily for race and gender.

Social Capital and Health Promotion Messages

The word social capital is utilized widely across disciplines; however, Viswanath, Steel, and Finnegan (2006) noted, social capital differed with the empirical literature measuring the concept differently. However, despite the differences, social capital included norms of cooperation that is dependent on civic engagement and social networks, solidarity, interpersonal trust, and reciprocity (p. 1456). Within the health literature, studies have indicated that social capital may be an efficient means for decreasing mortality, psychological distress, risky behaviors, and stressful conditions. Social capital may serve as a resource in the improvement of personal health. Viswanath et al. (2006) observed that social capital offered a community integration aspect. In particular, communication investigators cited a link involving media use and social capital. Building on the research line, Viswanath et al. incorporated the notion of pluralism within the community, signifying the community diversity and size. Residents in communities that exercised pluralism appeared to depend on impersonal communication avenues, for instance, mass media, while those in homogenous communities used interpersonal communication. The focal point of the study revolved around the effect that community pluralism and integration had on a person’s recall of health awareness messages associated with CVD risk. The information was drawn from the Minnesota Heart Health Program. Based upon the analysis, Viswanath et al. (2006) discovered that more individuals incorporated into the communities (evaluated by the proportion of community members), the better placed they are to remember non-specified and specified information associated to CVD prevention. Greater community involvement associated with a broad exposure scope to health awareness messages coupled with a comprehensive recollection for health information. Unsurprisingly, people actively engaged in institutions, which offered health education possessed a significant recall. Community ties and pluralism independently associated with the recollection of CVD-related health information. According to Viswanath et al., their findings brought to the fore the critical issue of the way targeted health promotion information to socially discriminated residents in small communities. However, the Minnesota Heart Health Program spanned from1980-1993 prior to the entry of the Internet. Community ties may not similar effects when health information existed widely on the internet. The authors recommended that further research should explore whether the identified correlation between healths used on virtual communities and community integration, and social capital.

Media Coverage of Health Disparities

The mass media provides routine reports on health disparities depending on ethnicity and race; however, the scholarly literature seldom investigates how such disparities are portrayed (Kim, Kumanyika, Shive, Igweatu, & Kim, 2010). Kim et al. suggested covering the aspect from different perspectives that include emphasizing individual responsibility for health; or on the other hand, a social justice viewpoint explaining health system disparities. To tackle the issue, the investigators evaluated articles about ethnic and racial health inequalities appearing within 40 newspapers from 1996-2005. The investigators coded the articles based on their coverage of potential causal factors within the proposed solution and health disparities. The evaluation yielded eight possible causes, compiled into four categories: a) genetic variations; b) behavioral factors including ethnic or racial variations in behaviors, cultural norms, attitudes, or knowledge, c) health care system factors, including variations in discrimination from healthcare providers and access towards healthcare; and d) societal factors associated with the severe influences of residing in unhealthy environmental situations, including an upsurge in fast food eateries, lack of entertainment spaces, and unsafe neighborhoods.

Kim et al. (2010) categorized possible solutions to the recorded disparities based on the aforementioned categories, including: a) societal, where efforts for improving health are embedded within policies that address environmental, physical, and social conditions, b) healthcare that refers to expanding health insurance cover or modifying medical treatment via mechanisms that include cultural sensitivity training of health experts, c) behavioral, including culturally –designed media health campaigns, educational programs, and behavioral interventions, and d)genetic indicating genetically targeted/testing drugs. Out of the 3,823 articles focusing on ethnic or racial health disparities, nearly 70% ignored the possible solutions or causes. Out of those that considered the solutions and causes, majority (86%) explored causes at the expense of solutions (46%). The most popular sources for causal information included practicing health nurses, the media, and academic investigators. Notably, many solutions emanated from the advocacy groups. Other solution sources included lay individuals, health clinicians, and the media.

Kim et al. (2010) asserted that overall media focus on health disparities reduced since the mid -1990s, while the interest in academics increased. However, some trends remained stable, particularly attention towards cancer, HIV/AIDS, CVD: all diseases, which affected Afro-Americans disproportionately. Behavioral factors were accorded the highest attention level concerning solutions and causes, with societal factors, healthcare, and genetics ranking second, third, and fourth respectively. Given the duration, it is not likely that genetic effects on health were accorded significant attention. Another study exploring articles written since the 1990s will possibly produce many references towards genetic factors.

According to Kim et al. (2010), an inadvertent effect of the focus on behavioral aspects was supporting views that an individual was responsible for his/her personal health, thus impeding public support towards policies that are designed for reducing health disparities. Highlighting the notion that scholarly investigators appeared largely absent from solution discourses, they argued that investigators may help press releases and interviews (p. S230). Additionally, they called for additional research to determine the public interpretation of various health disparity explanations with the purpose of increasing awareness on social health influences. The participants in the focal group within Webb and Gonzalez’s (2006) study of Afro- American men’s perceptions regarding hypertension accused the media of neglecting health concerns that affect Afro-Americans. For instance, one man observed that no one was sensitizing Blacks on the risk they faced with regard to high blood pressure. This features physicians who may not understand it themselves. Another man lamented that it seemed as though things did not apply to them. For instance, he said that when advertisements are presented-they do not feel part of the process (p. 262). According to another respondent, “Unless there is history of high blood pressure within the family, individuals may not even understand that they face the risk (p. 262). Interestingly, investigators usually praise the high knowledge levels regarding stroke and high blood pressure, which arises within surveys on health education initiatives. However, many surveys did not ask respondents where they acquired the information. The respondents within the hypertension focus group recounted their awareness about devastating effects from hypertension to community, friends, and family members, while many men had an individual diagnosis regarding hypertension (Webb & Gonzalez, 2006). Some men cited local health campaigns; indeed, one man was disturbed at the tender age of adults with hypertension. The focus group respondents’ indicated the need to have mass media messages intended at the Afro-American men.

Cardiovascular Risk Screening

Kleindorfer (2009) proposed that variations in understanding the risk factors and warning signs of stroke might be overlooked but it is a considerable contributor to disparities associated with race. The researcher observed that, paradoxically, people at the greatest stroke risk, particularly elderly adults and minorities, usually experienced the highest levels of ignorance. Further complicating the identification of stroke symptoms, stroke warning signs were not accompanied with pain and disappeared in a few seconds or hours (Willoughby et al., 2001). Consequently, symptoms may be overlooked easily, leading to dangerous delays in treatment. Advanced treatments have resulted in favorable neurological outcomes if provided in three hours after the identification of symptoms. However, many adults do not understand the severe warning signs. Willoughby, Sanders, and Privette (2001), suggested that identification of warning signs associated with stroke played a pivotal role in knowing the total benefits of life-changing treatment. In late 1990s, public health researchers noted a rise in death rates from stroke after declining for 40 years.

The effect was particularly prevalent in the southeast’s stroke belt. Many community venues in the United States regularly provided community health screening; however, Willoughby Sanders, and Privette noted that, despite the prevalent nature of stroke, there was limited empirical awareness of the efficacy in creating awareness and changing behavior associated with stroke. To overcome the issue, the investigators examined the effect of psycho-educational program and stroke screening on the respondents’ understanding of risk factors and warning signs, alongside self-reported changes in acceptable habits. The screening program took place in a state located in the stroke belt. Willoughby et al. (2001) based their investigation on a non-random convenience adult sample attending a screening program for preventing stroke held during the National Stroke Awareness (NSA) Week. The initial screening session attracted 107 respondents requested to fill the NSA risk appraisal form, which contained information about the screen test results, treatment history, stroke knowledge, and personal history. The test results included the respondent’s carotid artery auscultation, pulse palpitation, body fat percentage, weight, blood glucose, blood pressure, and serum cholesterol. A registered nurse (RN) offered respondents individually designed counseling, which featured mechanisms for reducing or controlling personal risk to stroke, instructions for contacting a person who has experienced stroke or calling the emergency number (911), and stroke recognition. After completion of the evaluation, all respondents were issued with a NSA stroke risk reduction plan. Averagely, the nurse spent around ten minutes interacting with a respondent; however, the time differed based on counseling needs and individual risk to stroke. A dietitian and a pharmacist were also present for respondents that sought more guidance and information. Following the NSA Screening Week, the manager in charge of stroke cases at the health facility that run the project undertook phone follow-ups at one, three, and six months respectively (Willoughby et al., 2001). 85 of the 107 respondents answered the questions, which pertained to emergency response, individual risk factors, warning signs, and knowledge about stroke. Men accounted for slightly over 53% (half of the respondents) whose age ranged from 32-84. Approximately 74% (three quarters) of the respondents comprised of Caucasians with Afro-Americans and other ethnicity accounting for 6% and 5%. The survey indicated that respondents acquired a considerable level of awareness from the stroke screening program. Six months following the program, nearly all participants answered the questions accurately whereby within the body stroke exists (98%, up from 52% at the pretest) and located all except one warning signs (loss of balance, dizziness, speech changes, vision change, and weakness) with precise answers varying between 92% and100%. All the respondents answered correctly with regard to the action to be taken when warning signs of stroke appear, up from 41% within the pretest. The only impediment was severe headache, even though a significant rise in the quantity of respondents that identified stroke symptoms accurately from the six-month survey pretest (42% against 68%).Willoughby et al. (2001) observed the screening initiative embodied the PRECEDE-PROCEED approach to community health promotion principles that commenced with a needs evaluation, unfolded alongside the active participation of community members and leaders, and included systematic, continuing assessment included into the model of the program. The follow-up interviews, which formed part of the project, indicated the community program’s efficiency for increasing knowledge and awareness but revealed common structural challenges to implementing such knowledge as well. A considerable issue revolved around the fact that a few respondents did not have access to primary healthcare providers. Identification of the obstacle resulted in the growth of a free clinic within an underserved area of the community designed for serving uninsured low-income customers. The health facility became the preliminary screening site with prompt referral to the physicians. Willoughby et al. recommended strongly the PRECEDE-PROCEED model for promoting public health and intervention.

Frank and Grubbs (2008) provided a description of a church-based educational and screening program intended for Afro-Americans within a community residing in rural Florida. Churches have previously been a common site for promoting health programs among Afro-American communities and the authors considered churches, particularly promising for creating health awareness within rural communities whereby the church served as the central point in cultural and social life. The project utilized a grassroots model that started with the investigators establishing relationships with pastors that managed the local community facility. The pastor played the role of a liaison between pastors heading four small churches in the rural areas and the investigators. Five screening sessions were undertaken within the four churches (Frank & Grubbs, 2008), four incorporated into the midweek sessions of Bible study and another after the Sunday service. The pastors incorporated the health thematic concern in the sermons, thus demonstrating their support and facilitating the movement to the session for health education. The nurse investigators offered church members a comprehensive explanation about the initiative and requested their participation. All respondents received a survey packet that included a health log for data recording from screening (blood glucose, blood pressure, weight, height) consumer contentment survey, post-test, and a pretest. Nursing students responded to questions and offered assistance to anyone that needed assistance with the survey, which proved particularly important to aged parishioners. A 20-minute educational session that had information on stroke, diabetes, and CVD alongside advice on physical exercise and nutrition used the pretest (Frank & Cobbs, 2008). After the session, the respondents completed the posttest survey and moved on to the screening site, which was filled with pamphlets and brochures on initial intervention for heart disease, diabetes, and stroke. The nursing students and nurse investigators were on hand to respond to any questions. The final element within the initiative constituted a healthy snacks buffet and door prizes, including big seasoning containers utilized in soul food and snacks recipe books. Additionally, there were recipes containing nutritious foods. Over 120 church members were present at the educational initiative with 78 finishing the posttest and pretest, and 89 finishing the pretest. Men accounted for 70%of the respondents, indicating the Bible study classes. Frank and Cobbs (2008) noted that the parishioners who finished the pretest appeared to be octogenarians and had low knowledge levels regarding the risk of CVD. They considered this evidence that the study survey may have been complex or too long for people with little awareness of health concerns, low literacy, and eye problems. Middle-aged respondents possessed significant knowledge levels. Young adults below 30 years had considerably lower knowledge scores, perhaps because they believed they were at low individual risk. However, the investigators explained the significance of targeting young adults in CVD education to promote healthy lifestyle behaviors. Older adults above 60 years had limited knowledge levels despite having high hypertension incidences. The older respondents experienced low literacy levels and the absence of transportation as an impediment to programs that include health screenings.

Frank and Cobbs (2008) observed that, while two-thirds of the respondents cited taking part in frequent physical activity, 84% were obese (overweight) based on their body mass indices (BMIs). A likely trigger was their consumption of unhealthy food, tackled by the nutritional portion of the initiative. Another explanation was that they needed a comprehensive exercise regimen, even though exercise without adequate diet was insufficient for loss of weight. The consumer contentment survey confirmed the program’s success escalating the respondent’s CVD risk factor and health awareness. The large proportion of respondents conceded to acquiring new information on stroke, diabetes, and heart disease, thus they would encourage others to enlist in the program. Nearly, all had an interest of featuring in such initiatives in the future. Moreover, the responses alerted the investigators to parts that require modification including accessing older adults having low-literacy levels and enhancing information delivery on nutrition and exercise. The investigators observed that church pastors were elated about the programs, thus would agree to take part in future programs.

Community Interventions

Blacks in the United States and United Kingdom have greater stroke and hypertension prevalence (Connell, Wolfe, & McKevitt, 2008). On the two sides (that is, UK and US), community health promotion programs may be an efficient means of fighting stroke and hypertension among high-risk populations. To investigate the efficiency of community initiatives designed to decrease the risk of stroke through promotion of high blood pressure control as well as identifying characteristics of initiatives linked to significant success, Connell, Wolfe, and McKevitt undertook a broad research review that spanned between 1981 and 2006. From the first 324 articles, the investigators chose 33 articles that described 27 studies, which fulfilled their incorporation criteria. All the articles that were explored put emphasis on Afro-American adults with about half featuring randomized- controlled tests. The remaining articles provided posttest and pretest evaluations, with one random-crossover clinical trial and two experimental designs. All studies were undertaken in the United States save for a single study that was undertaken in Jamaica. The interventions used different mechanisms that included community-wide risk factor reduction, reduction of risk factors, individualized screening, social support for hypertension management, active self-management methods, psychosocial counseling and education, and health awareness classes (Connell, Wolfe, & McKevitt, 2008). Most of them were multi-dimensional initiatives that involve many strategies. Indeed, Connell et al. discovered the multifaceted initiatives, combining support for hypertension management, self-management, and integrating health education, had successful outcomes. The findings indicated the programs might be equally efficient when delivered within healthcare environments or within other community facilities. Despite the good outcomes, one drawback of many of such studies, according to Connell et al., was their evaluation focusing solely on short-term program effects. Many studies cited outcomes for less than or one year following the intervention. The characteristics of an effective health intervention initiative appear to be similar regardless of the targeted population (Connell et al., 2008). Health awareness increases knowledge; however, it is not enough for sustaining change of behavior, achieved by equipping respondents with techniques and strategies for active self-management. Some initiatives, offer respondents support whereas others incorporate skills for securing informal and formal support within the training. According to Connell et al., people perceived the word community in various ways, as a word for a specific population or an inference for geographic location for instance, in community-wide or community –based interventions. Plescia, Herrick, and Chavis (2008) observed that community –driven mechanisms for fighting CVD took place in different environments. Community participation and acceptance allow the programs to access many people, thus community participation plays a critical role in eliminating health disparities. From 1999 – 2007, the Centers for Disease Control and Prevention (CDC) financed community-based initiatives via the Racial and Ethnic Approaches to Community Health (REACH) 2010, aimed at addressing health disparities. Plescia et al. (2008) examined the Charlotte REACH project intended to use and expand on relevant strategies for curbing diabetes and CVD risk within an urban Afro- American community within the city’s northwest. A new community health facility in the area had CVD death rates, which surpassed the county average by 40% alongside diabetes hospitalization three times more compared to those for the county. The project goals involved smoking cessation, dietary changes, and promoting frequent physical exercise.

Plescia et al. (2008) evaluated the efficiency of the Charlotte REACH program through surveying of community residents for five years. The survey questions were obtained from the BRFSS. The annual number of survey participants ranged between 904 and 1,028 and were mainly from Afro-Americans (95%). There were considerable modifications in the three targeted behaviors in 5-year period. Improvements that were statistically significant were cited for smoking and physical activity in men, for physical activity in middle-aged adults, in middle –aged adults, and for significant vegetable and fruit consumption. The design for REACH is based on the public policy, a coalition-based method advocated by Kim et al. (2010) for decreasing health disparities. As the Charlotte REACH program developed, community organizations, including the farmers’ market, the YMCA, the churches, and local health facility became active participants. Particularly, the partnership involving the YMCA and farmer’s market was a major force in overcoming perceived impediments to adoption of healthy lifestyle habits. Plescia et al. (2008) explained one barrier to extensive implementation of community initiatives such as REACH: maintaining such programs required considerable amount of external funding.

Ethnic and Gender Treatment Disparities

Since the 1980s, investigators have provided evidence that gender and race affected the use of invasive cardiac methods (Watson, Stein, Dwamena, Kroll, Mitra et al., 2001). Such procedures featured coronary artery bypass grafting (CABG), percutaneous transluminal coronary angioplasty (PTCA), and angiography (coronary catheterization), considered to decrease CVD mortality, reduce cardiac symptoms, and enhance diagnostic accuracy (Kressin & Petersen, 2001). Since CVD is the major cause of mortality regardless of gender or race, researchers strived to discover the factors underlying treatment-based disparities. CVD is a leading cause of death irrespective of race or gender, investigators endeavored to discover the reasons underlying disparities with the intention of enhancing outcomes for cardiac patients. Watson et al. (2001) observed that, from 1980 -1990, there was a 34% decline in CHD deaths, attributed generally to better treatment instead of reduction of risk factors. The decrease in mortality was drastic for Caucasian patients compared to that for Afro-American patients, thus treatment and variations might be a major reason. Kressin and Petersen (2001) reviewed studies regarding the application of invasive cardiac processes with studies in MEDLINE and undertaken from 1966 – 2000 including participants’ ethnicity and race. Out of 637 studies, 61 fulfilled the inclusion criteria of the author.The investigators divided the studies into three categories. The first category had 27 studies marked as administrative studies, 26 utilizing administrative data, such as insurance claims, and discharge data, and another drawn directly from the medical records. The second category featuring 11 studies used clinical databases from registries and clinical trials. The third category featured hypothesis-based survey study and qualitative research. As a different category, the studies within the group featured patients’ perceptions regarding their experience with medical experts, doctors’ recommendations and attitudes, and patient preferences.

Kressin and Petersen (2001) based the review on the conceptual model that outlined three factors, which might affect medical decisions including healthcare system features, provider features, and patient features. The focus of the study was solely on racial disparities regarding invasive cardiovascular procedure usage. However, the description for patient features alongside the sociodemographic aspects cited as potential effects on medical choices included health insurance status, marital status, income, education, age, and race. Gender was not mentioned. Provider features consisted of bias or attitudes, and practice speciality concerning patients that might influence the relationship quality and communication involving healthcare expert and the patient. Healthcare characteristics included the reimbursement and financial issues, local practices, service organization within the healthcare system, and presence of cardiac technology or procedures. The administrative studies revealed that, even when regulating for factors associated with the healthcare system, there was a significant gap between the use of CABG, PTCA, and coronary angiography for Afro- American patients (Kressin & Petersen, 2001). Additionally, the studies showed that Asian and Hispanic patients were less likely to receive such procedures compared to Caucasian patients. Even the clinical studies indicated racial gaps within treatment despite using respondents with comparable illness severity. The findings were inconsistent; some studies did not find racial disparities. However, as evidence for the importance of such disparities, Kressin and Petersen explained a 1997 study by Peterson et al., which reported that Afro-American patients possessed a 32% lower probability for accessing bypass surgery, leading to lower rates of survival over five years; for instance, 20% in Afro- Americans against 27% in Caucasians. In survey studies, one suggested that Afro-American patients were reluctant to undergo revascularization compared to Caucasian patients; however, understanding the mechanism superseded race as a decisive aspect (Kressin & Petersen, 2001).

Cardiovascular disease, which features heart failure, stroke and heart disease, is the major cause of mortality for all Americans; however, information from 2002 indicate that CVD mortalities in Afro-American women and men in Mississippi, for the size of the population, were 12% and 22% respectively; a higher figure than the entire United States (American Heart Association, 2007). The CVD risk factors include type 2 diabetes, obesity, overweight, high cholesterol, and high blood pressure. There is increasing evidence of disparities, which occur between other ethnic groupings and Afro-Americans with regard to CVD. For instance, a countrywide survey indicated that between 1999 and 2002, 40-43%of Afro-American women and men had high blood pressure than a mere 28% of White women and men (CDC, 2002). Additionally, Afro-Americans have nearly twice the risk for first stroke than Whites (Health US, 2004). Among Afro-American adults aged 20 years and above, 77% of women and 63% of men are obese (overweight) (Hedley et al., 2004). Such statistics significantly provide a description of the disproportionate levels that Afro-American have in developing CVD alongside the risk factors. The National Center for Minority Health and Health Disparities (NCMHD) and the National Heart, Lung, and Blood Institute (NHLBI) embarked on a study to tackle the problem of CVD in the Afro-American community. Jointly, they have financed the Jackson Heart Study (JHS) an investigation on the factors, which affect CVD development among Afro-American women and men. The study has investigated and would monitor 5,302 Afro- American women and men in their entire lives to precisely observe CVD risks. While previous studies on CVD have existed in the past, they have overlooked Afro-Americans. The JHS is not solely investigating conventional CVD risk factors but newly arising rising factors including discrimination and genetics. The city of Jackson was a suitable site for conducting such an extensive study. The population of Mississippi has the largest proportion of Afro-Americans (37%) than other states (The Henry J. Kaiser Family Foundation, n.d). The JHS is positioned uniquely to examine the risk factors of CVD, particularly manifestations associated with renal disease, peripheral arterial illness, stroke, heart failure, and coronary artery disease. First Exam (2000-2004) featured pulmonary function, echocardiography, ECG, 24-hour urine collection and phlebotomy, blood pressure and resting, anthropometry, medical history, psychosocial inventories, and demographics. Second Exam (2005-2008) featured a few repeated measures in First exam as well as other additional components, including a CT scanning for measuring abdominal fat and calcium of the coronary artery, DNA collection, and supply of personal-tracking blood pressure gadgets, a CT scanning, and DNA collection for measuring calcium and abdominal fat of the coronary artery. Third Exam (2009- 2012) included a few repeated measures in the initial two exams alongside new assessment questionnaires for cognitive function and sleep history, as well as cardiac MRI scanning by contrasting gadolinium MRI within a respondent subset to locate quiet myocardial infarctions. Abnormal results were presented to the respondents and healthcare facilities. Follow-up of critical condition alongside additional data gathering including location of intervening clinical events was undertaken annually though telephone calls. The colleges contracted for the JHS included Tougaloo College (Training Center for undergraduates) where chosen students are provided with a chance of taking course works in epidemiology and health, as well as acquire practical experiences within health studies to assist in preparing them for possible career in such fields, Jackson State University (A center for coordinating data), and the University of Mississippi Medical Center (A center for collecting data). The Jackson Heart Study featured 5,302 respondents selected from Jackson, Mississippi, metropolitan area (Rankin, Madison, and Hinds counties). The age of respondents ranged from 21-84 years when they enlisted within the study, and almost two-thirds were women (64%). A total of 1909 men and 3,393 women took part in the study, with half of the respondents being middle-aged. Many respondents came from Hinds County. Examining the course and natural history of CVD within Afro-Americans constitutes a notable characteristic of the Jackson Heart Study. CVD constitutes the major cause of mortality for Afro-American and Afro-Americans also appear to have significant levels of total cholesterol, diabetes, and hypertension levels that were found to be stroke and heart attack risk factors. Among JHS respondents, 3 in every 5 are diagnosed with hypertension, 1 out of 5 has diabetes, and one out of four has bad cholesterol (increased LDL) whereas 1 out of 3 posses a good (HDL) cholesterol level that is very low. Both environment and genetics play critical roles in determining complex correlations between CVD, risk factors, as well as behaviour. Thus, researchers within the Jackson Heart Study have gathered information on different aspects that include community characteristics, medical history, alongside access towards healthcare to acquire extensive knowledge on the way the environment might influence the CVD risk. A second notable characteristic of the Jackson Heart Study is a community outreach program. Understanding that a risk factor is significant constitutes an important step in decreasing stroke or heart attack chances. Among JHS respondents with hypertension, almost nine out of ten understood hypertension, but two out of 5 respondents having high cholesterol understood their high cholesterol levels. Increasing awareness at the level of community regarding CVD prevention coupled with enhancement of healthy practices constitutes a major objective of the initiative. Through a health advisor network, the JHS intends to enhance health knowledge and deliver critical information about health to the community. A third characteristic of the Jackson Heart Study revolves around the fact that it constitutes an initiative intended for increasing the proportion of Afro-American health experts. Through the combined research components, training, and community outreach, investigators having the JHS would gain crucial knowledge on the form of CVD among Afro-Americans while simultaneously and constructively influencing the community.

According to Lenfant (1994), the absence of extensive information on heart disease among Blacks undermines attempts of further explaining the disparities in outcomes as well as risk factors. It is not known to what extent ethnic and racial disparities in healthcare and health are triggered and aggravated by racism. Similarly, it is unknown how several factors linked to racism might combine interactively and additively with other psychosocial resources and risk factors to influence CVD risk. Despite hypothesized correlations between CVD, perceived discrimination, and racism perceptions, few-population based studies have investigated such links. Although findings are inconsistent, they indicate the potential for such relationships, especially with hypertension. The reviewed evidence suggests a strong desire for extensive acknowledgement and in-depth research of racism alongside its influences on outcomes and CVD risk factors. Focus on the form of racism coupled with the potential moderating and mediating factors that contribute to the connection between CVD and racism is required. Potential directions of such investigation were located, including the desire for a prospective longitudinal study to increase awareness about the causal and temporal relationships. The Jackson Heart Study, one of the biggest epidemiological cohort studies on the CVD causes and risk factors among Afro-Americans provides a distinct opportunity for investigating the correlation between CVD outcomes, perceived discrimination, and racism over time.


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