Cardiovascular disease risks in women.

Abstract: Cardiovascular disease (CVD) is the leading cause of mortality in the U.S., yet research demonstrates a lack of risk awareness among women. The purpose of this study was to evaluate CVD knowledge among female participants (N = 104) by age and race. Age categories were <25 years, 25-44 years, and 45 years and older. Race categories were white and non-white. The Check Your Healthy Heart I.Q. instrument (National Heart, Lung and Blood Institute, 2004) was used. Using ANOVA (p < .05), there was a significant difference between age categories (p = .001), but no significant difference between races (p = .38). Results indicate a need for educational interventions, particularly among younger women.

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A national investigation indicates that cardiovascular disease (CVD) is the single leading cause of death and a significant cause of morbidity among American women (Mosca, Ferris, Fabunmi, & Robertson, 2004). In fact, CVD claims the lives of more than 500,000 American women each year. This figure constitutes 41.3% of all U.S. female deaths, and is higher than the number of deaths from all types of cancer combined. Among ethnic minority groups, African American women have the highest CVD mortality rate (Mosca et al., 2004; U.S. Department of Health and Human Services [USDHHS], 2000).

CVD was traditionally thought of as a man's disease. Women's health issues focused on menopause and breast cancer. With a focus on menopause and breast cancer, women did not consider coronary artery disease as a major area of concern, thus leading women to be misinformed about CVD. A study in the American Association of Occupational Health Nurses Journal found that 50% of women will die of heart disease and stroke compared to only about 4% that will die of breast cancer (Birchfield, 2003).

Gender-related differences exist in responses to CVD. Women tend to dismiss chest pain as insignificant or caused by indigestion and delay treatment, if they seek treatment at all (Birchfield, 2003). Other investigations revealed that twice as many women die in the first year after a myocardial infarction compared to men (Anderson & Kessenich, 2001). Women also tend to delay longer in getting treatment for symptoms, have more myocardial infarctions that go unrecognized, and are treated less aggressively (Fleury, Keller, & Murdaugh, 2000). Specific risk factors that are unique to women include use of oral contraceptives, menopause, and hormone replacement therapy (Anderson & Kessenich).

The purpose of this investigation was to evaluate women's knowledge of CVD risk by age and race and to increase awareness. An evaluation of the current CVD literature was performed to assess how age, race and knowledge factors are represented in the literature.

AGE

In an investigation on "Social and Contextual Etiology of Coronary Heart Disease in Women" Fleury et al. (2000) stated that coronary heart disease is the leading cause of death and disability in American women over age 50. Before age 60, heart disease rates are higher in men than women. However, CVD increases markedly following menopause. A study by Mosca et al. (2000) revealed that younger women were more likely to respond that they did not know the leading cause of death or did not answer the question compared with women aged 45 to 64 years. Interestingly, 16% of younger women (ages 25-34 years) recognized heart disease as the leading cause of death for women, but only 4% perceived it as the greatest health problem among women. Twenty-seven percent of the women ages 25-34 were least likely to report feeling very well or well informed. An American Heart Association survey found increased cardiovascular disease awareness among women but plenty of room for improvement. Twenty-two percent of the women surveyed reported feeling not at all informed (American Heart Association, 2004a).

RACE

Race is also an issue in considering risk factors for coronary artery disease (Birchfield, 2003, p. 19). In fact, Birchfield claims that African American women are more likely to be hypertensive, diabetic, and obese than white women. African American women were also more likely to develop coronary artery disease or suffer a stroke. Moreover, the death rate for African American women with CVD is almost 70% higher than that of white women (Cheek & Cesan, 2003). An American Heart Association Survey found that the rate of CVD was nearly twice as high among white women (55%) compared to African American women (30%). The same investigation indicated that rates for Hispanic women (27%) were also twice as high as those for white women (American Heart Association [AHA], 2004a). Another study reported that Native American women have higher incidences of diabetes which increases their risk to CVD (Anderson & Kessenich, 2001).

KNOWLEDGE

Researchers have found that women's lack of knowledge regarding CVD may contribute to a higher risk of CVD (Meisler, 2001). A study published in the Journal of Women's Health and Gender-Based Medicine found that women's concerns about cancer have made them pay special attention to scheduling annual Pap smears and regular mammograms yet the same urgency is not given to heart disease (Meisler). This same study also found that four of five women and one in three primary care physicians were unaware that CVD is the single leading cause of death and disability among women.

A study by Bedinghaus, Leshan, and Dieher (2001) provides an example of the lack of knowledge on CVD. In this study, the authors write that public campaigns have emphasized breast cancer risks in an effort to promote screening mammography. The article concludes that many women are more afraid of developing breast cancer than CVD.

Historically, women's health issues have focused on menopause and breast cancer, which may have led women to believe that CVD is not a vital problem for them (Oliver-McNeil & Artinian, 2002, p. 221). Another investigation ascertained that the public's perception is that breast cancer poses the greater threat because of the similar incidence of breast cancer and heart disease in younger women (Holdright, 1998). Finally, Mosca et al. (2004) suggested that U.S. women of all ethnic and age groups have inadequate knowledge about CVD risk factors, inspite of entrenched behavioral and medical routines to lower their risk.

SIGNIFICANCE

According to the World Health Organization, it is estimated that CVD causes 8.5 million deaths among women annually (AHA, 2004b). CVD is the largest single cause of mortality among women, and is responsible for one-third of all deaths in women worldwide. In fact, heart attack and stroke deaths are responsible for twice as many deaths in women as all cancers combined. According to the Healthy People 2010 (HP 2010) report, "heart disease is the leading cause of death for all people. About 12 million people in the United States have coronary heart disease (CHD)" (USDHHS, 2001).

The goal of HP 2010 Objective 12 is to improve cardiovascular health and quality of life through the prevention, detection, and treatment of risk factors (USDHHS, 2001). In the year 2000, the death rate for U.S. women ages 35-74 from CVD was 177 per 100,000 (AHA 2004a).

In 1999, CVD was responsible for nearly 40% of all deaths in Texas. Heart disease alone claimed 43,335 lives or 29.6% of all deaths that year (Texas Council on Cardiovascular Disease and Stroke, 2002). According to the Texas Department of Health (TDH) for the region where this university is located, 3,263 deaths related to CVD were reported in the year 2000 (Center for Health Statistics, TDH, 2002). Although the difference is not statistically significant for all age groups, men (8.9%) reported having CVD more often than women (6.4%; Texas Council on Cardiovascular Disease and Stroke).

When considering these statistics along with the advances in medicine and communication technology, women's knowledge of their risk for CVD needs to be studied. In addition, further and meaningful educational prevention strategies should be presented to all women (Oliver-McNeil & Artinian, 2002). The purpose of this study was to evaluate knowledge of CVD risks among women, by age and race, and to increase awareness.

METHOD

The investigation to evaluate the knowledge of CVD risks among women, by age and race, was designed as a non-experimental, correlational study. This study was conducted at a public Texas university that enrolls approximately 5,600 female students. The Institutional Review Board approved the research study. Survey data was collected from a volunteer sample (N = 104) of female faculty, students, and staff participants attending a health fair that was held in conjunction with the Week of Wellness sponsored by the Student Health Center. The health fair and data collection site was located at the student center. Data was collected on March 4, 2004 between the hours of 10 a.m. and 2 p.m.

The Check Your Healthy Heart I.Q.. survey instrument was developed and published by the National Heart, Lung and Blood Institute of the National Institutes of Health (2004; see Table 1). The survey is an educational health risk assessment tool that was utilized to evaluate knowledge of CVD among women by age and race in one administration. The survey consisted of fourteen true and false statements relating to knowledge of CVD risk factors. Demographic information collected by the investigators included the variables age and race. Age categories were less than 25 years, 25-44 years, and 45 years and older. Race categories were white and non-white. The non-white category included African American, Hispanic, Asian/Pacific Islander, American Indian/Alaskan, and other.

A Healthy Heart I.Q. display of cardiovascular facts specific to women was the focal point of the data collection site. As health fair attendees passed the display, the investigators asked for volunteers to complete the questionnaire. Participants were informed that the survey was created for educational purposes only, and should not be used as a substitute for professional medical advice, diagnosis, treatment, or care. The investigators scored the questionnaire based on the number of statements answered correctly. Results were reviewed individually with each participant. Participants were informed of correct answers for the questions that they answered incorrectly. Participants also received content knowledge information via a Healthy Heart IQ display and brochures from the American Heart Association that promoted awareness of heart disease in women. The data was gathered from the scores of participants (N = 104) using Analysis of Variance (ANOVA) at the .05 alpha level. Data was divided into three age categories and two race categories and analyzed with the StatView[R] software.

LIMITATIONS

The sample of participants for the investigation was small and nonrandomized, therefore generalization of the findings is restricted to female faculty, staff and students at the university. Also, the number of Hispanic (n = 8) and other (n = 5) minorities in the non-white race category were considerably less than the number of African American minorities (n = 39) in the same category. Participants were those attending the health fair, which limited participants available for survey by age and race. Despite these limitations, these findings are worth consideration.

RESULTS

DEMOGRAPHICS

The distribution of participants in the Check Your Healthy Heart I.Q. investigation by age category was 32.7% for less than 25 years (n = 33), 42.3% for 25-44 years (n = 45), and 25% for 45 years and older (n = 26). Participants were evenly distributed between white (n=52) and non-white (n=52). The non-white category consisted of African Americans (n = 39), Hispanics (n = 8), and Other (n = 5).

KNOWLEDGE BY AGE AND RACE

Check Your Healthy Heart I.Q. survey scores ranged from 57% (8 correct answers) to 100% (14 correct answers). The mean score was 77% (10.78 correct answers, SD=9.53). Table 2 reflects the frequency distribution of percent correct subdivided by age. Participants who scored between 80% to 100% correct comprised 12.12% of the less than 25 years age category, 28.89% of the 25-44 years category, and 50% of those age 45 years and older. Table 2 also contains the frequency distribution of percent correct subdivided by race. Of participants who scored 80% to 100% correct, 38.46% identified as white and 19.23% identified as Non-White.

Using Analysis of Variance (ANOVA), there was a significant difference (p = .001) between age categories in terms of percentages of correct responses to the Check Your Healthy Heart I.Q. instrument (see Table 3). There were no significant differences (p = .38) between race categories in terms of percentages of correct (see Table 3).

The frequency distribution of percent correct by age categories and the ANOVA for percent correct by age consistently indicated that women 45 and older have a higher level of knowledge concerning the risks for developing CVD. In the frequency distribution of percent correct by age, the study revealed that 54.5% of women who were younger than 25 years of age and 51.1% of women 25-44 years of age scored between 70-79% correct. Only 42.3% of women who were 45 years and older scored between 70-79% correct; less than one-half (49.9%) scored 80-100% correct on the survey. Although the frequency distribution of percent correct by indicated white women have a higher level of knowledge than non-white women concerning the risks of developing CVD, the ANOVA revealed that these differences were not significant (p = .38).

DISCUSSION

This investigation suggests that as women increase in age, their level of knowledge of CVD risk factors increases. Mosca et al. (2004) indicated that women younger than 45 years of age generally cited heart disease less frequently than did older women. This study supports Mosca et al.'s (2000) finding that most women do not perceive CVD as an important health threat and indicated that women are not knowledgeable about their risks for CVD. This investigation also concurs with Mosca et al. (2000) in concluding that age influences knowledge to a greater extent than race.

This study supports findings by Anderson and Kessenich (2001) who found that there are important opportunities to educate women about CVD risk and prevention. Educating clinicians and female patients on the magnitude of this problem and differences that exist between men and women is critical (Anderson & Kessenich). These findings also lend support to Mosca et al. (2000) who found a need for heart disease and stroke education programs for all women, including programs that target adults over 65 years of age and younger adults 25-35 years of age.

Even though this investigation did not find a significant relationship between knowledge and race, models of CVD prevention may encourage policymakers to devise multifaceted approaches for women's health promotion (Fleury et al., 2000). It is recommended that promotion of cardiovascular health for women requires the development of culturally appropriate intervention strategies and theoretical models. The results of this investigation support research by Mosca et al. (2000). Without programs to educate women on symptoms and preventive measures of heart disease, this lack of CVD awareness may impede preventive efforts to adopt positive lifestyle changes. Focusing on meaningful educational programs for young women and promoting the adoption of healthy lifestyle behaviors in the present may influence women's risk of developing long-term disease (Mosca et al.). The challenge for health promotion and disease prevention in women requires that researchers and clinicians explore new options for addressing CVD risk factors and increasing knowledge in women of all ages and races (Fleury et al.).

REFERENCES

American Heart Association. (2004a). American Heart Association special report: Survey finds increased cardiovascular disease awareness among women but plenty of room for improvement. Retrieved March 18, 2004, from http://www.americanheart.org/downloadable/heart/1075921958310SURVEY% 20at-a-glance1.pdf

American Heart Association. (2004b). International cardiovascular disease statistics. (2004). Retrieved April 12, 2004 from http://www.americanheart.org/downloadable/heart/ 1077185395308FS06INT4(e-book).pdf

Anderson, J., & Kessenich, C.R. (2001). Women and coronary heart disease. The Nurse Practitioner, 26, 12-31.

Bedinghaus, J., Leshan, L., & Dieher, S. (2001). Coronary artery disease prevention: What's different for women? American Family Physician, 63, 1393-1400.

Birchfield, P.C. (2003). Identifying women at risk for coronary artery disease. American Association of Occupational Health Nurses Journal, 51, 15-22.

Center for Health Statistics, Texas Department of Health. (2002). Selected facts for Region 5, 2000. Retrieved April 12, 2004 from http://www.tdh.state.tx.us/dpa/

Cheek, D., & Cesan, A. (2003). What's different about heart disease in women? Nursing, 33, 36-42.

Fleury, J., Keller, C., & Murdaugh, C. (2000). Social and contextual etiology of coronary heart disease in women. Journal of Women's Health and Gender-Based Medicine, 9, 967-978

Holdright, D. R. (1998). Risk factors for cardiovascular disease in women. Journal of Human Hypertension, 12, 667-673.

Meisler, J. G. (2001). Toward optimal health: The experts discuss heart disease in women. Journal of Women's Health and Gender-Based Medicine, 10, 17-25.

Mosca, L., Ferris, A., Fabunmi, R., & Robertson, R. M. (2004). Tracking women's awareness of heart disease: An American Heart Association national study. Circulation, 109, 573-579.

Mosca, L., Grundy, S. M., Judelson, D., King, K., Limacher, M., Oparil, S., et al. (1999). Guide to preventive cardiology in women. Circulation, 99, 2480-2484.

Mosca, L., Jones, W. K., King, K. B., Ouyang, P, Redberg, R. F., & Hill, M. N. (2000). Awareness, perception, and knowledge of heart disease risk and prevention among women in the United States. Archives of Family Medicine, 9, 506-515.

National Heart, Lung and Blood Institute of the National Institute of Health and the United States Department of Health and Human Services (2004). Check you heart healthy I.Q. (Publication #932724). Retrieved February 2, 2004 from http://www.nhlbi.nih.gov/health/public/heart/other/hh_iq.htm

Oliver-McNeil, S., & Artinian, N. T. (2002). Women's perceptions of personal cardiovascular risk and their risk-reducing behaviors. American Journal of Critical Care, 11, 221-227.

Texas Council on Cardiovascular Disease and Stroke. (2002). Cardiovascular disease in Texas: A risk factor report 1999 survey data. Retrieved April 22, 2004 from http://www.tdh.texas.gov/chronicd/cvdrep.pdf

U.S. Department of Health and Human Services. (2000). Healthy People 2010. Washington, DC: U.S. Department of Health and Human Services.

U.S. Department of Health and Human Services. (2001). Heart disease and stroke. Retrieved April 22, 2004, from http://www.healthypeople.gov/Document/HTML/Volume1/12Heart.htm

CHES AREAS

Responsibility I-Assessing Individual and Community Needs for Health Education

Competency C--Infer needs for health education on the basis of obtained data

Responsibility VII-Communicating Heath and Health Education Needs, Concerns, and Resources

Competency C--Select a variety of communication methods and techniques in providing health information.

Debra Long, MS and Staci Waldrep, MS are Instructors at Lamar Institute of Technology. Barbara Hernandez, PhD, CHES and George Strickland, PhD are Assistant Professors at Lamar University. Address all correspondence to Barbara Hernandez, PhD, CHES, Associate Professor, PO Box 10039, Lamar University, Beaumont, TX 77710; PHONE: [phone]; E-MAIL: [e-mail].

Table 1. Check your Healthy Heart I.Q.

Answer "true" or "false" to the following questions to test your
knowledge of heart disease and its risk factors. Be sure to check
the answers and explanations on the reference page to see how
well you did.

1. The risk factors for heart disease that you can do
   something about are: high blood pressure, high blood
   cholesterol, smoking, obesity, and physical activity.    T   F

2. A stroke is often the first symptom of high blood
   pressure, and a heart attack is often the first
   symptom of high blood cholesterol.                       T   F

3. A blood pressure greater than or equal to 140/90 mm Hg
   is generally considered to be high.                      T   F

4. High blood pressure affects the same number of blacks
   as it does whites.                                       T   F

5. The best ways to treat and control high blood pressure
   are to control your weight, exercise, eat less salt
   (sodium), restrict your intake of alcohol, and take
   your high blood pressure medicine, if prescribed
   by your doctor.                                          T   F

6. A blood cholesterol level of 240 mg/dL is desirable
   for adults.                                              T   F

7. The most effective dietary way to lower the level
   of your blood cholesterol is to eat foods low in
   cholesterol.                                             T   F

8. Lowering blood cholesterol levels can help people
   who have already had a heart attack.                     T   F

9. Only children from families at high risk of heart
   disease need to have their blood cholesterol
   levels checked.                                          T   F

10. Smoking is a major risk factor for four of the five
    leading causes of death including heart attack,
    stroke, cancer, and lung diseases such as emphysema
    and bronchitis.                                         T   F

11. If you have had a heart attack, quitting smoke can
    help reduce your chances of having a second attack.     T   F

12. Someone who has smoked for 30 to 40 years probably
    will not be able to quit smoking.                       T   F

13. The best way to lose weight is to increase physical
    activity and eat fewer calories.                        T   F

14. Heart disease is the leading killer of men and women
    in the United States.                                   T   F

Disclaimer: This questionnaire has been created for educational
purposes only and should not be used as a substitute for
professional medical advice, diagnosis, treatment, or care.
If you have a particular health concern, contact your doctor
and follow his/her recommendations regarding your specific
medical needs.

Answers: True = 1, 2, 3, 5, 8, 9, 10, 11, 13, 14 False = 4, 6, 7, 12

Note. From the survey "Check Your Healthy Heart I.Q" by the National
Heart, Lung and Blood Institute of the National Institute of Health
and the United States Department of Health and Human Services,
2004, NIH Publication No. 93-2724. Reprinted with permission.

Table 2. Frequency Distribution for Percent Correct on Survey
by Age & Race.

                       Age                              Race

         <25          25-44        45 & >          white      non-white

Range    N      P     N      P     N      P     N      P     N      P

50-59     2    6.06    1    2.22    1    3.85    2    3.85    2    3.85
60-69     9   27.27    8   17.78    1    3.85   10   19.23    8   15.39
70-79    18   54.55   23   51.11   11   42.31   20   38.46   32   61.54
80-89     3    9.09    9   20.00    8   30.77   12   23.08    8   15.39
90-100    1    3.03    4    8.89    5   19.23    8   15.39    2    3.85

Table 3. ANOVA for Percent Correct on Survey by Age & Race

              n       M        SD      SE

Age
  <25         33   72.94 *     8.70   1.52
  25-44       45   77.30 *     9.05   1.35
  45 & >      26   81.87 *     9.31   1.83
Race
  white       52   77.89 **   10.70   1.48
  non-white   52   76.24 **    8.21   1.14

* p < .05

** p > .05