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Women's Perceptions of Coronary Heart Disease: An Integrative Review

Hart, Patricia L. MS, RN

The Journal of Cardiovascular Nursing: May-June 2005 - Volume 20 - Issue 3 - p 170–176
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Coronary heart disease (CHD) is the leading cause of death in American women and is a major cause of morbidity. The American Heart Association (AHA) reports that in the year 2000, 515,661 women died from all categories of cardiovascular disease. An estimated 254,630 women suffer a myocardial infarction annually. Women diagnosed with CHD experienced greater morbidity and mortality than men. Women's perceptions of their risk for heart disease can greatly influence their decision-making process in regard to healthcare decisions. The general public still perceives heart disease as primarily a health problem for men. Evidence shows that women perceive breast cancer as a greater risk than CHD. These misperceptions may lead women to underestimate their risk for CHD and fail to seek early interventions to prevent unnecessary morbidity and mortality. The purpose of this article is to report the results of an integrative review of nursing research related to women's perceptions of risks for heart disease. CINAHL, Medline, EBSCO host, and Proquest databases were searched for nursing research conducted between the years of 1985 and 2002. Key search terms were women, heart disease, coronary artery disease, perceptions, risk factors, and health promotion behaviors. Study selection was limited to the first author being a nurse researcher. Twenty articles and dissertations were retrieved that met the key search terms. Eleven articles were excluded because the first author was not a nurse researcher. This integrative review includes 5 articles and 4 dissertations. Results revealed that women's perceptions of their CHD risks are underestimated, that health-promoting behaviors are not influenced by risk perceptions, that society imposes barriers that prevent participation in health promotion behavior, and that communication between women and their healthcare providers is lacking.

Patricia L. Hart, MS, RN Manager, Acute Care Nursing, WellStar Health System, Marietta, Ga.

Corresponding author Patricia L. Hart, MS, RN, 5181 Marsden Trace, Powder Springs, GA 30127 (e-mail: hartrish@bellsouth.net).

The author thanks Alice Demi, DNS, FAAN, director, School of Nursing, College of Health and Human Sciences, Georgia State University, for her assistance in developing the article and for her support and encouragement in this endeavor.

Coronary heart disease (CHD) is the leading cause of death in American women and is a major cause of morbidity.1 The American Heart Association (AHA)1 reports that in the year 2000, 515,661 women died from all categories of cardiovascular disease. An estimated 254,630 women suffer a myocardial infarction annually.1 Women diagnosed with CHD experienced greater morbidity and mortality than men. Thirty-eight percent of the women suffering a heart attack die within 1 year compared to 25% of men.1 Heart failure occurs in 46% of the women within 6 years after a heart attack compared to 22% of men.1

Women's perceptions of their risk for heart disease can greatly influence their decision-making process in regard to healthcare decisions. The general public still perceives heart disease as primarily a health problem for men. Evidence shows that women perceive breast cancer as a greater risk than CHD. These misperceptions may lead women to underestimate their risk for CHD so that they fail to seek early interventions to prevent unnecessary morbidity and mortality.

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Purpose

The purpose of this article is to present results of an integrative review of nursing research regarding women's perceptions of risks for heart disease. The review focused on the following 5 questions:

  1. What is known about women's perceptions regarding perceived risk factors for CHD?
  2. What health-promoting behavior do women practice to prevent the development of CHD?
  3. What barriers are identified by women that prevent them from participating in health-promoting behavior?
  4. How do women receive information about their risks for CHD?
  5. What age and race populations have been studied and are they representative of diverse populations of women?

The CINAHL, Medline, EBSCO host, and Proquest databases were searched for nursing research conducted between the years 1985 and 2002. Key search terms were women, heart disease, coronary artery disease, perceptions, risk factors and health promotion behavior. Study selection was limited to those where a nurse researcher was first author so as to examine the scope of nursing research conducted in the area of women's perceptions of their risk for CHD. Conducting such an integrative review synthesizes current nursing research knowledge, which will strengthen evidence-based nursing practice and identify new areas for future nursing research studies. Twenty articles and dissertations were retrieved that met the key search terms. Eleven articles were excluded because the first author was not a nurse researcher. This integrative review included 5 articles and 4 dissertations conducted by nurse researchers.2–10 Of the 9 studies, 7 are quantitative2,5–10 and 2 are qualitative3,4 studies. Table 1 summarizes the findings from each study.

TABLE 1

TABLE 1

TABLE 1

TABLE 1

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Women's Perceived Risk Factors

Major risk factors for CHD in women are age, cigarette smoking, hypertension, dyslipidemia, diabetes mellitus, obesity, sedentary lifestyle, family history, and eating food high in saturated fat and low in fiber.11,12 The most common risk factors identified by women in the 9 studies reviewed were diet high in saturated fat, lack of exercise, family history of CHD, and hypertension. Risk factors least identified by the women were obesity, diabetes, and smoking. Even women who identified a family history of CHD as a risk factor did not recognize this as a personal risk factor.3 In 8 of the 9 studies, women underestimated their risk for CHD.2,3,5–10 In one study,4 middle-aged women did perceive themselves as vulnerable to CHD after they reached the age of 60.

African American women report perceiving their race as a risk factor that greatly increased their chances for developing CHD.6 Older women also believed that their risk for CHD was greatly influenced by factors such as their race, age, overall cardiac risk, blood pressure, and postmenopausal status. Fiandt et al5 found that older rural women underestimated their risk for chronic illnesses and perceived their personal risk was not as great as their peer group. Most women were aware of their physical condition and lifestyle habits, but the vast majority did not comprehend their comorbidities as risk factors.7 Ultimately, women perceived breast cancer as their leading cause of death instead of heart disease.2,4,5,8

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Health-promoting Behavior

In 5 of the 9 studies, the relationship between health-promoting behavior and perceived risk factors for CHD was examined.2,4,7,8,10 No relationship was found between knowledge of risk for CHD and risk-reducing behavior.2,8,10 There was no relationship among knowledge of CHD risk factors, self-perception of CHD risk, and practice of health-promoting behavior between women health-professionals and women non–health professionals.10 Women acknowledged the importance of health-promoting behavior but lacked understanding of how health-promoting behaviors could prevent CHD.4 Women's ages did not influence participation in health-promoting behavior.8 Ali2 found that there was no difference in health-promoting behavior in women with a family history of CHD compared to women without a family history of CHD.

Income plays a role in the type of health-promoting behaviors engaged in by women.9 Women with higher incomes were involved in cardiovascular risk-reducing behavior such as diet control, exercise, and weight management.9 Types of exercise behavior for middle-income women included walking, jogging, health club activities, use of home exercise videos and self-planned home exercises while lower-income women primarily participated in walking.9 Regardless of income, women who participated in cardiovascular risk-reducing behavior had higher levels of diet and exercise efficacy.

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Barriers to Health-promoting Behavior

Barriers to health-promoting behavior are role and caretaking responsibilities, athletic incompetence or lack of exercise experience, lack of money, lack of time, and fear for one's own safety.3,4 Boudrea4 found that the 2 greatest barriers to health-promoting behavior were family obligations and lack of time. Women prioritized their family's health needs above their own health needs.4 Women who were unable to participate in risk reduction behavior mitigate their perceived risk through various strategies such as rationalizing, comparing, believing that they could control the disease process, and practicing self-care.3 Women who did participate in health-promoting behavior found benefits of increased self-esteem and opportunity for socialization.3

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Information About CHD

The general public lacks the knowledge about the impact that CHD has on women and their health. More education is needed to increase the public's awareness of CHD in women to decrease the morbidity and mortality of the disease. A major responsibility of healthcare providers is to inform women of their risk for CHD. King et al7 found only one third of the women in their study had been told that they were at risk for CHD by their physicians. Women with higher education levels are more able to recall conversations with their physicians about CHD than less-educated women. Younger women had a better recall than older women.7 Reasons for the lack of recall may be related to women's lack of perceptions between their risk for CHD and physician conversations. Women commonly hold the media and their physicians responsible for not informing them about CHD and the impact CHD can have on their health status.4

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Age

In general, women are at lower risk of CHD than men until they reach the age of 65. One in 8 American women compared to 1 in 6 American men aged 45 to 64 has some form of heart disease.1 Women usually develop signs and symptoms of CHD 10 to 15 years later than men.13,14 Heart disease affects 1 out of every 3 women older than 65. Premenopausal hormones play a role in the protective effects against CHD. After menopause, women's risk for CHD sharply increases and levels of cholesterol rise.2,15–17 African American women younger than 55 are at twice the risk for CHD than Caucasian women at the same age.18 The incidence of high blood pressure and obesity in African American women is thought to be related to this increase risk.

Age of the sample population was described in each study. The ages in the studies ranged from 18 to 95 years. Four studies only included women younger than 65 years.3,4,9,10 The other 5 studies included women younger than 65 years of age as well as women 65 years and older.2,5–8 The ages of the participants in the 9 studies are representative of the general population of women.

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Race

Race influences several risk factors that contribute to CHD. Coronary heart disease death rates are 34% higher for African American women than Caucasian women.11 Death rates declined more rapidly for Caucasian women than for African American women during the 1980s and 1990s.1

The prevalence of hypertension varies with race. Among women 20 years and older, 36.6% non-Hispanic blacks, 20.5% of non-Hispanic white women, and 22.4% Mexican Americans have hypertension. High blood pressure causes 20% of all deaths in hypertensive African American women.1 It is estimated that 27.5% of American Indian women aged 45 to 74 have high blood pressure.1

Smoking is a contributory factor for the development of CHD. The AHA1 reports that 29.3% of American Indian women, 23.4% of Caucasian women, 20.8% of African American women, and 12.3% of Hispanic women are current smokers.

Mexican American women aged 20 and older have the highest rate of diabetes mellitus that is diagnosed by a physician, which increases their risk for CHD. African American women 18 years and older have a rate of obesity at 64.5%. Hispanic and African American women 18 years and older have the highest rate of sedentary lifestyle at 57.1% each.1 Race is a significant risk factor that plays a major role in the development of CHD in women.

Eight of the 9 studies reported race.2,3,5–10 More than half (56%) of the studies had a population of either all or at least 80% Caucasian women.2,5–8 Walcott-McQuigg9 study population was 100% African American. Only 2 studies included Hispanics and Asian/Pacific Islander women.7,10 The 9 studies did not represent the diverse female population.

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Summary of Findings

Research Question 1

Diet high in saturated fat, lack of exercise, family history of CHD, and hypertension were the most common risk factors identified by women in the 9 studies. Obesity, diabetes, and smoking were the least common risk factors identified by women. The overall conclusion in most of the studies was that women underestimated their risk for CHD and did not view themselves at risk even when personal risk factors were present.

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Research Question 2

Age, job status, knowledge of CHD risk factors, and family history do not positively influence health-promoting behavior of women. Income level plays a role in the type of exercise chosen by women. Middle-income women participated in walking, jogging, health club activities, use of home exercise videos, and self-planned home exercises compared to lower-income women who participated in walking only. Women who participated in health-promoting behavior have a higher exercise and diet self-efficacy.

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Research Question 3

Women are confronted with numerous barriers related to health-promoting behavior. Societal barriers interfering with health-promoting behavior include role and caretaking responsibilities, athletic incompetence or lack of exercise experience, lack of money, lack of time, and fear for one's own safety. Women cited family obligations and lack of time as the 2 greatest barriers. Increased self-esteem and increase opportunity for socialization were identified as benefits for women who did engage in health-promoting behavior.

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Research Question 4

Lack of effective communication between healthcare providers and women about their risk factors for CHD continues to be a major problem. In one study, only one third of the women reported discussing their CHD risk factors with their healthcare provider. This lack of effective communication leads to decreased awareness of CHD risk factors in women and decreased knowledge of the importance of participating in risk-reducing behavior. Women expect their healthcare providers and the media to take responsibity for communicating effective messages about CHD in women. Increased efforts to educate women and the general public about women and heart disease are needed. Myths still exist in the general public that heart disease is a man's disease.

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Research Question 5

The age of the women participating in the 9 studies ranged from 18 to 95 years. The ages of the participants in the studies are representative of the general population of women.

More than half of the studies only had participants who were Caucasian women. Limited representation of African American, Hispanic, and Asian/Pacific women were in the study sample populations. Diverse female populations were not represented in the 9 studies. More studies need to be conducted with African American, Hispanic, Native American, and Asian/Pacific Islander women to expand the knowledge of how race impacts CHD risk factors and women's perceptions of the risk for CHD.

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Gaps in Current Research

Women's perceptions of their CHD risk and its implications on their health needs to be further studied. Research exploring the meaning of cardiovascular disease to women needs to be conducted. There is a need to continue to explore women's perceptions of CHD risk factors because of the gaps in knowledge about race, and motivational factors that enhance health-promoting behavior, the impact of health-promoting behavior on the prevention of CHD, spousal influence in health-promoting behavior, and the influence of health beliefs and values on women's perceptions of CHD risk. Understanding the relationship between perceived risk for CHD in women and motivation to engage in health-promoting behavior is important to improve the health of women and prevent CHD. Further, studies that explore the conflict between current behavior and barriers to behavior change would give insight into the decision-making processes of women.

More studies need to be conducted on diverse populations as 5 out of 9 studies reviewed had a population of either all or at least 80% Caucasian women.2,5–8 Comparison studies of younger and older women to evaluate difference in perceptions would expand the current knowledge base. Studies that compare healthy women to women who have suffered a cardiac event and the differences in their health-promoting behavior may expand the knowledge about what motivates women to participate in health-promoting behavior.

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Nursing Implications

The findings from this review have implications for nursing practice in the areas of assessment, education, and referral. Obtaining appropriate history information and performing skillful assessments focusing on CHD risk factors will identify women at risk for heart disease. Early identification of potential risk factors can assist in reducing morbidity and mortality in women related to CHD.

As patient advocates, it is the responsibility of nurses to ensure the public is educated about women and CHD. Nurses need to identify opportunities (office visits, health fairs, well clinic checks, community programs) to engage in effective conversations with the general public to expand awareness of the impact CHD has on the health status of women. Formal and informal education programs need to be developed and implemented to disseminate CHD information, especially to women. Education brochures and pamphlets discussing CHD risk factors, impact of CHD on womens' health, and strategies to protect against CHD should be distributed in places where women frequently congregate (churches, women's clubs, schools, health clinics). Public screenings for women to review their potential risk factors is another method of identifying women at risk for CHD.

Referrals to other disciplines such as dietitians, cardiac educators, and exercise specialists promote a multidisciplinary approach to effective planning, education, and management of women at risk for CHD. Collaboration between all healthcare disciplines can greatly impact outcomes of CHD in women and those at risk for CHD.

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Conclusion

Heart disease is the number one killer of women.1 Women's perceptions of CHD risk factors are underestimated. Research findings indicate that women's perception of CHD risk does not influence health promotion behavior. Society-imposed barriers often prevent women from participating in health-promoting behavior. Lack of communication between women and their healthcare providers about CHD further compounds misperceptions of CHD risk in women. Education opportunities to increase the awareness of the impact of heart disease on women need to be implemented.

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REFERENCES

1. American Heart Association. 2002 Heart and Stroke Facts: Statistical Update. Dallas, Tex: American Heart Association; 2001. Available at:
2. Ali NS. Predictors of quality of life in women: hormone therapy self-efficacy and health-promoting behaviors. Women Health. 1999;29(2):69–79.
3. Anderson FD. A Grounded Theory Study of Women's Perceptions of Cardiovascular Risk [dissertation]. Seattle, Wash: University of Washington; 1992.
4. Boudreau, MA. A Qualitative Assessment of Susceptibility to Coronary Heart Diseases as Perceived by Selected Middle-aged Women [dissertation]. Carbondale, Ill: Southern Illinois University; 1995.
5. Fiandt K, Pullen CH, Walker SN. Actual and perceived risk for chronic illness in rural older women. Clin Excel Nurse Prac. 1999;3(2):105–115.
6. Haas MLY. Women's Perception of Risk for Coronary Artery Disease [dissertation]. Columbia, SC: University of South Carolina; 1996.
7. King KB, Quinn JR, Delehanty JM, et al. Perception of risk for coronary heart disease in women undergoing coronary angiography. Heart Lung. 2002;31(4):246–252.
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9. Walcott-McQuigg JA. Psychological factors influencing cardiovascular risk reduction behavior in low and middle income African-American women. J Natl Black Nurses Assoc. 2000;11(1):27–35.
10. Webb PH. A Study of the Association Among Women's Knowledge of Coronary Heart Disease Risk Factors, Self-perception of Risk, And Personal Health Habits [dissertation]. San Francisco, Calif: University of San Francisco; 1996.
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12. Mosca L, Jones WK, King KB, Ouyang P, Redberg RF, Hill MN. Awareness, perception, and knowledge of heart disease risk and prevention among women in the United States. Arch Fam Med. 2000;9:506–515.
13. Berra K. Women, coronary heart disease, and dyslipidemia: does gender alter detection, evaluation, or therapy? J Cardiovasc Nurs. 2000;14(2):59–78.
14. Milner KA, Funk M, Richards S, Wilmes RM, Vaccarino V, Krumholz HM. Gender differences in symptom presentation associated with coronary heart disease. Am J Cardiol. 1999;84(4):396–399.
15. Grodstein F, Stampfer MJ, Manson JE, et al. Postmenopausal estrogen and progestin use and the risk of cardiovascular disease. N Engl J Med. 1996;335(7):453–461.
16. Guetta V, Cannon RO. Cardiovascular effects of estrogen and lipid-lowering therapies in postmenopausal women. Circulation. 1996;93:1928–1937.
17. Mosca L, Collins P, Herrington DM, et al. Hormone replacement therapy and cardiovascular disease. Circulation. 2001;104:499–503.
18. Casper ML, Barnett E, Halcerson JA, et al. Women and Heart Disease: An Atlas of Racial and Ethnic Disparities in Mortality. 2nd ed. Office for Social Environment and Health Research. Morgantown, Wva: West Virginia University; 2000.
Keywords:

coronary artery disease; health promotion behavior; heart disease; perceptions; risk factors; women

© 2005 Lippincott Williams & Wilkins, Inc.