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African American Women's Perceptions of Cardiovascular Disease After Myocardial Infarction

A Phenomenological Inquiry

Jones, Loretta PhD, RN; Williams, Susan PhD, RN; Bydalek, Kathryn PhD, FNP-BC; Elkins, Casey DNP, NP-C, CLS; Fruh, Sharon PhD, FNP-BC

doi: 10.1097/JCN.0000000000000614
ARTICLES: Women and Cardiovascular Disease
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Background The primary cause of death among African American women older than 50 years is cardiovascular disease. Cardiovascular disease affects more than 16.8 million Americans and occurs when plaque builds up in the arteries that provide blood to the heart. This often leads to a partial or complete blockage, causing a myocardial infarction (heart attack). There is limited research regarding the lived experiences of African American women before and after a myocardial infarction.

Objective The purpose of this qualitative study was to explore the experiences of African American women living in the southern region of the United States who have experienced a myocardial infarction.

Methods A hermeneutic phenomenological framework guided the study. Semistructured, audiotaped interviews were conducted to elicit narratives from 7 participants. Interview data were transcribed verbatim and then coded and analyzed using Colaizzi's phenomenological analysis framework.

Results The findings revealed 6 major themes: life before myocardial infarction, causes of my myocardial infarction, myocardial infarction warning signs, life after myocardial infarction, cardiac rehabilitation, and family support. Lifestyle changes must be implemented to prevent a second blockage. Attending cardiac rehabilitation and incorporating regular physical exercise are recommended to help prevent further heart damage and to improve quality of life.

Loretta Jones, PhD, RN Assistant Professor, Adult Health Nursing, University of South Alabama College of Nursing, Mobile.

Susan Williams, PhD, RN Assistant Professor, Community Mental Health Nursing, University of South Alabama College of Nursing, Mobile.

Kathryn Bydalek, PhD, FNP-BC Associate Dean for Academic Affairs, University of South Alabama College of Nursing, Mobile.

Casey Elkins, DNP, NP-C, CLS Assistant Professor, Director, DNP Program, University of South Alabama College of Nursing, Mobile.

Sharon Fruh, PhD, FNP-BC Associate Dean for Research, Evaluation, and Development, University of South Alabama College of Nursing, Mobile.

The authors have no funding or conflicts of interest to disclose.

Correspondence Loretta Jones, PhD, RN, Adult Health Nursing, University of South Alabama College of Nursing, 5721 USA Drive North, Mobile, AL 36688-0002 (lorettajones@southalabama.edu).

Online date: September 9, 2019

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Background

Cardiovascular disease (CVD) is the leading cause of death in 1 in 4 men and women in the United States.1 The American Heart Association indicates that nearly half of all African American (AA) adults have some form of CVD, 47.7% of women and 46.0% of men.2 Also, CVD causes the death of approximately 50 000 AA women each year. An estimated 7.4 million adult women older than 20 years (5.3%) have coronary heart disease, a subset of CVD.2 Furthermore, approximately 530 000 men and 385 000 women experience a new or recurrent myocardial infarction (MI) or fatal CVD each year. In fact, disability rates and mortality after a CVD event are higher in AA women.3 Within 5 years after experiencing the first MI, 28% of AA women aged 45 to 64 years will die as opposed to 17% of white women.4

Often, AA women are the matriarch of their family and have many struggles while trying to work and care for others.5 They are often not aware of the signs of a MI and do not understand that heart disease is their greatest risk of death.4 Kalinowski et al5 further discuss that there are complex interactions when genetics and environmental factors coincide, particularly when related to chronic stress issues such as single parenthood, discrimination, domestic violence, possibly raising grandchildren, and at the same time dealing with family members who may be incarcerated or have addiction problems. Being socioeconomically disadvantaged may also add to the inability to seek regular physician visits to learn about and monitor for cardiac problems before they occur.3 When considering biological risk, AA women were compared with white, Asian, Latino, and other mixed-race individuals when researchers were examining the physiological aspects of discrimination. Researchers collected a composite of 15 biomarkers to examine cortisol, epinephrine, norepinephrine, interleukin-6, C-reactive protein, glucose, glycosylated hemoglobin, high- and low-density lipoprotein, triglycerides, and total cholesterol, as well as blood pressure, waist circumference, and body mass index.6 High levels of discrimination were related to blunted physiologic activity and blunted cardiometabolic activity (b = −161, P = .03, 95% confidence interval [CI], −3.06 to −0.15). A higher level of discrimination was associated with higher levels of epinephrine (b = 0.63, P = .03, 95% CI, 0.05–1.2) and higher waist circumference (b = 0.52, P = .03, 95% CI, 0.05–0.98).6 These researchers concluded that race was an important predictor of physiologic dysregulation over time. The 1 item that was found to mitigate this chronic social stress was educational attainment.6

The genetics of an AA woman may also play a substantial role in CVD as compared with other races. In a review of the literature, researchers found 7 studies that provide a better understanding of the reproductive traits in AA women that specifically link this population for risk of cardiometabolic disorders. These specific genes are related to the biological age of menarche and also menopause.7 Other biological factors included regulating body weight, managing cholesterol, and maintaining vascular homeostasis.8

By 2030, the older adult AA population is projected to increase by 99%.9 In addition, most older AAs have at least 1 chronic illness, and most have multiple chronic illnesses and comorbid conditions.9 Between 2013 and 2030, the medical costs of CVD are projected to increase by about 100%.2 The annual cost of MIs is estimated at US$11.5 billion yearly, making it one of the most expensive hospital principal discharge diagnoses.2 Despite continuous research, there remains a limited universal understanding of how to manage CVD health disparities in Southern AA women.10 Furthermore, previous studies have failed to evaluate the unique needs of AA women. For instance, only a few research studies focus specifically on AA women after they experience an MI, whereas only a small number of AA women are included in other studies.11 Such factors limit the generalizability of findings of studies in which AA women participate. Moreover, because of the lack of research on AA women and their experiences post-MI, it is not clear what factors may contribute to poor outcomes in this population. Researchers agree that the phenomenon of managing AA women with CVD post-MI is complex and lacks clarity.10

After an AA woman has an MI, she is at the highest risk for another heart event or death. Therefore, knowing how much this population understands the importance of taking medications, following up with their doctor, managing risk factors, going to cardiac rehabilitation, and getting support is important for preventing future heart events.12 The most recent update from the American Heart Association's Panel on Secondary Prevention emphasized that additional evidence from clinical trials supports intensive risk-reduction therapies for patients with CVD.12 Management and reduction of risk decrease recurrent MIs and improve survival rates and quality of life for patients.12 More research is needed to develop and/or tailor existing interventions for AA women to prevent a reoccurrence of MI. Sound scientific evidence regarding the effectiveness of secondary prevention of MIs in AA women in the South is a gap in the research literature.8 Explorations of AA women's perceptions and knowledge of CVD and lifestyle changes post-MI are paramount in decreasing the incidence of this health disparity.8

According to the Centers for Disease Control and Prevention, heart disease is responsible for approximately 1 of 5 deaths among women in the United States and is the leading cause of death for both AA and white women.3 The prevalence of obesity is higher among AA women in the United States compared with men of the same racial background.5 High blood pressure prevalence in AAs in the United States is the highest in the world.5 The high rates of high blood pressure and heart disease affect AA women, increasing the risk of disease-related deaths.13

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Objective

The aim of this phenomenological study was to explore the lived experience of AA women, 50 years or older, who had experienced an MI within the past 5 years. The overarching goal was to decrease health disparities of AA women post-MI along with the Healthy People 2020 goal to improve cardiovascular health through prevention, detection, and treatment of risk.14 Therefore, this study sought to answer the following questions: What do Southern AA women know about risk factors for CVD? How do these women perceive CVD? How do these women manage CVD post-MI, and how has having an MI changed the lifestyles of these women?

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Methods

Scientific Framework

Phenomenology can be viewed as emerging from Edmound Husserl (1859–1938).15 Groenewald15 indicated that Husserl believed that all objects exist in the world in a dependent manner, not independently. Laverty16 noted that such interdependence becomes evident as a phenomenon and is interpreted by human experiences involving personal knowledge and feelings. Thus, knowledge is constructed based on personal experiences. Interpretative phenomenology, an exploratory, descriptive approach, deals with phenomena and experiences as they are lived.17 This method examines human experiences and typically answers questions essential to increasing sound nursing knowledge.18 Furthermore, a qualitative approach is most often used to research an absence of information regarding a particular phenomenon.19 Phenomenology was selected to examine the unknown influences of the outcomes of MIs in Southern AA women.

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Participants and Procedures

The research protocol was approved by the University of Alabama at Birmingham Institutional Review Board before data collection. Convenience sampling was used to obtain participants who met inclusion criteria: (a) self-identification as an AA woman, (b) 50 years or older, (c) proficient in English, and (d) 3 months or longer post-MI. Individuals who were severely ill or had a diagnosed mental condition were excluded. Participants were recruited by advertisements (eg, flyers) placed in 3 cardiology physician offices in a city on the southern Gulf Coast.

Over 10 months, 12 women expressed interest in participating in the study. Ten potential participants met inclusion criteria; 2 participants withdrew from the study before the scheduled interview, and 1 participant became seriously ill and was unable to participate in the study. Among the participants, the time post-MI ranged from 6 months to nearly 5 years. Ages ranged from 55 to 86 years. See Table 1 for participants' demographics.

TABLE 1

TABLE 1

Upon expressing interest, potential participants were given a letter including information regarding the study, followed by initial screening via telephone call. During the call, participants were informed of the study purpose, along with standardized information needed to obtain informed consent.

Semistructured audiotaped interviews were conducted in the participants' homes or a private office in the cardiology practices. An interview guide was developed by the principal investigator. The following questions were used to begin the first interview: “Tell me about life since having an MI. I'm interested in anything you want to tell me about that. Since having a MI, what has changed? How has your lifestyle changed?” To obtain more in-depth information during the interview, additional questions and probes were used as needed (see Table 2). Interviews lasted from 30 to 60 minutes. Data saturation was reached with 7 participants. Participants received $20 cash at the time of each interview.

TABLE 2

TABLE 2

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Plan of Analysis

Interpretive phenomenology was the guiding philosophical position for our data analysis. The selected data analysis method is based on the work of Colaizzi.18 The steps in Colaizzi's analytical method are as follows: (1) acquire a sense of original transcripts, (2) develop significant statements, (3) formulate meanings, (4) organize and develop theme clusters, (5) create exhaustive description of phenomena, (6) describe the fundamental structure of phenomena, and (7) perform final validating steps.20

Validation of findings included 4 primary strategies. They included (a) bracketing—temporary setting aside of the researcher's assumptions (by written diary before and during study) and creating an audit trail of analyzed data; (b) providing rich descriptions to convey the findings; and (c) external audit—asking a person outside the project to conduct a thorough review of the study results; (d) member checking—getting feedback from the participants on the accuracy of the identified categories and themes.21 Within 2 months of the first interview, a follow-up interview was conducted to present findings to the participants and receive verification of information accuracy. The second interview began with the following question: “Since you have had time to think about our last talk, is there anything you would like to add to help me better understand your life since you had a heart attack?” Relevant data obtained from the second interview was assimilated into the final study results.

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Results

The data analysis revealed 6 major themes: life before MI, causes of my MI, MI warning signs, life after the MI, cardiac rehabilitation, and family support (Table 3).

TABLE 3

TABLE 3

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Life Before Myocardial Infarction

Before an MI, the participants reflected on what they believed to be conventional lives, such as working and taking care of their husbands and grandchildren and being actively involved in the church and community. Three participants exercised pre-MI, citing activities such as gliding, stationary biking, walking, cutting grass, and gardening. One participant responded by saying, “My exercise has always been gardening for years and years.” Four participants said they were regular smokers before their MI. Another participant reported, “I was not a heavy smoker, maybe about a one-third or one-fourth pack a day.” Most participants perceived that they ate normal diets before their MI. One participant reported, “I ate a good diet but, did not really keep track.” However, 3 participants indicated that they tried to eat relatively healthy by watching salt, fried food, and sugar intake. Most of the participants acknowledged that they “Had a little high blood pressure” before their MI and were compliant with taking blood pressure medicines.

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Causes of My Myocardial Infarction

Four of the participants believed that their MI was stress related, attributed to by the demands of juggling work and family responsibilities. For example, 1 participant noted that “Working retail is very, very stressful.” Another noted, “When you have a heart attack, you have a lot on your mind.” Aside from job and family-related stress, most of the participants indicated that having high blood pressure might have been a factor. Four participants remarked that CVD is perhaps inheritable. In fact, a few participants had family members who died of an MI. A participant explained that “My mother had a heart attack and died at 52, I am barely older than that.” The overwhelming majority of participants (6/7) underestimated their risk factors for CVD before experiencing an MI, and their responses indicated that most of them never expected that they would have an MI.

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Myocardial Warning Signs

There was significant variance in the symptoms reported by participants when they were asked whether they had experienced signs of their impending MI. The key warning signs identified included profuse diaphoresis, chest pains, the feeling of indigestion, and fatigue. One participant reported having headaches and severe back pain. One participant reported having “indigestion that would not go away.” A second participant stated, “They took me from work, my chest would not stop hurting.” Two participants maintained that they had no warning signs. For example, 1 participant reported that she had a normal electrocardiogram 1 week before her MI. In contrast to underestimating risk factors, most (5/7) of the participants were aware of the early warning signs of an MI pre-MI.

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Perceptions of Life After Myocardial Infarction

Most of the participants reported making lifestyle changes to reduce the risk of a second MI. All participants reported being more cognizant of their daily activities and taking things a little more slowly. Major preventative behaviors included smoking cessation, changes in diet, and exercise. Eating a proper diet (ie, low cholesterol) and regular exercising were common threads among all the participants. Most participants reported diets low in salt, low in fat, and high in vegetable intake. Fried food was replaced with baked foods as reported by most of the participants. One participant remarked, “No more fried foods.” Another explained, “Sunday was pot roast, baked meat so long, and I do not think about frying it anymore.”

Six of the participants said that since their MI, they continued to exercise regularly (eg, daily walks). One participant reported, “I had to build myself up to walk at least a mile a day.” However, 1 participant noted that her exercise was limited secondary to orthopedic conditions. All participants reported that they felt that exercise was part of a healthy lifestyle, and all but 1 said they participated in a regular exercise routine. Different participants reported, “I walk and talk to my neighbors.” “I do gliding when I get to it.”

Although 6 of the 7 (86%) participants appeared to be overweight, only 1 participant talked about being overweight and her weight loss (20–30 lb) immediately after experiencing an MI, whereas another participant talked about having another MI even though she was not overweight (116 to 117 lb). However, more than half of the women (5/7 [71%]) did not state whether they were trying to lose weight after experiencing an MI.

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Cardiac Rehabilitation

None of the participants reported attending formal cardiac rehabilitation. Cardiac rehabilitation was mentioned by only 1 participant; however, rehabilitation-related activities explained by some of the participants seemed to indicate that some form of post-MI education had taken place. For example, 3 of the participants mentioned that they participated in supervised exercise sessions, and 1 mentioned carefully following instructions related to exercise from healthcare providers. A participant said, “The therapist told me that I had to get up every day” and “They told my son to take me for a walk around the house every day.” Another participant explained that she walks every day as part of her exercise therapy, she said: “I had to get the vessels in my heart stronger than what they were to make the blood flow better than what it was doing.” Smoking cessation was also a part of therapy. One participant remarked, “I stopped smoking because that is what my doctor advised me to do.” Another explained, “I did not completely stop then because it was hard to quit smoking after you have been smoking for 25 years.” One participant mentioned in her interview that she learned some months after her MI that she was scheduled for cardiac rehabilitation. She explained that a family member misplaced the instructions regarding cardiac rehabilitation when she was discharged from the hospital. After attending, she stated, “All men were in a class I went to and driving across town was terrible. I did not go again.”

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Family Support

All of the study participants reported some type of day-to-day struggles with lifestyle changes, such as preventing increase stress at work or at home, attempting smoking cessation and not being completely successful, and wanting to exercise but not having time. The participants indicated feeling supported by immediate and extended family members during the recovery process. For example, 1 participant reported that her son and her sister assisted her and walked with her around the house for exercise after her MI. She said, “I was so tired, but they said come on, you can do it.” Another participant stated, “My granddaughter moved in with me after my heart attack to help with my recovery.”

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Discussion

Gender and ethnic differences play a role in the development, presentation, treatment, and prognosis of CVD.10,21,22 These findings support previous studies that reported that AA women's knowledge of CVD has improved, but it remains subpar.8,23 An important finding of the current study was the general lack of knowledge among the study participants on risk factors or risk behaviors, symptoms of CVD, and taking action to prevent CVD before MI. Previous studies demonstrated a similar knowledge deficit in AA women.22 However, these knowledge deficits were improved with educational intervention.24 This is particularly concerning as AA women have a higher prevalence of MI than all other racial and ethnic groups of women, have a higher incidence of sudden cardiac death as the first manifestation of coronary heart disease, and have a lower survival rate after out-of-hospital arrest than do white women.22 Increasing participation of AA women in cardiovascular research helps to decrease CVD by creating effective educational interventions, thereby increasing awareness and understanding of their risk and understanding behaviors that will reduce such risk.24

Most participants in this study were more familiar with the early warning signs of an MI than risk factors. Participants stated the absence of chest pain before their MI; however, they reported experiencing severe indigestion, fatigue, and profuse sweating before their MI. These findings are consistent with previous research showing women are more likely to have high-risk presentations and less likely to manifest chest pain but more likely to have fatigue, dyspnea, indigestion, palpitations, and weakness than men.22 Second, the study findings support that despite possessing many of the risk factors and signs, most participants did not predict that they would experience an MI, which is supported by a plethora of previous research literature.10,25,26 Third, most participants improved their dietary habits, increased activity levels, and discontinued tobacco use. Evidence supports that smoking cessation, a low-cholesterol diet, and adequate physical activity reduce the incidence of CVD and MIs.25,27,28 However, because of the single time point and qualitative nature of the study, the consistency and effectiveness of these lifestyle changes are unclear.

Cardiac rehabilitation is a key factor in reducing the reoccurrence of MI, is an essential component of comprehensive care, and produces significant morbidity and mortality benefits. As in other instances, cardiac rehabilitation continues to be underused.21,22,29,30 None of the participants in the current study attended cardiac rehabilitation. Although cardiac rehabilitation is designated as a performance indicator of healthcare quality after MI, women who are uninsured, unmarried, smokers, depressed, obese, sedentary, elderly, nonwhite, and socioeconomically disadvantaged underuse cardiac rehabilitation. Considering the difficulty for most people with CVD to adhere to recommended treatments and lifestyle changes post-MI, especially long-term modifications, it is surprising that our participants reported being adherent to physicians' recommendations without formal cardiac rehabilitation. Such results are especially surprising, given that the prescribed treatments and lifestyle changes are likely to be counter to a sense of normalcy. As with this study, findings from Wagner et al25 noted that most patients with cardiac diseases had to make significant lifestyle changes, and success rates skyrocketed when family members were involved. In contrast, women in another study felt only tangible support and lack of emotion and experienced feelings of minimization after their MI.31 Furthermore, it should be noted that most of the exercise described by the participants post-MI did not meet daily requirements set forward by the Department of Health and Human Services.32 Most of the participants attempted to increase physical activity, despite not attending cardiac rehabilitation.

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Limitations

This study incorporated a convenience sampling technique to ensure that AA women with a history of MI were recruited. In phenomenology, the goal is to generate findings that increase the depth of understanding of a phenomenon rather than generalizability. It must be noted that the findings reflect the uniqueness of the population and the setting/context in which the study was implemented. Because the study was conducted among a sample of AA women in the Southern region of the United States, the beliefs and perspectives of the study participants may not apply to persons living in other geographical locations or of other ethnicities or for men. Finally, a few interview questions required participants to reflect on experiences several years before the interview. For this reason, time lapses may have caused omission of some details.

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Implications for Practice

Improvements in the rates of CVD and MI have occurred in the United States over the last several decades, but the incidence among AA women has remained unchanged.8,31,33 Healthcare providers that use current research findings may impact this ongoing disparity. Performing thorough assessments of CVD risk factors and improving patient education related to the consequences of ongoing risk factors may assist in decreasing risk factors at a more urgent rate. Healthcare providers may also address this disparity in knowledge by seeking community support to provide research-based education courses, providing pamphlets at health provider visits related to the risk factors and warning signs of an MI, and diligent advertisement of existing heart health programs.

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Conclusion

The findings of this study indicate that healthcare providers should consider research results and perform more thorough assessments of CVD risk factors. Furthermore, interactions related to improving patient education regarding lifestyle behaviors and the consequences of ongoing risk factors cannot be overstated. Increased vigilance and urgency are necessary to improve AA women's understanding and perception of this disparity. Creating culturally appropriate, feasible interventions is paramount for decreasing the rate and incidence of CVD and MIs in AA women.

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What’s New and Important
  • Despite the significant body of literature addressing CVD and post-MI lifestyle changes, little is known about the experiences of AA women after MI.
  • Although familiar with early-warning signs of MI, AA women are not familiar with modifiable and nonmodifiable risk factors for MI.
  • Recognition of these findings will allow nurses and other healthcare providers to develop meaningful interventions for assisting AA women with lifestyle changes after MI.
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Keywords:

African Americans; cardiovascular diseases; myocardial infarction; phenomenology; qualitative research; women

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