EXPLORING THE ISSUE OF HEART DISEASE IN THE AFRICAN AMERICAN
COMMUNITY
Deanna Lavonne Bennett
B.A, California State University, Hayward, 2002
PROJECT
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SOCIAL WORK
at
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
SPRING
2011
© 2011
Deanna Lavonne Bennett
ALL RIGHTS RESERVED
ii
EXPLORING THE ISSUE OF HEART DISEASE IN THE AFRICAN AMERICAN
COMMUNITY
A Project
by
Deanna Lavonne Bennett
Approved by:
__________________________________, Committee Chair
Teiahsha Bankhead, Ph.D., L.C.S.W.
____________________________
Date
iii
Student: Deanna Lavonne Bennett
I certify that this student has met the requirements for format contained in the University
format manual, and that this project is suitable for shelving in the Library and credit is to
be awarded for the project.
_______________________________, Division Chair
Robin Kennedy, Ph.D.
Division of Social Work
iv
_______________
Date
Abstract
of
EXPLORING THE ISSUE OF HEART DISEASE IN THE AFRICAN AMERICAN
COMMUNITY
by
Deanna Lavonne Bennett
This study explored the issue of heart disease in the African American community. The
emphasis is placed on the exploration of whether there is an association of socioeconomic
status and knowledge of risk factors of heart disease amongst African Americans. A
survey was developed and distributed to individuals that stated they identified themselves
as being African American. Data was collected from 60 African Americans with a
socioeconomic status categorized as either working class or middle class or above. The
study included an evaluation of the frequency of the data obtained. The results indicated
that there is not an association between socioeconomic status and knowledge of risk
factors of heart disease amongst African Americans. The researcher concludes that there
is more of a need to address implementation and healthcare disparities with heart disease
in the African American community.
, Committee Chair
Teiahsha Bankhead, Ph.D., L.C.S.W
______________________
Date
v
DEDICATION
This project is dedicated to the loving memory of Professor Carolyn Rebecca
Stewart (November 7, 1951-November 29, 2010).
vi
ACKNOWLEDGMENTS
First and foremost, I want to thank God for providing me with the strength and
determination to complete this process. I would like to thank my family for being by my
side and encouraging me throughout this process. To the love of my life, Brian Lee
Ridgway, Sr., thank you so much for your unconditional love and support. I am forever
grateful for you. To my son Brian II and my bonus children Adrian and Armani, I love
and appreciate you all just for being you. To my mother Emily and step father Gerald,
thank you for all your love and support. Special thanks to the National Association of
Social Workers-California chapter for your endless support and words of encouragement.
I would like to recognize the Master of Social Work faculty at CSU, Sacramento for all
of the support provided throughout my entire graduate experience. A very special thank
you to Dr. Joseph Anderson, Dr. Teiahsha Bankhead, Dr. Chris Barranti, Dr. Andrew
Bein, Dr. Lynn Cooper, Dr. Maria Dinis, Dr. Susan Eggman, Professor Jill Kelly, Dr.
David Nylund, Professor John Davis and Professor Bart Phelps. Last but not least, I
would like to recognize the National Council of Negro Women Sacramento Valley
Chapter for their efforts to bring health awareness to the African American community.
Peace and blessings to all of you.
vii
TABLE OF CONTENTS
Page
Dedication .................................................................................................................... vi
Acknowledgments....................................................................................................... vii
List of Tables .................................................................................................................x
Chapter
1. INTRODUCTION ...................................................................................................1
Background ........................................................................................................3
Statement of the Problem ...................................................................................3
Purpose of the Study ..........................................................................................4
Conceptual Framework ......................................................................................5
Definition of Terms............................................................................................6
Assumptions.......................................................................................................7
Justifications ......................................................................................................7
Limitations .........................................................................................................8
2. REVIEW OF THE LITERATURE .........................................................................9
Introduction ........................................................................................................9
Historical Background .......................................................................................9
Heart Disease Risk Factors ..............................................................................11
Smoking/Tobacco ................................................................................12
Alcohol .................................................................................................13
Excess Weight ......................................................................................13
Poor Eating Habits/Unhealthy Diet .....................................................14
Lack of Physical Activity.....................................................................15
High Blood Cholesterol .......................................................................15
High Blood Pressure ............................................................................16
Stress ....................................................................................................17
Heart Disease and African Americans .............................................................18
Types of Heart Disease Care............................................................................20
viii
Socioeconomic Status of African Americans……………………………….. 22
Heart Disease and Socioeconomic Status of African Americans........ 23
Socioeconomic Effects of Lifestyle Choices………………………………... 25
Lifestyle Choices of African Americans……………………………………..26
Obesity in the African American Community………………………. 27
Smoking and Other tobacco Use in the African American
Community………………………………………………………….. 28
Disparities in Health and Healthcare for African Americans……………….. 28
Studies of Disparities in Healthcare…………………………………. 29
Gaps in the Literature………………………………………………………...32
Summary…………………………………………………………………….. 33
3. METHODOLOGY ................................................................................................35
Introduction ......................................................................................................35
Study Design ....................................................................................................35
Population ........................................................................................................36
Sample..............................................................................................................36
Data Collection ................................................................................................36
Instrument ........................................................................................................37
Data Analysis ...................................................................................................38
Human Subject’s Protection ............................................................................39
4. RESULTS ..............................................................................................................40
Demographic Characteristics of the Sample ....................................................40
Age .......................................................................................................40
Highest Level of Education .................................................................41
Gross Annual Household Income ........................................................41
Number of People in Household ..........................................................42
Research Findings ............................................................................................43
Access to Healthcare.. ..........................................................................43
Type of Healthcare Coverage ..............................................................44
ix
The Setting of a Physician ...................................................................44
Best Setting ..........................................................................................45
Routine Check-Ups ..............................................................................45
Diabetes as a Risk Factor .....................................................................46
Whether 140/90 mm Hg is a Normal Blood Pressure..........................47
Family History as a Risk Factor...........................................................47
Smoking or the Use of Tobacco...........................................................48
Alcohol Consumption as a Risk Factor ...............................................48
Weight as a Risk Factor .......................................................................49
Menopause as a Risk Factor ................................................................50
Stress as a Risk Factor .........................................................................50
Maximum Daily Sodium Intake...........................................................51
Maximum Daily Cholesterol Intake.....................................................52
Least Amount of Fruits and Vegetables for Daily Consumption ........52
Least Amount of Physical Activity Per Day ........................................53
Maximum Servings of Fried Foods Per Week .....................................54
Summary ..........................................................................................................55
5. DISCUSSION ........................................................................................................56
Important Findings ...........................................................................................56
Implications for Social Work Practice .............................................................57
Implications for Future Research .....................................................................58
Implications for Social Work Policy................................................................59
Appendix A. Informed Consent and Questionnaire ...................................................60
Appendix B. The New Soul Food Pyramid ...............................................................65
References ....................................................................................................................67
x
LIST OF TABLES
Page
1.
Table 1 Highest Level of Education………………………………………. 41
2.
Table 2 Gross Annual Household Income…………………………………. 42
3.
Table 3 Number of People in Household………………………………….. 43
4.
Table 4 Access to Healthcare………………………………………………. 43
5.
Table 5 Type of Healthcare Coverage……………………………………… 44
6.
Table 6 The Setting of a Physician…………………………………………. 44
7.
Table 7 Best Setting………………………………………………………… 45
8.
Table 8 Routine Check-Ups……………………………………………….. 46
9.
Table 9 Diabetes as a Risk Factor………………………………………….. 46
10.
Table 10 Whether 140/90 mm Hg is a Normal Blood Pressure…………… 47
11.
Table 11 Family History as a Risk Factor………………………………….. 48
12.
Table 12 Smoking or the Use of Tobacco………………………………….. 48
13.
Table 13 Alcohol Consumption as a Risk Factor………………………….. 49
14.
Table 14 Weight as a Risk Factor………………………………………….. 49
15.
Table 15 Menopause as a Risk Factor……………………………………… 50
16.
Table 16 Stress as a Risk Factor……………………………………………. 51
17.
Table 17 Maximum Daily Sodium Intake………………………………….. 52
18.
Table 18 Least Amount of Fruits and Vegetables for Daily Consumption… 53
19.
Table 19 Least Amount of Physical Activity Per Day……………………... 54
20.
Table 20 Maximum Servings of Fried Foods Per Week…………………… 55
xi
1
Chapter 1
INTRODUCTION
According to the Centers for Disease Control and Prevention (CDC), heart disease
is the number one cause of death in the United States (CDC, 2011). Heart disease is also
referred to as cardiovascular disease. The major types of heart disease are atherosclerosis,
coronary, rheumatic, congenital, myocarditis, angina, arrhythmia and sudden cardiac
arrest (National Heart Lung &Blood Institute [NHLBI], 2009). Approximately 25% of all
Americans have one or more types of cardiovascular disease (NHLBI, 2009). The major
types of heart disease are due to congenital defects, infection, high blood pressure or
plaque build-up which can cause the narrowing of the coronary arteries or blood clots
(Mayo Clinic, 2011). Plaque is comprised of cholesterol, fat and additional substances
found in the blood such as platelets, plasma, white and red blood cells. Blood clots can
cause cardiac arrest as well as strokes (NHLBI, 2009). In general, these health conditions
are categorized as heart disease.
The researcher currently suffers from hypertension (high blood pressure), a risk
factor for heart disease (Burr, Tavares & Murchler, 2011). The researcher had multiple
risk factors that contributed to this condition. The most prevalent attribute occurred
approximately 36 weeks into her first pregnancy. The researcher began to consistently
have high blood pressure. The researcher eventually had to have the labor process
induced, which ultimately led to an emergency cesarean section. The researcher was not
satisfied with the care that she received and requested to leave the hospital against
medical advice. The researcher was rushed to the emergency room and hospitalized a few
2
days later. The researcher was diagnosed with congestive heart failure. The researcher
was placed on several variations of high blood pressure medication to assist with the
overall management of the heart disease diagnosis. Approximately two years after the
diagnosis, the researcher inquired to her personal physician about the congestive heart
failure diagnosis for further insight. After proper review of the researcher’s medical
information, the primary physician informed the researcher that she did not have
congestive heart failure, but showed symptoms that created a false diagnosis. It appears
that the researcher had in fact suffered from preeclampsia. Although the researcher does
still suffer from high blood pressure, this intrigued the researcher about the subject
matter.
Through this process, the researcher was amazed about the various components of
the issue of heart disease. The researcher was raised in a lower middle-class African
American home. On many occasions, the researcher indulged in inexpensive convenience
foods such as top ramen, kool-aid and fried bologna sandwiches with cheese. The
researcher used table salt sparingly as urged by her father who had diabetes and high
blood pressure. It was not until the heart disease misdiagnosis that the researcher found
that these convenience foods contained more sugar and or more sodium than a person
should typically have in one day. In many cases foods such as these are associated with a
lower socioeconomic status or stereotypically associated with African American culture.
This raises the question, is socioeconomic status associated with the knowledge of risk
factors for heart disease in the African American community?
3
Background
The United States Department of Health and Human Services has the Office of
Minority Health (OMH). The purpose of the OMH is to assist in the creation of health
programs and policies to assist in the elimination of health disparities among ethnic and
racial minorities. According to the OMH, African American adults are less likely to be
diagnosed with heart disease; however they are more likely to die from heart disease
(OMH, 2009). Although African American adults are 40% more likely to have high
blood pressure, they are 10% less likely than their non-Hispanic White counterparts to
have their blood pressure under control. According to the Center for Disease Control and
prevention (CDC), in 2006, African American men were 30% more likely to die from
heart disease, in comparison to non-Hispanic white men. In 2005, the Center on Budget
and Policy Priorities reported that 19.6 % of African Americans did not have healthcare
insurance and over 40% of the African American population suffered from heart disease
(American Heart Association [AHA], 2011). This equates to four out of ten African
Americans that suffer from heart disease and close to two out of ten do not have health
care insurance for either preventative care or treatment.
Statement of the Problem
African Americans have the highest rate of heart disease compared to any other
ethnic group (Heron, 2004). Prior to the turn of the century, there is minimal data
regarding research conducted on the issue of heart disease in the African American
community. Studies reflect that there was a decrease in heart disease mortality rates
amongst African Americans. Between the years 1950-2007, although there was a
4
decrease, the rate was substantially lower than that of the total population (National
Center for Health Statistics, 2011). Over the past five years, there have been educational
programs geared specifically to the education of African Americans regarding the deadly
disease. The American Heart Association created two national programs, Go Red for
Women began in 2004 and Power to End Stroke, began in 2006. Although Go Red for
Women is geared towards all women, the program recognizes that African American
women are of the highest effected population. The Power to End Stroke, program is
geared specifically towards African Americans. Although these programs have been
created, there remains a disparity in the number of heart disease related deaths in the
African American community compared to Whites.
Purpose of the Study
The purpose of this study is to explore to what extent socioeconomic status is
associated with the knowledge of risk factors of heart disease in a sample of African
Americans. This will enable the researcher to evaluate if socioeconomic status is
associated with the knowledge of risk factors for heart disease in the African American
community. The socioeconomic status will be divided into two categories; 1.) working
class 2.) middle class or above. There will be thirty participants chosen from each
category. The economic status will be determined based on the educational level, gross
annual income and household size. The study design is an explorative study that will
utilize quantitative methods. The motivation for this study is to make an argument for the
need for community based outreach and outpatient clinics to address prevention,
counseling and routine testing for heart related issues.
5
Conceptual Framework
The theoretical framework of empowerment is appropriate with socioeconomic
status and knowledge of risk factors of heart disease for African Americans. The
empowerment approach is a multilevel approach that addresses the micro, mezzo and
macro. The micro aspect of the theory addresses the individual by promoting a stronger
sense of self also referred to as self-actualization. The mezzo aspect addresses a higher
sense of knowledge and awareness of a person’s environment and how it is effected
socially as well as politically. The macro aspect incorporates the strategies and resources
of the group in order to address a common goal. The empowerment approach has
historically proven to be effective with working with the oppressed and disenfranchised.
Judith A.B. Lee provides evidence of the empowerment approach in assisting to build a
better community (Lee, 2001). This evidence-based framework can be utilized effectively
within a community of underrepresented people. It is essential to educate the community
in order to empower them. The empowerment approach allows creativity on the part of
the social worker and utilizes multiple resources. It is essential that a common ground is
established in order to have success. The idea behind the empowerment theory is to gain
access to resources as well as utilization of the resources. The main objective is to
support resilience in a community and allow its members to own their success.
Addressing heart disease in the African American community is a multifaceted
issue. The empowerment theory incorporates the ideology of the utilization of a
multidisciplinary team. This is necessary especially because the issue of heart disease in
the African American community is a multi socioeconomic phenomena. The
6
empowerment approach is not only beneficial for the client but also for the provider and
or social worker. The empowerment approach utilizes the teacher trainer role. This allows
the social worker to educate the communities as well as other professionals regarding
barriers. The empowerment approach addresses issues of historical oppression as
emphasized by the concept of critical consciousness. The term critical consciousness is
adopted from Paulo Freire’s, The Pedagogy of the Oppressed (Lee, 2001). Critical
consciousness is the notion that implies that empowerment can manifest if the community
is fully engaged. The process of engagement is to educate the community and promote
collectivism. The theory will assist in prompting more African Americans to be more
proactive about accessing healthcare for screening or obtaining care for issues
surrounding heart disease. The ultimate goal is to alleviate the false dichotomy of
socioeconomic status as defined through the ideology of capitalism. Although
socioeconomic is a defining factor in today’s society, it is conducive and necessary to
combine resources in order to address heart disease in the African American community.
Definition of Terms
The researcher will use the term heart disease in reference to all heart related
conditions unless otherwise specified. This will include but will not be limited to
atherosclerosis, coronary, rheumatic, congenital, myocarditis, angina, arrhythmia, sudden
cardiac arrest and cardiovascular disease. Being that the term heart disease is nontechnical language; it will be utilized in order to describe what can be complex and
medical terminology. The term heart disease risk factors are the risk factors as defined by
7
the National Heart Lung and Blood Institute (2009). The researcher will explain and
define specific risk factors relevant to the research.
In the African American community there is not a consensus on how people
would like to be referenced ethnically or racially. The focus of the research is on
individuals in the United States. All persons that identify themselves as being a part of
the Black American cultural community will be included. The current politically correct
term is African American. The researcher will use the term African American when
referencing any person with any Black American culture and ethnicity.
Assumptions
The researcher assumes that African Americans of all socioeconomic status are
dying at high rates from heart disease. The researcher assumes that the risk factors of
heart disease are not common knowledge amongst African Americans. The researcher
assumes that the collaboration of all socioeconomic statuses in the African American
community are necessary. The researcher assumes that by drawing attention to the issue,
it will assist in alleviating some disparities in decreasing the mortality rates of heart
disease within the African American community.
Justifications
The goal of this research study is to suggest the implementation of community
outreach and community based outpatient clinics to address prevention, counseling and
routine testing for heart related issues. The objective of the outpatient clinics is to assist
in the possible decline of heart related deaths in the African American community. In the
profession of social work, public health is an issue of concern because it is something that
8
has a direct effect on our clientele. In order to promote cultural competency and
sensitivity for the African American community, it is important for social workers to
understand major issues that affect the African American community. The Affordable
Care Act of 2010 has placed several healthcare disparities in the forefront. As an effort to
work towards social justice, social workers should be aware of the disparities that remain
to exist today amongst African Americans (Littrell, 2008). It is therefore also important
to identify possible solutions.
Limitations
The researcher understands and recognizes that heart disease is a major issue for
all Americans. Research has shown that African Americans suffer from heart disease at a
greater rate than any other American (AHA, 2009). African American women are dying
at a higher rate than African American men (AHA, 2010). The researcher will not focus
only on African American women. The researcher feels that focusing on one sex in
particular would be a disservice to the African American community. The idea is to
create cohesiveness and massive community engagement. Due to the fact that there is
limited research on African Americans as a group, this process would diminish the
overall value of the research.
9
Chapter 2
REVIEW OF THE LITERATURE
Introduction
This section will begin by providing a historical background of heart disease for
African Americans. One important factor of this research is to address issues of
disparities in the number of African Americans that die from heart disease related issues.
The themes discussed are heart disease risk factors, heart disease and African Americans,
types of heart disease care, socioeconomic status of African Americans, socioeconomic
effects on lifestyle choices, lifestyle choices for African Americans and disparities in
health and healthcare for African Americans. Gaps in the literature will also be discussed.
Historical Background
Post Civil War was a time for Reconstruction for African Americans. During this
time, the first African American cardiologist by the name of Daniel Hale Williams began
to assist in the provision of locating competent surgeons for African Americans (Gordon,
2005). Dr. Williams helped to train African American doctors and contributed to assisting
with the necessary overhaul of medical care for the African American community
(Gordon, 2005). Being that the majority of the United States was segregated, the training
of health care professionals meant that there would be more research conducted on the
causes of diseases in the African American community. Dr. Williams passed away in
1931 (Gordon, 2005). During this year (1931), Dr. S.R. Roberts of Emory University
Hospital addressed the American Heart Association. During his address, Dr. Roberts
10
presented his conclusion that the cardiology disease, angina, did not occur in, “humorous,
careless, musical black (people)” (Heslin & Scott, 2003, p.1349). According to Dr.
Roberts, there was a correlation between the nervous system, mental influences and the
development of the disease, amongst African Americans. Dr. Roberts believed African
Americans suffered from a deficiency in the nervous system, which makes African
Americans less sensitive to pain therefore the African American, could not be affected by
the disease (Heslin & Scott, 2003). During a study conducted between 1950 and 1954, it
was concluded that African Americans did not suffer from any dysfunction with the
nervous systems as concluded by Dr. Roberts in 1931, refuting his conclusion (Heslin &
Scott, 2003). Over the next quarter of a century, there was more emphasis on the
treatment of heart disease, excluding race as a factor or possible cause for any
predisposition.
The National Black Health Providers Task Force in High Blood Pressure
Education was formed in cooperation with the National Heart, Lung and Blood Institute
(NHLBI) in 1977 (Heslin & Scott, 2003). In 1980 the National Black Health Providers
Task Force in High Blood Pressure Education made the recommendation of an increase
in research geared towards cardiovascular disease in minorities (Heslin & Scott, 2003).
The Clinton administration has been noted for actively attempting to address issues of
heart disease and the disparities based upon race (Kressin & Petersen, 2001). The year
2006 marked the beginning of one of the largest studies on cardiovascular disease among
African Americans entitled the Jackson Heart Study (Dreyfus, 2006). The study is
scheduled to continue until 2014. The study will investigate the inherited (genetic) factors
11
that affect heart disease as well as high blood pressure, strokes, diabetes and other
important diseases in African Americans. The study will be led by cardiologist, Dr.
Herman Taylor, Jr. The study will be conducted in Mississippi, an area with one of the
nation’s highest African American populations that suffers from cardiovascular disease.
The study will include 5,302 African American residents of Mississippi. The study will
follow the lives of these residents and make observations regarding both their
environment as well as their heart health (Dreyfus, 2006). This will be the first in depth
study of its kind regarding heart disease in the African American community (Dreyfus,
2006).
Heart Disease Risk Factors
There are several risk factors for heart disease. The National Heart Lung and
Blood Institute list more than fifteen risk factors for heart disease (NHLBI, 2009). Many
risk factors can be reduced with lifestyle changes (NHLBI, 2009). These risk factors
include smoking or use of tobacco products, alcohol consumption, excess body weight,
poor eating habits/unhealthy diet, high blood cholesterol, high blood pressure, lack of
physical activity and stress (NHLBI, 2009).
The risk factors of heart disease that can't be controlled are age, gender, and
family history of heart disease. For women this includes menopause and preeclampsia.
Menopause is the biological and natural process that occurs one year after a woman’s last
period. Menopause is a woman’s permanent end of menstruation and fertility. Although
menopause is considered a biological change that occurs in women over fifty, there are
other instances where the onset can occur earlier in life (Sherman, 2005). Preeclampsia is
12
a condition that occurs in women during pregnancy. During preeclampsia, the pregnant
woman has onset of hypertension and high levels of protein in her urine that can be found
after 20 weeks of pregnancy (Tan, Gast & van der Schouw, 2010). For some women, the
changes that occur with preeclampsia have continuous effects.
Many people have at least one risk factor for heart disease. A person’s risk of
heart disease increases with the number of risk factors and their severity. Many risk
factors start during childhood. This has become more common because many children are
overweight and don't get enough physical activity. Some risk factors can even develop
within the first 10 years of life (NHLBI, 2009). Most recently a study revealed that a
person’s stature could be a risk factor for heart disease. According to a study in the
European Heart Journal, short stature was associated with a 50 percent greater risk of
heart disease. Short for men was defined as a height of 5 feet, five inches and below.
Short for women was defined as 5 feet and below (Singer-Vine, 2010). Nevertheless,
researchers continue to study and learn more about risk factors of heart disease.
Smoking/Tobacco
Smoking or use of tobacco causes harm to the blood cells. This can cause direct
damage to the overall functioning of the heart (NHLBI, 2009). The risk for heart disease
among smokers tends to be related to the amount that is smoked. Smoking as little as one
cigarette per day increases a person’s risk of heart disease by 100 percent (Prasad, Kabir,
Dash & Das, 2009). Smoking four cigarettes per day significantly increases the risk of
heart disease up to 400 percent. Smoking and tobacco use has been estimated to cause
about 11 percent of all deaths due to heart disease (Prasad, Kabir, Dash & Das, 2009).
13
When a person smokes, it is estimated that only 15 percent of the tobacco smoke gets
inhaled by the smoker (Prasad, Kabir, Dash & Das, 2009). The remaining 85 percent
lingers in the air for others to breathe. This lingering smoke in the air is generally referred
to as secondhand smoke. Secondhand smoke is also known as environmental tobacco
smoke (ETS) or passive smoke. If a person spends two hours or more in a room where
someone is smoking, the nonsmoker inhales the equivalent of four cigarettes (University
of Minnesota, 2003). Whether a person uses tobacco products or is exposed to second
hand smoke, there is an increased risk of heart disease.
Alcohol
According to the American Heart Association (AHA), alcohol consumption in
moderation does not pose any serious risk factors (AHA, 2009). Moderation is defined as
an average of one drink per day for women and one to two drinks per day for men. A
drink is one 12 oz. beer, 4 oz. of wine, 1.5 oz. of 80-proof spirits, or 1 oz. of 100-proof
spirits. Consumption of alcohol in excess can raise the levels of some fats in the blood
also known as triglycerides, which can lead to heart disease (AHA, 2009).
Excess Weight
The most common way to determine whether a person is defined as being
overweight or obese is through the use of the body mass index (BMI). BMI is based on a
person’s height and weight. A BMI between 25 to 29 is considered overweight. A BMI
between 30 to 39 is considered obese. A BMI of 40 and above is considered extremely
obese. The limitations to the use of the BMI is that it may overestimate body fat in
athletes and others who have a muscular build and underestimate body fat in older people
14
and others who have lost muscle (NHLBI, 2009). A person’s weight is the result of many
factors which include environment, family history and genetics, metabolism (the process
in which the body changes food and oxygen into energy) and behavior or habits. Excess
weight can contribute to an increase in a person’s blood pressure as well as plaque buildup in the arteries. Excess weight can also lead to other medical dispositions such as
diabetes.
Poor Eating Habits/Unhealthy Diet
Although excess weight is generally emphasized when discussing poor eating
habits, weight does not translate as the only defining factor of an unhealthy diet. Poor
eating habits or an unhealthy diet can be found in individuals of all body weights. Foods
that are high in saturated fat, trans fat or cholesterol can raise an individual’s LDL
cholesterol also known as bad cholesterol levels in the body (USDA, 2011). Saturated fat
is generally found in foods that are processed or foods that have been deep-fried.
Saturated fat can also be found in foods such as dairy products and some meats. Trans-fat
is found in processed or canned foods. Americans should limit their daily intake of
dietary cholesterol to 300mg (USDA, 2011). Cholesterol can also be found in dairy
products, various meats and some shellfish, as well as eggs and store bought baked
goods.
Consumption of foods that are high in sodium and or high in simple sugars is also
unhealthy. High sodium or high salt products can increase a person’s risk of high blood
pressure. However, sodium is an essential nutrient and is needed by the body in small
amounts. The more a person perspires, the amount of sodium necessary for that
15
individual increases (USDA, 2011). On average, the higher an individual’s sodium
intake, the higher the individual’s blood pressure. Foods that are composed of simple
sugars have no nutritional value (minerals and vitamins) and are simply calories that are
consumed. Simple sugar foods are candies, non-diet sodas as well as fruit drinks and
canned fruits with syrup. These types of foods are what most people consider
convenience foods.
Lack of Physical Activity
Physical activity is not only for weight loss. Physical activity is necessary to the
assistance of maintaining a healthy body weight. The amount of physical activity
necessary for an individual to maintain a healthy body weight depends on the individual
as well as their calorie intake. The United States Department of Agriculture recommends
that adults should engage in a minimum of 150 minutes of moderate-intensity aerobic
activity per week. Children and adolescents are encouraged to engage in 60 minutes per
day (USDA, 2010). For individuals that need to lose weight in order to achieve a healthy
weight, it is recommended that there be an increase in the intensity of daily activity. In
some instances this may result in a gradual increase of weekly activity as well to an
average of 60 minutes per day, five days per week.
High Blood Cholesterol
Cholesterol is a substance that can be found in the body. Every five years, all
adults over the age of 20 should have their cholesterol levels tested. In order to test the
cholesterol levels, an individual must fast. In order to fast a person must reframe from
consuming any substance other than water for a period of 9 to 12 hours. A person’s blood
16
will be drawn and tested. The results of the test will measure the total cholesterol for the
individual. The total cholesterol is broken into three components. These three
components are LDL (bad) cholesterol, HDL (good) cholesterol and triglycerides (type of
fat) (AHA, 2011). Cholesterol levels of less than 200 mg/dL places a person at a lower
risk level of heart disease. A cholesterol level of 240 mg/dL and above is classified as a
high blood cholesterol level (AHA, 2011). With HDL (good) cholesterol, higher levels
are better. Low HDL cholesterol puts an individual at higher risk for heart disease. An
ideal HDL level for a man is 40 mg/dL. The ideal HDL level for a woman is 50 mg/dL. A
LDL (bad) cholesterol level of less than 100 mg/dL is considered ideal. A LDL level of
190 mg/dL and above is considered very high. Triglyceride is the most common type of
fat in the body. A high triglyceride level translates into more fat in the blood, which is not
good. Normal triglyceride levels vary by age and sex (AHA, 2011). However, a high
triglyceride level combined with low HDL cholesterol or high LDL cholesterol increases
the risk factor for heart disease.
High Blood Pressure
A person can have high blood pressure (hypertension) for years without any
symptoms (MayoClinic, 2011). High blood pressure is a common condition in which the
force of the blood against the artery walls is high enough that it can eventually cause
heart disease. Blood pressure is determined by the amount of blood the heart pumps and
the amount of resistance to blood flow in the arteries. The more blood the heart pumps
and the narrower your arteries, the higher the blood pressure (MayoClinic, 2011). A
systolic level or top number and a diastolic level or bottom number defines a blood
17
pressure. The force of blood in the arteries as the heart beats is the systolic pressure. The
force of the blood in the arteries as the heart relaxes between beats is the diastolic
pressure. A normal blood pressure is a systolic level less than 120 and a diastolic level
less than 80 (NHLBI). A high blood pressure is a systolic level of 140 and above and a
diastolic level of 90 and above. A person with a blood pressure of 140/90mmHg is
defined as having hypertension. One factor that can increase a person’s blood pressure is
stress.
Stress
Stress is a term that is difficult to define. According to the American Institute of
Stress, this difficulty is attributed to the fact that stress is different for everyone. In many
instances, stress is not a useful term for scientists because it is such a highly subjective
phenomenon that it defies definition. Canadian endocrinologist, Hans Selye, as it is
currently used coined the term “stress”, in 1936. Selye defined stress as the body’s nonspecific response to any demand for change (AIS, 2011). When a person is under
constant stress, their body releases hormones such as Cortisol and adrenaline. The body
then sends the brain a signal that the heart needs attention (Callahan, 2011). The physical
affect of stress can be symptoms such as headache, muscle tension or pain, chest pain,
fatigue, change in sex drive, stomach upset, sleep problems. Stress can affect a person’s
mood by causing anxiety, restlessness, lack of motivation or focus, irritability or anger,
sadness or depression. Stress can cause adverse behaviors such as overeating or under
eating, angry outbursts, drug or alcohol abuse, tobacco use and/or social withdrawal
(MayoClinic, 2011).
18
Heart Disease and African Americans
Heart disease in African Americans may have differences in origin and drug
response (Ferdinand, 2009). Heart disease in African Americans is marked by earlier
onset, increased prevalence of hypertension as the underlying cause of disease and
increased risk for hospitalization and mortality (Ferdinand, 2009). There are apparent
differences in response and changes of normal body functions to cardiac drugs
(Ferdinand, 2009). A dysfunction in the inner lining of the blood vessels (endothelial) is
potentially among the hallmarks of heart disease in African Americans. This dysfunction
causes a decrease in the nitrate oxygen. Monitoring cholesterol, use of lipid-lowering
agents, and achievement of guideline-recommended low-density lipoprotein (LDL) levels
may assist with the possible prevention of heart disease (Kressin, Petersen & Woodard,
2004).
Although a heart attack or stroke may seem sudden, the primary cause of heart
disease occurs over many years. In many cases heart disease begins at a young age. This
may contribute to the rate of obesity. Statistics reveal that in 2008, 44 percent of African
Americans were obese and nearly 50 percent of African American women were obese
(Flegal, Carroll, Ogden, et al., 2010) The significance of this is that these same statistics
revealed that although obesity is considered to be a concern throughout the United States,
33 percent of Whites were defined as obese. Approximately 33 percent of White women
were defined as obese compared to more than half of the population of African American
women. Statistics in 2009 revealed that African American women were 1.7 times more
likely as non-Hispanic white women to be obese (OMH, 2009; NCHS, 2009; Moulton,
19
2009). African American adults are less likely to be diagnosed with coronary heart
disease; however they are more likely to die from heart disease (US Department of
Health and Human Services, 2010). In 2006, African American men were 30% more
likely to die from heart disease, than non-Hispanic white men (OMH, 2009). African
Americans were 1.5 times more likely than non-Hispanic whites to have high blood
pressure. This may result in part from lack of timely prevention or screening. The US
Department of Health and Human Services reports that high blood pressure contributes to
both heart disease and strokes, and African American adults are 1.5 times more likely to
have high blood pressure and 1.7 times more likely to have a stroke than white adults.
This means that African American adults are 40 percent more likely to have high blood
pressure than non-Hispanic Whites (OMH, 2009). African Americans are 10 percent less
likely than their non-Hispanic White counterparts to have their blood pressure under
control (OMH, 2009). Between the years 2003 and 2006, an estimated 46.8 percent of
American adults were clinically defined as having high blood cholesterol. Among
African Americans, 41.8 percent of women and 40.2 percent of men were clinically
defined as having high cholesterol (AHA, 2010). African American women rank the
highest for multiple risk factors for heart disease (Hayes, Denny, Keenan,
Croft, Sundaram, et al., 2006).
Prevention is an important attribute for decreasing the mortality and risk factors of
heart disease for African Americans. This includes promoting consistent exercise, low fat
and low sodium diets, restraining from smoking and decreasing obesity. Foods that best
assist with low fat and sodium requirements are whole grains, fruits, and vegetables.
20
Socioeconomic factors have a direct effect on obtaining and consuming these types of
foods. The USDA (2011) recommends a daily intake of 3-5 servings of fruits and
vegetables per day. Although there are programs designed to educate African Americans
regarding risk factors of heart disease, it does not address the issues and concerns of
individuals diagnosed with heart disease.
Individuals with heart disease continue to not receive adequate follow up care,
medication or fail to have a diagnosis in many cases. This is due to the lack of trust of the
healthcare system among many African Americans. Historically, there have been
instances where medical professionals (King, 2003) have knowingly used African
Americans for experimentation. Unfortunately, the participants were unaware. One
instance is the study of poor African American men with the syphilis virus in Alabama.
The United State Public Health Service from 1932 to 1972 conducted the study (Walker,
2009). The study is commonly referred to as the Tuskegee syphilis experiment. The
African American men were promised treatment and instead were used for
experimentation. This has created an overall hesitation of African Americans to
participate in possible life saving trials for heart disease care. It is recommended that a
person receive a routine check-up annually regardless if they have health concerns or not.
A regular check-up can assist with the diagnosis of heart disease. There are several types
of heart disease care.
Types of Heart Disease Care
A diet high in fat, sodium and cholesterol is associated with increased weight,
elevated blood cholesterol levels and blood pressure, all of which increase the chances of
21
atherosclerosis to possibly occur (Sandmaier, 2005; NHLBI, 2009). If a person is at risk
of heart disease, it is important for them to have their cholesterol levels checked
regularly, especially if there is a family history of heart disease. Street drugs such as
cocaine, using intravenous drugs or smoking tobacco can damage the heart (AHA,
2009). If a physician feels a patient is at risk for heart disease a computed tomography
(CT) scan of the heart can be completed. The CT scan is an imaging method that uses xrays to create detailed pictures of the heart and its blood vessels (Achenbach & Daniel,
2007; Huntzinger, 2008).
For persons diagnosed with heart disease, it is important for them to follow any
physical activity recommendations and restrictions, complete tests ordered by their
physician, take medication as prescribed and keep follow-up appointments.
Communication with the physician and or cardiologist is important especially if a person
feels that the treatment they are receiving is unnecessary or makes them feel worse. It is
important that no changes are made prior to the consultation of the physician. Regular
dental care is important. The purpose is to minimize the chance of an infection that could
affect the heart. Depending on the type of heart disease, certain over-the-counter
medications, vitamins, herbal preparations or prescription medications including
antibiotics and anesthesia can have an effect on the heart (Bairey Merz, Alberts, Balady,
Ballantyne, Berra, et al., 2009). It is important for individuals with heart disease to learn
as much as possible about their condition. This includes knowing the particular type of
heart defect and what surgeries if any have been completed. It is important for individuals
with heart disease to carry a list of their medications, including the quantity and daily
22
dosage (AHA, 2009). Adequate healthcare is essential for individuals with heart disease.
Although addressing harmful lifestyle choices is important, the overall care and
monitoring of a physician is pertinent.
Socioeconomic Status of African Americans
Socioeconomic status is also referred to by the acronyms SES. Generally, SES is
often measured as a combination of education, income, and occupation. According to the
American Psychological Association (APA), SES is commonly conceptualized as the
social standing or class of an individual or group. Typically, social class is viewed as a
way of defining a person’s privilege, control and or power. It is no surprise that
researching SES reveals inequities in access to and distribution of resources. SES is
relevant in various aspects such as behavioral and social science, including research,
practice, education, and advocacy (APA, 2011).
In 2008, the United State Census bureau conducted a survey. A total of 37,966
African Americans were interviewed. Of the participants, 24.7% of the population lived
below the poverty level where 75.3% lived at or above the poverty level (US Census
Bureau, 2010). The poverty level takes in account inflation. Poverty guidelines are used
for the forty-eight major states and District Columbia, excluding Alaska and Hawaii.
Alaska and Hawaii are excluded because historically the cost of living has been
substantially higher for these two states. According to the 2008 Health and Human
Services guidelines, a family size of three with an income of $17,600 is considered living
in poverty.
23
In a similar survey conducted by the U.S. Census Bureau in 2007, there was a
total of 14,551 African American participants. The survey revealed that the largest
percentage of participants, 16.2%, had an annual income of between $50,000-$74,999.
According to the 2000 census, 34.7 million people reported they were African American
or Black. An additional 1.8 million reported being African American or Black and at least
one other race. Only approximately 4 percent of the total African American population
was surveyed in 2008 regarding their income. It is obvious that this does not create an
accurate depiction of the total percentage or number of African American incomes in
regards to their total household income in comparison to the federal poverty level
(Federal Register, 2008). There was no additional census data found that provided a more
accurate depiction of the socioeconomic status of African Americans. However, there
were some independent studies that focused on the prevalence of heart disease in the
African American community in specific socioeconomic groups (Heslin & Scott, 2003;
Grothe, Bodenlos, Whitehead, Olivier, & Brantley, 2008).
Heart Disease and Socioeconomic Status of African Americans
After observing the large number of African American patients with heart disease
admitted to Hubbard Hospital in the late 1950’s, Dr. John Thomas of Meharry Medical
College decided to implement a cohort study (Heslin & Scott, 2003). The health of
African American men that attended John Hopkins University from 1958 to 1965 and
White men that attended from 1957 to 1964 were observed over a 30 year period. The
data was analyzed in 1988. African American men had a 40% higher rate of hypertension
than their white counterparts. The heart disease fatality rate for African American
24
participants was 51.5 percent where the white participants was only 9.4 percent. The
study concluded that a higher socioeconomic status did not change the risk of heart
disease among the African American men.
A cross sectional study conducted observed 31-year trends in heart disease risk
factors of American adults by annual income and educational levels. The cross sectional
analysis was based on four national surveys. The surveys addressed high blood pressure,
high cholesterol, diabetes and smoking beginning in 1971 and concluded in 2002. The
purpose of this study was to review the possible trends in disparities in the risk factors of
heart disease due to socioeconomic status (Kanjilal, Gregg, Cheng, Zhang, Nelson, et al.,
2006). The focus of the study was not on the socioeconomic status of African Americans.
However, the study could not ignore the fact that there was an obvious disparity in the
decrease of risk factors for heart disease among African Americans. This is attributed to
the findings that African Americans have a higher probability of experiencing poverty at
all ages. Studies have also shown that African Americans historically have a higher rate
of unemployment and lower levels of education (Farmer & Ferraro, 2005).
A quantitative study was conducted to examine the psychosocial vulnerability
model of hostility as a predictor of coronary heart disease in low-income African
Americans. The study examined social support and stress as mediators of the hostility.
The authors use hostility as a psychosocial variable that has been linked to heart disease.
The authors do not provide additional definitions of the terms hostility and stress. Based
on the use of the term hostility, it appears that authors are defining the term as instances
of anger. The study consisted of 95 heart disease patients and 30 healthy controls. The
25
study suggests that the lower a person’s socioeconomic status, the higher the prevalence
of stress and instances of hostility (Grothe, Bodenlos, Whitehead, Olivier, &
Brantley, 2008). Among the participants, hostility was negatively correlated with social
support, but was not related to minor stress. Heart disease patients had higher levels of
hostility; however, the relationship between hostility and heart disease status decreased
once stress and social support were included in the model (Grothe, Bodenlos, Whitehead,
Olivier, & Brantley, 2008). The assumption of the authors was that African Americans of
a lower socioeconomic status have greater instances of hostility and stress. This is an
example of how socioeconomic status has an effect on lifestyle choices.
Socioeconomic Effects on Lifestyle Choices
Socioeconomic status in most cases determines the type of environment in which
a person resides. If a person does not have access to adequate healthcare or
transportation, this generally translates into a limitation in their overall resources.
Something that may appear to be simple such as the consumption of fruits and vegetables
is an obstacle for a person of a lower socioeconomic status (SES). There are few stores in
low-income areas that carry fresh fruits and vegetables. There are other concerns such as
financial burdens, which in most cases cause stress. All of which are risk factors for heart
disease. A quantitative study was conducted in 2003 regarding risk factors for heart
disease among women. The data consisted of the response of 153, 466 U.S. adult women.
The authors used descriptive and multivariable analysis to assess the differences in risk
factors of heart disease. The study focused on socioeconomic status as well as race and
ethnicity. Results of the study found that individuals of lower socioeconomic status had
26
more risk factors for heart disease. The study suggested that there is a critical need for
prevention programs that target risk reduction, especially in women with higher risk. The
study concluded that more than one third of women in the United States have two or
more risk factors for heart disease and stroke (Hayes, Denny, Keenan, Croft, Sundaram,
et al. , 2006). The study did not provide any data regarding a cross tab analysis of
socioeconomic factors and race/ethnicity.
Lifestyle Choices for African Americans
African Americans have been in the United States for hundreds of years. While
not all African Americans were slaves, slavery was the largest migration of the race to the
United States. Being that slavery was not a voluntary migration to the United States;
slaves were thought of and treated as property. Subpar treatment was obvious in many
aspects of the life of the slave but was extremely prominent in the treatment of the health
of the African American. African Americans were given the left over scraps of animal
carcasses to eat. This food is what is now referred to as soul food. Soul food was survival
food. This food was high in fat and sodium.
During slavery, most large plantation owners utilized the services of an older
female slave on the premises to facilitate medical services to the slaves (Heslin & Scott,
2003). There was no access to even the minimal advances in healthcare for African
Americans and the causes of death were seldom known. Beginning in 1850, the Census
Bureau began to collect mortality data in a limited number of states. The data was
collected based on the cause of death by disease and race and ethnicity of the deceased
(Heslin & Scott, 2003). The significance in the cause of the death is that this creates an
27
opportunity to further research on major disease causes. Many African Americans live on
the values created centuries ago as a form of survival of the oppression endured during
slavery. As in the case of slavery, African Americans of lower socioeconomic status
generally acquire food based on price as well as convenience. This includes unhealthy
eating habits.
African Americans of lower socioeconomic status have difficulty with
encompassing fruits and vegetables in their daily diet (Shankar & Klassen, 2001). This is
attributed to the cost as well as the lack of knowledge of how to introduce fruits and
vegetables into their daily lives (Shankar & Klassen, 2001). In many instances, there has
been a lack of knowledge regarding the significance and necessity of incorporating fruits
and vegetables in their daily lives. This can result in the consumption of foods that are
high in sodium and trans-fat. The USDA (2011) recommends that African Americans
limit their daily sodium intake to 1500 mg. There was no research found on the maximum
servings of fried foods a person should consume per day or per week. The basic
recommendation is to simply avoid fried foods entirely.
Obesity in the African American Community
As previously stated, African American have the highest rate of obesity with a
largest prevalence among women. The rate of obesity for African American women is 1.7
times more likely than that of non-Hispanic white women (OMH, 2009). One significant
contributor is a lack of physical activity. According to the American Heart Association,
24.8 percent of African Americans over the age of 18, report regular physical activity
28
(AHA, 2010). The physical activity noted is outside of every day activity, meaning
during an individual’s leisure time.
Smoking and Other Tobacco Use in the African American Community
An issue that remains to be of concern in the African American community is
smoking and other tobacco use. In 2008, 20.6 percent of Americans over the age of 18
were cigarette smokers. Among African Americans, 25.6 percent of males and 17.8
percent of females were cigarette smokers (AHA, 2010). Although smoking is a big
problem among adults, second hand smoke provides its own implications. The largest
concern is that second hand smoke, in many cases, effects individuals that are unable to
legally consent to smoke. Statistics showed that in 2010, 55.9% of African Americans
were exposed to secondhand smoke (CDC, 2011). This is more than half of the African
American population.
Disparities in Health and Healthcare for African Americans
There have been arguments that the food pyramid does not properly address the
nutritional needs of African Americans (USDA, 1997). This is attributed to the fact that
the traditional food pyramid does not provide a variety for suggested foods for
consumption. It does not appear to be common knowledge that the USDA food pyramid
is not the only food pyramid available. Although the traditional food pyramid is more
widely recognized, a food pyramid was created to address the historical eating habits of
African Americans in a healthy manner. The Soul Food pyramid has infused the
traditional USDA food pyramid with recommendations of traditional foods of African
Americans (Hebni, 2010). Although the Soul Food Pyramid does not change the USDA
29
recommendations, it provides a relatable resource for African Americans to adopt a
healthier lifestyle. Hebni nutrition consultants, inc. (HNC), created the Soul Food
pyramid in 1997 (Hebni, 2010). HNC is a non-profit organization that was created
through the partnership of three Florida based dieticians. The purpose of the Soul Food
pyramid was to assist in closing the gap in health disparities in the African American
community that are attributed to health and nutrition (Dwyer & Marino, 1998). A newer
version of the pyramid was created in 2006 entitled, The New Soul Food Pyramid
(Hebni, 2010), (Appendix B). The newer version was created in order to adhere to the
updated standards of the American Dietetic Association (ADA) and the USDA (Hebni,
2010). The significance of The New Soul Food pyramid is that it addresses healthy eating
with cultural sensitivity. The pyramid is easy to read for individuals of various
socioeconomic backgrounds. Food consumption is one of the less complex health
disparities for African Americans.
Studies of Disparities in Healthcare
Disparities in healthcare are far more complex. Socioeconomic status and
race/ethnicity have been associated with disparities such as avoidable procedures,
avoidable hospitalizations, and untreated disease (APA, 2011). Addressing the issue of
heart disease and socioeconomic status for all ethnic groups was a concept that began in
the 1960’s.
A retrospective cohort study was conducted by three physicians from the
University of Iowa. The population consisted of 1,215,924 African American and white
Medicare beneficiaries age 68 and older. These individuals had suffered a heart attack
30
and were hospitalized between January 1, 2000 through June 30, 2005. The study
involved 4,627 US hospitals with and without revascularization services. The analysis
was based on 85, 069 (6.7%) African American patients and 1,130,085 (89.5%) white
patients. There were 48,211 (3.8%) patients that were excluded on the basis that race data
was either missing or were of a race other than white or African American. The
researchers found that African-Americans were far less likely to receive life-saving and
advanced treatment for heart disease than white patients (Popescu, Vaughan-Sarrazin &
Rosenthal, 2007; Townes, 2007). This study is one of many to reveal that there is a
disparity in the quality of healthcare being offered to African Americans.
Prejudice on a systemic level against African Americans creates additional
barriers in health care that exist regardless of class (APA, 2011). Although
socioeconomic status is generally the defining factor for the disparity in healthcare for
most Americans, African Americans face a disparity simply because of the color of their
skin. Farmer & Ferraro (2005), conducted a study to explore if racial disparities in health
were conditional on socioeconomic status. The study was a stratified, multistage,
probability sample. The participants ranged from 25 to 74 years of age. The study
consisted of 873 African Americans and 5,968 white participants of various
socioeconomic statuses (SES). The health of the participants was measured through a
self-analysis of their personal health. Over a twenty year period, there was no change in
self reported health status with African American participants where there were with
White participants. The results revealed that African Americans with a higher SES did
not differ much from those of African Americans in a lower SES. The study provided
31
evidence of the significance of race when addressing health disparities for African
Americans.
Being that health disparities among African Americans have such prominence,
there is reason to believe that there is some prejudice on a macro level. This means that
there are some preconceived assumptions for the rationalization of why African
Americans are not being offered certain types of healthcare (Popescu, Vaughan-Sarrazin
& Rosenthal, 2007). The disparities are occurring in different parts of the country
meaning that it is not individualized or based in one geographic community. There
appears to be some obvious prejudice on a national level, a macro level. When there is
prejudice on a macro level, it should be referred to as institutionalized racism (Jones,
2000). Institutionalized racism is carried out on a systemic level or a macro level. An
obvious example of this is the Tuskegee experiment (Walker, 2009) or Jim Crow laws
that were enforced from 1876 to 1965. Institutionalized racism is no longer as blatant as
the previous examples. However, it can now been seen in the lack of funding and
research for African American specific issues. It is important to understand that there is a
correlation between the emerging role of policy, community environment change
strategies and community participation. These aspects are leading to promising practices
to improve health behaviors in the African American community and to reduce health
disparities (Chavis, Herrick & Plescia, 2008; Baskar, Bhalodkar, Blum, & Garg, 2006).
Although the issue of healthcare disparities among African Americans is recognized
among various disciplines, there has yet to be a concrete solution or macro
recommendation on how to address the issue.
32
Gaps in the Literature
There was not a significant amount of literature referencing any advances made
by African American physicians during segregation in regards to heart disease in African
American patients. The literature focused on the lack of advanced medical training and
continued education of African American physicians prior to desegregation of the
American Medical Association (AMA) (Baker, 2009). Due to the obvious distrust of
many in the African American community regarding healthcare after desegregation, it
would be important to conduct a pre and post segregation study for comparison. A
comparison would provide data regarding whether the race of the medical
provider/administrator is associated with healthcare disparities for African Americans.
There would also be a greater sense of knowledge about how heart disease was being
addressed and possible rationale for the increase of morbidity amongst African
Americans over the years. It took several years for the issue of heart disease amongst
African Americans to be addressed on a national level.
In 1980, the National Black Health Providers Task Force in High Blood Pressure
Education made the recommendation for an increase in heart disease studies in minorities
(Heslin & Scott, 2003). After the publication of the United States Census of 2004, there
were more studies and programs created to assist in the awareness of heart disease and
heart disease related deaths (US Department of Health and Human Services, 2010;
Ferdinand, 2009; NHLBI, 2009; OMH, 2009; Sandmaier, 2005). According to the
literature, the programs focus more on addressing risk factors than effective treatment
(AHA, 2010; Chavis, Herrick & Plescia, 2008; Popescu, Vaughan-Sarrazin & Rosenthal,
33
2007; Baskar, Bhalodkar, Blum, & Garg, 2006; Farmer & Ferraro, 2005). The literature
does not address whether or not African Americans are effectively obtaining any
knowledge of the risk factors of heart disease.
The literature reflects that there is a lack of consistency in daily dietary
recommendation for all people, especially for African Americans (USDA, 2011; Hebni,
2010; Dwyer & Marino, 1998 ). There is still an apparent disconnect in finding ways to
decrease the death rate and instances of heart disease in the African American
community. There are apparent differences in the reactions to both the prevention and
treatment of heart disease for African Americans. Many aspects of the literature are
vague and lack cultural competence regarding issues in the African American
community. The research tends to focus on socioeconomic status (SES) as the primary
explanation for health disparities in the African American community (Farmer & Ferraro,
2005). Few studies address the overall disparity of heart disease in both the male and
female population of African Americans of various socioeconomic statuses. There is
limited literature regarding socioeconomic status and its association with the knowledge
of risk factors of heart disease in the African American community (AHA, 2010;
Kanjilal, Gregg, Cheng, Zhang, Nelson, et al., 2006) .
Summary
The literature reviewed various aspects of heart disease, socioeconomic status and
how these issues effect heart disease in the African American community. It is apparent
that there are disparities in how to address heart disease in the African American
community. Studies reveal that heart disease is an issue in the African American
34
community across socioeconomic statuses. Heart disease is especially prevalent among
African American women. The literature revealed that African Americans have higher
rates of heart disease risk factors. Although there were several studies that addressed
different aspects of heart disease, there was a lack of research regarding possible
resolutions regarding the disparity of heart disease in the African American community.
There is an obvious need to explore the knowledge of risk factors of heart disease in the
African American community. This exploration could provide more insight on how to
address the disparities in the diagnosis and mortality rates of the disease in the African
American community.
35
Chapter 3
METHODOLOGY
Introduction
The purpose of this research study is to explore the extent to which
socioeconomic status is associated with the knowledge of risk factors for heart disease in
the African American community. This section will address the components of the
research conducted. The researcher will provide an analysis of the principles of methods
utilized. The researcher will provide a detailed explanation of the study design,
population and sample. The researcher will also provide an explanation of the data
collection process, instrument, measurement, data analysis and human subject’s
protection.
Study Design
The study consists of a descriptive quantitative design. The strength of the design
was that the design provided general findings based on the knowledge and personal
opinion of the participants. This allowed the participants to reflect on their knowledge of
heart disease and possibly reference personal experiences in a safe manner. The design
allows the researcher to obtain necessary precise information. The subject’s data was
confidential which allowed the subjects to answer questions without bias. The survey was
accommodating because the subjects were able to complete the survey in their own time.
The weakness of the study was that the information obtained does not provide any
personal medical history about the participant. The survey options were multiple choice
with the exception for two demographic questions regarding age and family size. The
36
subjects were not allowed to provide additional information or the opportunity to explain
their answers. There was no space provided for elaboration. To maintain confidentiality,
there was no opportunity to discuss answers verbally.
Population
The subjects for participation in this research study consist of sixty (60) African
American adults over eighteen (18) years of age. The individuals involved in the study
range in both age and socioeconomic status.
Sample
A snowball sampling method was performed. The sample is a non-probability
sampling of African Americans adults. The participants consisted of twenty (20)
individuals from three gross annual household income categories. The income categories
were a) 0-20,000 b) 20,001-40,000 c) 40, 001 or more. The sample was obtained by
utilizing personal contacts such as friends, family members and colleagues. There were
not any inducements offered for participation in this research. The researcher provided
assistance with completion of surveys for participants who requested assistance. The
researcher avoided any conflict of interest by not surveying anyone with whom she acts
as a social worker or case manager.
Data Collection
The researcher began the data collection effort by soliciting friends and family.
Each participant was provided with a consent form that detailed the subject matter and
the issue of confidentiality. Each participant was informed that his or her names would
not be used on the questionnaire. The participants were informed that their signature on
37
the consent form would be utilized as a way to protect both the researcher and the
participant regarding the study. Once the participant agreed to the terms of the consent
form, confirmation was affirmed with their signature. The researcher provided the
participant with a copy of the consent form for their personal records. The researcher
proceeded by providing the participant with a survey. In a few instances, the assistance of
the researcher was requested. In these cases, the researcher sat with the participant in a
private area to complete the survey. The researcher read the questions and responses out
loud. The researcher would make the selection as indicated by the participant.
The researcher kept a confidential tally of the income of the individuals that had
participated in the study. The researcher requested referrals from friends and family of
individuals they could suggest that they felt would be willing to participate in the study.
The researcher recruited two adult volunteer assistants to distribute and collect the survey
and consent form to their friends and family. The volunteer assistants were trained on
how to distribute the consent forms and the surveys. The researcher emphasized the
importance of maintaining confidentiality. The assistants consisted of a fellow colleague
as well as a family member of the researcher. Participation in the survey process was
purely voluntary. Several individuals that were solicited did not complete the survey.
Many stated they declined because they either did not have the time or simply did not feel
like participating.
Instrument
The instrument that was utilized in this research study consisted of a survey
(Appendix A). The survey consisted of twenty-two questions that covered heart health
38
knowledge and demographic information. There was a minimal risk of discomfort or
harm. The questions requested demographic information such as age, income and highest
level of education. The age of the participant was permitted to be written in. The number
of members in the household was also allowed to be written in. There was one
contingency question present regarding healthcare. This question requested a yes or no
answer. If the participant responded no to the question, the next question could be
skipped. The remaining questions on the questionnaire were a reflection of the personal
opinion of the participant. The remaining questions were in multiple-choice format. The
questions were closed ended. The questionnaire was developed by reviewing the general
risk factors for heart disease as well as possible reasons for disparities as identified in
various literatures. Questions regarding the participant’s ideas of eating habits, exercise
and family history were requested to measure the participant’s knowledge of the risk
factors of heart disease. Personal questions were omitted in order to maintain the minimal
risk level of the study. The survey did not request any information regarding mental
health, drug abuse or involvement in any illegal activities.
Data Analysis
Using the experimental instruments (surveys), data was collected. The data was
placed into the PASW (formerly SPSS), statistical data modeling tool. Using the PASW
program, the researcher conducted a quantitative analysis of the frequencies of the
variables. This consisted of reviewing each individual question as a variable. The
researcher reviewed the frequency of each variable and the significance of each variable.
39
Human Subject’s Protection
The researcher obtained approval from the California State University,
Sacramento, Division of Social Work subcommittee for the protection of human subjects
to conduct the study. This study is of minimal risk (Appendix A). The researcher has
concluded this consideration for the level of risk based on the probability of discomfort or
harm anticipated for the participant. The participants may question their own heart health
status after completing the survey. The questions included in the survey do not have a
probability greater than daily life encounters of harm or discomfort. The questions posed
request some personal demographic information.
40
Chapter 4
RESULTS
This study explored the association between socioeconomic status and the
knowledge of heart disease risk factors in the African American community. All
participants defined themselves as being African American. As defined in Chapter 1, the
term African American references any person with any Black American culture and
ethnicity.
Not all participants answered all of the questions. The survey included one
contingency question that made it unnecessary for one question to be answered.
However, there were questions where participants did not answer all of the questions as
requested. For this reason, the data will reflect fewer responses and missing data.
Being that this is an exploratory study; the researcher will provide data using
descriptive statistics. The descriptive statistics will include demographic characteristics
that are relevant to socioeconomic status. As described in Chapter 2, socioeconomic
status is defined by the level of education and the household income. The researcher will
also provide descriptive statistics of the knowledge of risk factors for heart disease.
Demographic Characteristics of the Sample
Age
The ages of participants ranged from 19 to 63 years old. The largest age group
consisted of individuals age 24. One participated opted out of providing a response.
41
Highest Level of Education
The highest level of education completed contained six categories. The highest
percentage of participants, 35 percent, responded that they had obtained at a high school
education or general equivalency diploma (GED). The second highest percent of
participants consisted of 23.3 percent from two separate categories. These were subjects
with associate or vocational degrees and the bachelor degree categories. Participants that
stated they had earned a master’s degree equated to 15 percent. The lowest categories
were the educational levels less than high school or GED with 3.3 percent (See table 1).
Table 1
Highest Level of Education
Frequency Percent
Valid Less than high
school/GED
High school/GED
Associate
degree/Vocational
program
Bachelor degree
Master's degree
Total
Valid
Percent
Cumulative
Percent
2
3.3
3.3
3.3
21
14
35.0
23.3
35.0
23.3
38.3
61.7
14
9
60
23.3
15.0
100.0
23.3
15.0
100.0
85.0
100.0
Gross Annual Household Income
The gross annual household income for participants was collected evenly into
three categories (n=60/3). This was intentional on the part of the researcher. The
42
purpose was to assist in comparing the working class and middle class and above.
Therefore, the gross annual income was 33.3 percent for each category (See table 2).
Table 2
Gross Annual Household Income
Frequency Percent
Valid $0-20,000
$20,001-40,000
$40,001 or
more
Total
Valid
Percent
20
20
20
33.3
33.3
33.3
33.3
33.3
33.3
60
100.0
100.0
Cumulative
Percent
33.3
66.7
100.0
Number of People in Household
The majority of the participants reported having a two person household. There
were 43.3 percent of the participants who indicated that there were two people in their
household. The second highest reporting number of people in the household was 16.7
percent of participants. There were 15 percent of participants that reported having a
household size of three and 11.7 percent that reported a household size of four. There
were 8.3 percent of participants that reported a household size of five, 3.3 percent that
reported a family size of 8 and 1.7 that reported a family size of six (See table 3).
43
Table 3
Number of People in Household
Valid 1.00
2.00
3.00
Frequency Percent
10
16.7
26
43.3
9
15.0
4.00
5.00
6.00
8.00
Total
7
5
1
2
60
11.7
8.3
1.7
3.3
100.0
Valid
Percent
16.7
43.3
15.0
Cumulative
Percent
16.7
60.0
75.0
11.7
8.3
1.7
3.3
100.0
86.7
95.0
96.7
100.0
Research Findings
Access to Healthcare
Of the participants, 95 percent stated they believed that access to healthcare has
an effect on heart disease risk factors. Only 5 percent felt that access to healthcare does
not have an effect on heart disease risk factors (See table 4).
Table 4
Access to Healthcare
Valid yes
no
Total
Frequency Percent
57
95.0
3
60
5.0
100.0
Valid
Percent
95.0
Cumulative
Percent
95.0
5.0
100.0
100.0
44
Type of Healthcare Coverage
When the participants were asked if they believed if the type of healthcare
coverage a person has effects the diagnosing of heart disease, 93 percent responded yes
and 6.7 responded no (See table 5).
Table 5
Type of Healthcare Coverage
Valid yes
no
Total
Frequency Percent
56
93.3
4
6.7
60
100.0
Valid
Percent
93.3
6.7
100.0
Cumulative
Percent
93.3
100.0
The Setting of a Physician
When asked if they believed if where a person receives care determines the
quality of care, 78.3 percent stated yes and 21.7 stated no. This contingency question
allowed for participants to skip the next question regarding what setting they felt was best
if they answered no (See table 6).
Table 6
The Setting of a Physician
Frequency Percent
Valid yes
no
Total
47
13
60
78.3
21.7
100.0
Valid
Percent
78.3
21.7
100.0
Cumulative
Percent
78.3
100.0
45
Best Setting
For the participants that answered yes, 40.4 percent responded that they felt a
HMO was the best setting. The second highest response was a PPO at 29.8 percent of
responses. Public clinic and other each had a response of 10.6 percent of the participants.
The emergency room had a total percentage of 8.5 percent of participants (See table 7).
Table 7
Best Setting
Valid
Public Clinic
HMO
PPO
Emergency
room
Other
Total
Missing System
Total
Frequency Percent
5
8.3
19
31.7
14
23.3
4
6.7
5
47
13
60
8.3
78.3
21.7
100.0
Valid
Percent
10.6
40.4
29.8
8.5
Cumulative
Percent
10.6
51.1
80.9
89.4
10.6
100.0
100.0
Routine Check-Ups
When asked how often a person should receive a routine check-up, 90 percent of
participants responded that a person should have a routine check-up once a year. Only 6.7
percent believed every other year and 3.3 percent every five years (See table 8).
46
Table 8
Routine Check-Ups
Valid once a year
every other
year
Valid
Cumulative
Percent
Percent
90.0
90.0
6.7
96.7
Frequency
54
4
Percent
90.0
6.7
2
3.3
3.3
60
100.0
100.0
every five
years
Total
100.0
Diabetes as a Risk Factor
With diabetes as a risk factor for heart disease, the participants were questioned if
they believed that having diabetes makes a person more at risk for heart disease. The
majority of participants, 78.3 percent, believed that yes it does. However, 18.3 percent
stated they were unsure and 3.3 percent did not believe diabetes made a person more at
risk for heart disease (See table 9).
Table 9
Diabetes as a Risk Factor
Valid yes
no
unsure
Total
Frequency Percent
47
78.3
2
11
60
3.3
18.3
100.0
Valid
Percent
78.3
Cumulative
Percent
78.3
3.3
18.3
100.0
81.7
100.0
47
Whether 140/90 mm Hg is a Normal Blood Pressure
A blood pressure of 140/90 mm Hg is considered to be a high blood pressure.
When participants were asked if this was a normal blood pressure, 66.7 percent stated this
was not. There were 16.7 percent that believed either that this was a normal blood
pressure or stated they were unsure (See table 10).
Table 10
Whether 140/90 mm Hg is a Normal Blood Pressure
Valid yes
no
unsure
Total
Frequency Percent
10
16.7
40
66.7
10
16.7
60
100.0
Valid
Percent
16.7
66.7
16.7
100.0
Cumulative
Percent
16.7
83.3
100.0
Family History as a Risk Factor
Family history is a risk factor for heart disease. A man whose father or brother
had a heart attack before the age of 55 increases their risk of heart disease. A woman,
whose mother or sister had a heart attack before age 65, is at increased risk of heart
disease. There were 81.7 percent of participants that stated they believed that yes this
does increase their risk of heart disease. There were 11.7 percent of participants stated
that no this was not risk and 6.7 percent were unsure (See table 11).
48
Table 11
Family History as a Risk Factor
Valid yes
no
unsure
Frequency Percent
49
81.7
7
11.7
4
6.7
Total
60
100.0
Valid
Percent
81.7
11.7
6.7
Cumulative
Percent
81.7
93.3
100.0
100.0
Smoking or the Use of Tobacco
Smoking or the use of tobacco increases risk for heart disease. When participants
were asked if they believed smoking or use of tobacco increases a person’s risk for heart
disease, 95 percent replied yes. Only 1.7 percent responded no and 3.3 percent were
unsure (See table 12).
Table 12
Smoking or the Use of Tobacco
Valid yes
no
unsure
Total
Frequency Percent
57
95.0
1
1.7
2
3.3
60
100.0
Valid
Percent
95.0
1.7
3.3
100.0
Cumulative
Percent
95.0
96.7
100.0
Alcohol Consumption as a Risk Factor
Excessive alcohol consumption increases a person’s risk of heart disease. There
were 76.7 percent of participants that responded yes they believed alcohol consumption
49
increases a person’s risk of heart disease. Of the respondents, 15 percent replied no and
8.3 percent were unsure (See table 13).
Table 13
Alcohol Consumption as a Risk Factor
Frequency Percent
Valid yes
no
unsure
Total
Valid
Percent
Cumulative
Percent
46
9
76.7
15.0
76.7
15.0
76.7
91.7
5
60
8.3
100.0
8.3
100.0
100.0
Weight as a Risk Factor
A person’s weight can be a determining factor of their risk of heart disease. There
were 83.3 percent of participants who stated yes weight determines a person’s risk of
heart disease. Only 6.7 percent of participants were unsure and 5 percent responded no
(See table 14).
Table 14
Weight as a Risk Factor
Valid yes
no
unsure
Total
Frequency Percent
53
88.3
3
4
60
5.0
6.7
100.0
Valid
Percent
88.3
Cumulative
Percent
88.3
5.0
6.7
100.0
93.3
100.0
50
Menopause as a Risk Factor
Menopause is considered to be a risk factor for heart disease in women. Only 21.7
percent of participants responded that menopause is considered a risk factor for heart
disease. There were 33.3 percent of participants that believed menopause was not a risk
factor and 45 percent of participants stated they were unsure (See table 15).
Table 15
Menopause as a Risk Factor
Valid yes
no
unsure
Total
Frequency Percent
13
21.7
20
33.3
27
45.0
60
100.0
Valid
Percent
21.7
33.3
45.0
100.0
Cumulative
Percent
21.7
55.0
100.0
Stress as a Risk Factor
A person’s level of stress can increase their risk of heart disease. When
participants were asked if they believed a person’s level of stress increases their risk of
heart disease, 96.6 percent responded yes. There were 3.3 percent of respondents were
unsure. There was one participant that did not respond, equating to 1.7 percent. None of
the participants did not believe that stress was not a risk factor of heart disease (See table
16).
51
Table 16
Stress as a Risk Factor
Frequency Percent
Valid
yes
57
95.0
unsure
2
3.3
Total
59
98.3
Missing System
1
1.7
Total
60
100.0
Valid
Percent
96.6
3.4
100.0
Cumulative
Percent
96.6
100.0
Maximum Daily Sodium Intake
The maximum sodium intake for a person in a day varies. The USDA (2011)
recommended that African Americans only take in 1500 mg of sodium in a day. In
previous years the amount was higher at approximately 2000 mg. The study revealed that
40 percent of participants believed the 1000 mg was the daily maximum sodium intake.
There were 35 percent of participants that believed 1400 mg was the maximum amount.
There were 11.7 percent of participants that believed 2000 mg was the maximum daily
intake. There were 10 percent of participants that believed 2400mg was the maximum.
There were no respondents that believed 2800 mg was the maximum sodium intake a
person should have per day. Two participants did not respond to the question, 3.3 percent
(See table 17).
52
Table 17
Maximum Daily Sodium Intake
Valid
Frequency Percent
1000 mg
24
40.0
1400 mg
21
35.0
2000 mg
7
11.7
2400 mg
Total
Missing System
Total
6
58
2
60
10.0
96.7
3.3
100.0
Valid
Cumulative
Percent
Percent
41.4
41.4
36.2
77.6
12.1
89.7
10.3
100.0
100.0
Maximum Daily Cholesterol Intake
The maximum amount of cholesterol intake a person should have per day is 30
mg. The questionnaire asked the question in grams but without the correct conversion.
The researcher will not report these findings because of the error in questioning.
Least Amount of Fruits and Vegetables for Daily Consumption
At least three to five servings of fruits and vegetables are recommended for
consumption per day. Half of the participants, 50 percent, stated that a person should eat
at least five servings of fruits and vegetables per day. There were 36.7 stated at least three
servings of fruits and vegetables per day and 11.6 percent stated one serving per day. One
participant did not respond to the question, 1.7 percent (See table 18).
53
Table 18
Least Amount of Fruits and Vegetables for Daily Consumption
Valid
Frequency Percent
At least one serving per
7
11.7
day
At least three servings
22
36.7
per day
At least five servings
per day
Total
Missing System
Total
Valid
Percent
11.9
Cumulative
Percent
11.9
37.3
49.2
100.0
30
50.0
50.8
59
1
60
98.3
1.7
100.0
100.0
Least Amount of Physical Activity Per Day
It is recommended that an adult participate in at least 30 minutes of physical
activity on most days. Over half of the participants, 73.3 percent, responded that a person
should get 30 minutes of physical on most days. There were 10 percent responded 1 hour
per day and 6.8 percent responded 45 minutes per day. Only 8.5 percent of participants
responded 20 minutes and one participant opted not to respond (See table 19).
54
Table 19
Least Amount of Physical Activity Per Day
Valid
20 minutes per
day
30 minutes per
day
45 minutes per
day
1 hour per day
Total
Missing System
Total
Frequency Percent
5
8.3
Valid
Percent
8.5
Cumulative
Percent
8.5
44
73.3
74.6
83.1
4
6.7
6.8
89.8
6
59
1
60
10.0
98.3
1.7
100.0
10.2
100.0
100.0
Maximum Servings of Fried Foods Per Week
There was no research found regarding the maximum amount of fried food a
person should eat. The overall recommendation is that people do not consume fried
foods. When participants were asked, what they believed is an acceptable number of
servings of fried food that a person can eat a week, 90 percent responded 0-4 times a
week. There were five participants, 8.3 percent, that selected 5-10 times a week and 1.7
percent responded 11 or more times a week as an acceptable number of servings of fried
food that a person can eat per week (See table 20).
55
Table 20
Maximum Servings of Fried Foods Per Week
Valid 0-4 times a week
5-10 times a week
11 or more times a
week
Total
Frequency Percent
54
90.0
5
8.3
1
1.7
60
100.0
Valid
Percent
90.0
8.3
1.7
Cumulative
Percent
90.0
98.3
100.0
100.0
Summary
There was even distribution of the number of participants in each gross income
category. The research revealed that the participants were knowledgeable of the majority
of the risk factors for heart disease. In the case of menopause as a risk factor for heart
disease, the majority of responses were either incorrect or respondents were unsure. The
significance in the responses is that African American women have the highest heart
disease mortality rate (AHA, 2010). Based on the data, the research concludes that
socioeconomic status is not associated with the knowledge of risk factors for heart
disease in the African American community.
56
Chapter 5
DISCUSSION
African Americans have the highest rate of heart disease compared to any other
ethnic group (Heron, 2004). This study explored the issue of heart disease in the African
American community. The exploration focused on whether socioeconomic status was
associated with knowledge of risk factors of heart disease in the African American
community.
Using a confidential in person survey, data was collected from 60 African
Americans. Twenty African Americans who reported an income of between $0-20,000;
twenty African Americans who reported an income of between $20,001-40,000; and
twenty African Americans who reported an income of between $40,001 and above. A
self-administered questionnaire was developed for this study. Descriptive analysis
techniques were utilized to analyze the study’s data.
Important Findings
This study’s findings suggest that socioeconomic status was not associated with
risk factors of heart disease in the African American community. The majority of the
tests that focused specifically on risk factors of heart disease revealed that the more than
half of the responses were correct. The results indicated that all of the participants
regardless of SES were knowledgeable of risk factors for heart disease. This study
concludes that knowledge of risk factors of heart disease is not the defining factor for the
disparity in mortality rates of heart disease in the African American community.
57
The programs created to assist with decreasing the mortality rate of heart disease,
focus on increasing the knowledge of risk factors of heart disease. It is possible that the
programs have in fact increased the knowledge of heart disease. However, African
Americans continue to perish due to heart disease at higher rate than any other American
population.
The knowledge of risk factors for heart disease is at times inconsistent. The
researcher found that the literature changed from the beginning of the research up until
the time of completion. Despite these inconsistencies, the researcher found that in the
sample population utilized for this particular research study revealed the knowledge is
present. Being that the issue does not appear to be knowledge of risk factors, it must
something more profound.
The literature provided some possible attributes. One is that African Americans
do not know how to incorporate their knowledge of risk factors practically in their daily
lives. This would create a need for there to be an emphasis placed on workshops and inhome assistance. Another possible attribute is socioeconomic status as a barrier to
obtaining adequate resources to reduce risk factors for heart disease. The most significant
possible factors are the disparities in healthcare for African Americans. The disparities in
healthcare state that the health issues that African Americans face are based on
institutionalized racism.
Implications for Social Work Practice
Recommendations and implications for social work education and social work
practice are discussed. More precise specifications and assessments are needed regarding
58
the disparities of health and healthcare in the African American community. It appears
that the issue is multi-systemic. There is a need for social workers to be more proactive
about addressing the social injustice faced by African Americans especially in regards to
health related issues.
Public health is an area of expertise for many social workers. It is important for all
social workers to be more aware of the health implications that effect various
populations, especially African Americans. This is also an issue of cultural competency
and cultural sensitivity. If a social worker is not aware of the issues that are faced in a
community, they cannot be used as a tool in order to assist in the empowerment of the
people of that community.
Therefore, the empowerment approach is recommended as the theoretical
framework. To address the issue of heart disease in the African American community, it
is necessary for a multidisciplinary approach to be made to address the issue. This is
especially pertinent to address disparities in the healthcare system.
Implications for Future Research
There is a need for additional research to focus on specifics of the disparities in
heart disease health and healthcare for African Americans. The issue no longer appears to
be the knowledge of the risk factors. The issue appears to be the overall implementation
of the knowledge. It appears that there is a barrier in how African Americans can
effectively decrease the risk factors in their personal lives.
59
Implications for Social Work Policy
The Affordable Care Act (2010) states it will address many of the health
disparities. It is important that social workers stay abreast of the changes that may come
with its implementation into the healthcare system. This will allow social workers to be
aware of how these policy changes will affect their clients. This will also simplify the
process of providing advocacy services to the client. This could also provide an
opportunity for the African American community to be more proactive and involved in
the changes that will be made in the healthcare system.
There is a necessity for social work as a profession to be more involved in
addressing the disparities of heart disease in the African American community. It is
obviously more than education. There are well educated mothers, fathers, daughters and
brothers that are dying from this disease.
When the researcher first began this research project, she was under the
assumption that African Americans were not aware of the risk factors for heart disease.
African Americans need to know and understand that this is bigger than an individual.
Heart disease in the African American community is a multi socioeconomic issue that
will take the determination and motivation of the people directly affected in order to
create change.
60
APPENDIX A
Informed Consent and Questionnaire
(Purpose of the Research) You are being asked to participate in research which will be
conducted by Deanna L. Bennett, a 2nd year Master’s student in Social Work at California
State University, Sacramento. The study will explore lifestyle choices for the purposes of
obtaining some insight of the knowledge of heart disease according to socioeconomic
status in the African American community.
(Research Procedures) You will be asked to complete a questionnaire about your
knowledge of heart health and heart disease such as eating habits, exercise and a person’s
personal history of heart disease. The questionnaire may require up to 30 minutes of your
time.
(Risks) Some of the items in the questionnaire may seem personal, but you do not have to
answer any question if you do not want to. You may withdraw from the study at any time
without penalty.
(Benefits) You may gain additional insight into lifestyle factors that affect heart disease
for African Americans or you may not personally benefit from participating in this
research. It is hoped that the results of the study will be beneficial for programs designed
to address heart disease in the African American community.
(Confidentiality) Your responses to the questions will be confidential. Each participant
will be assigned a number. All information will be stored in a secure location. No
personal information such as social security numbers will be obtained or requested.
(Compensation) You will not receive any compensation for participating in this study.
(Contact Information) If you have any questions about this research, you may contact
Deanna Bennett at (916) 868-3751 or by e-mail at db2379@saclink.csus.edu or her
thesis advisor Teiahsha Bankhead, Ph.D, LCSW at bankhead@csus.edu.
Your participation in this research is entirely voluntary. Your signature below
indicates that you have read this page and agree to participate in the research.
____________________________
Signature of Participant
________________________
Date
61
1. What is your age
2. What is your highest level of education completed
Not Applicable
High School/GED
Associate degree/Vocational program
Bachelor degree
Master's degree
Doctorate degree (JD,PhD,EdD,MD,PsyD,DSW,etc.)
3. What is your gross annual income (Please include income from all
sources such as employment, social security, unemployment, child
support, etc.)
$0-20000
$20001-40000
$40001 or more
4. How many people are in your household including yourself
5. Do you believe access to healthcare have an effect on heart disease risk
factors
Yes
No
6. Do you believe the type of healthcare coverage a person has effects the
diagnosing of heart disease
Yes
No
7. Do you believe that the setting of a physician makes a difference for
receiving a diagnosis for heart disease (If no, skip to question 9)
Yes
No
8. If yes, what setting is the best
Public clinic
HMO
PPO
Emergency room
Other
62
9. How often should a person receive a routine check up
Once a year
Every other year
Every five years
Every 10 years
Not necessary
10. Do you believe having diabetes makes a person more at risk for heart
disease
Yes
No
Unsure
11. Is a blood pressure of 140/90 mm Hg a normal blood pressure
Yes
No
Unsure
12. If a person’s father or brother had a heart attack before age 55 OR their
mother or sister had a heart attack before age 65, does this increase their
risk of heart disease
Yes
No
Unsure
13. Do you believe smoking or use of tobacco increases risk for heart
disease
Yes
No
Unsure
14. Do you believe alcohol consumption increases a person risk of heart
disease
Yes
No
Unsure
15. Do you believe a person’s weight determines a person’s risk of heart
disease
Yes
No
Unsure
63
16. Is menopause considered to be a risk factor for heart disease in women
Yes
No
Unsure
17. Do you believe a person’s level of stress increases their risk of heart
disease
Yes
No
Unsure
18. What is the maximum sodium intake that a person should have per day
1000 mg
1400 mg
2000 mg
2400 mg
2800 mg
19. What is the maximum amount of cholesterol intake that a person should
have per day
No limit
10 grams
20 grams
30 grams
20. How many servings of fruits and vegetables do believe a person should
eat per day
At least once a day
At least three times a day
At least five times a day
No minimum
21. How many minutes of physical activity should a person get on most
days
20 minutes per day
30 minutes per day
45 minutes per day
1 hour per day
64
22. What do you believe is an acceptable number of servings of fried food
that a person can eat per week
0-4 times a week
5-10 times a week
11 or more times a week
65
APPENDIX B
The New Soul Food Pyramid
66
67
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