Forms of cardiovascular disease include high blood pressure, stroke, rheumatic heart disease, coronary heart disease and valvular disease. Approximately 70% of deaths from heart disease and 48% of deaths from stroke occur before arrival to a hospital or the arrival of medical emergency personnel. According to the American Heart Association (AHA), stroke is a leading cause of serious, long-term disability in the United States, while coronary heart disease can result in permanent disability at a young age.
African Americans have the highest mortality rate from heart-related diseases than any other racial/ethnic group. According to the Centers for Disease Control and Prevention (CDC), in 2000 cardiovascular disease accounted for 40% of deaths in the nation, of which 29% were African American adults and approximately 45,000 were African Americans under the age of 18.1 The CDC also reports that in 2002, age-adjusted heart disease death rates were 30% higher among African Americans than for non-Hispanic whites.
Prevention of heart disease and stroke is one of the 28 key focus areas of the U.S. Department of Health and Human Services’ Healthy People 2010 initiative. Healthy People 2010’s two goals are to:
These goals can only be accomplished through the collaborative efforts of health care professionals, educators, government officials, public health departments and local communities—including faith-based organizations, community organizations, local businesses, community leaders and individual community members. Nurses can play a substantial leadership role in these efforts, on multiple fronts: as care providers, health educators, patient advocates and through community outreach.
To understand the reasons why cardiovascular disease mortality rates are disproportionately high in the African American population, we must first look at the factors that contribute to the development of CVD. These include uncontrolled high blood pressure, smoking, coronary artery disease, diabetes, obesity, family history of heart disease, hyperlipidemia and high blood cholesterol.
The AHA states that African Americans develop hypertension more often than whites, and it tends to occur earlier and be more severe. Other studies have found that 70% of all hypertensive patients do not have their blood pressure under control. Uncontrolled hypertension can lead to stroke and heart attack, as well as kidney damage and blindness. Persons with uncontrolled high blood pressure are seven times more likely to have a stroke, six times more likely to develop congestive heart failure and three times more likely to have a heart attack.2
According to the CDC, in 2000 smoking contributed to an estimated 438,000 deaths in the U.S., a financial burden of $75 billion in medical costs, $82 billion in lost productivity and 8.6 million illnesses, including chronic bronchitis, emphysema, lung cancer and heart attack. Smoking contributes to elevated blood pressure and heart rate and decreased coronary and cardiac output. A number of studies have shown that tobacco companies have aggressively targeted African Americans in their marketing efforts. Ninety percent of tobacco billboards are located in African American communities, portraying an African American as the central character, while three major African American publications—Ebony, Jet and Essence—received proportionately higher revenues from cigarette advertisements than did other magazines.3
People with diabetes are at a higher risk of developing cardiovascular disease than non-diabetics. Recent studies from the American Heart Association show that approximately 60-65% of people with diabetes have hypertension, lower levels of HDL (good cholesterol), higher levels of LDL (bad cholesterol) and are overweight. AHA researchers also found that nerve damage caused by diabetes can prevent patients from recognizing symptoms of heart attack when they occur, directly contributing to CVD-related mortality among diabetics. In fact, over 55% of diabetes-related deaths are due to cardiovascular disease.4
Statistics from the American Diabetes Association show that African Americans are 1.8 times more likely to have diabetes than non-Hispanic whites. Another recent study found that complications from diabetes are more likely to develop in African Americans, even if the disease is caught early.5
Health education is one of the areas where nurses can make a real difference in preventing cardiovascular disease disparities in African American communities. All too often, physicians and hospitals spend more time on curative than preventive health matters during the delivery of health care services. Preventive care is one of the core needs of every community, and it must be emphasized in nurses’ training. The nurse’s role in CVD preventive education should be to teach the importance of a healthy diet, exercise, stress reduction, smoking cessation and other health behaviors that can reduce African Americans’ disproportionately high risk of developing heart-related disease.
Studies show that African Americans often have limited knowledge about hypertension and stroke.6 In some cases, cultural barriers may contribute to these knowledge gaps. Some African Americans, especially those from older generations, continue to resist health education because of long-standing distrust of the medical system resulting from the Tuskegee Syphilis Study of 1932-1972.7 Undocumented immigrants may not trust health care personnel for fear of being reported to immigration officials.
Nurses as health educators must build trust in the African American community in order to educate people about cardiovascular disease prevention. The health educator must understand the community’s dynamics and develop preventive education strategies that are culturally relevant, easily understood, affordable and appropriate.
For example, the nurse must know what kinds of foods are culturally acceptable, affordable and easily available in the community, rather than assuming that everyone will be able to obtain items like tofu and turkey. Health education about sources of protein must include a wide variety of food options, such as eggs, beans, peanuts, meat, chicken, turkey, fish and more.
Nurses must build rapport with community members to gain their attention and loyalty. Clear, effective, culturally sensitive communication is key. Health education information, both oral and written, should be presented in simple language that is commonly understood in the community, rather than nursing/medical jargon such as LDL, HDL, PRN, qid, BP and so on.
When establishing contact with individuals in the community, the nurse must know whether, for example, eye contact or a firm handshake is acceptable in the culture or not. The nurse must introduce himself or herself clearly and explain the importance and benefits of the health education topic being presented. For cardiovascular disease education to be effective, the audience must clearly understand the reason for the lesson and why they should be concerned about preventing CVD.
Forming partnerships with key stakeholders in the community—such as community leaders, churches and other faith-based groups, youth groups, YMCAs, local health care providers, legislators, school officials and local businesses—can also maximize the effectiveness of a preventive education program. It is important to include these stakeholders in the planning process. People are more likely to participate in a program when they are involved in planning and implementing that program. Nurses should motivate community members to form health promotion coalitions, such as youth groups, adult groups, women’s groups and more.
To design health education programs that will affect behavior change in African American communities, nurses must turn to the literature and study various theories of health behavior. Behaviors such as smoking and consuming foods high in saturated fat, for example, contribute to negative health outcomes such as cardiovascular disease.
In particular, nurses should study theories that address health behavior as learned routines of an individual, such as the Social Cognitive Theory (Bandura, 1986), the Protection Motivation Theory (Rogers, 1983) and the Health Belief Model (Rosenstock, 1974). These three theories are essential resources for developing health education and intervention programs because they address individual motives for health behavior maintenance and change.
Unless a person understands the consequences of a behavior such as smoking or consuming a high-fat/high-cholesterol diet, he or she will not understand why the habit is bad. The nurse educator must bear in mind that lifestyle and habit changes can only occur if the person is motivated to make those changes. The individual must desire to achieve a goal—such as reduction in body weight, quitting smoking or a reduction in fat and cholesterol intake—to prevent cardiovascular disease.
In creating culturally sensitive behavior-change interventions for African American communities, nurses must understand that socioeconomic factors such as poverty, unemployment, illiteracy and lack of social support can contribute to high levels of stress, depression and other conditions that may negatively impact health behaviors. For example, some people cope with stress by smoking or overeating. Recent studies have found that there is a link between these types of socioeconomic issues and negative health behaviors that can increase a person’s risk of developing cardiovascular disease, such as smoking, eating an unhealthy diet and lack of exercise.8
Teaching heart-healthy behaviors must start early, and children are at an ideal period for learning. When planning community health education on CVD prevention, nurses must partner with local schools, youth organizations, parents, grandparents and others to reach this important audience, so that future generations of African Americans can grow up knowing how to reduce their risk of developing cardiovascular disease.
Rheumatic Heart Disease
Rheumatic heart disease accounts for approximately 1.8 million deaths per year in the United States.2 It sometimes leads to congestive heart failure. Rheumatic heart disease develops when streptococcal throat infection progresses into rheumatic fever, eventually leading to permanent damage to the heart valves. Community education on the importance of getting early treatment for strep throat with antibiotics has proven to be helpful in preventing rheumatic fever and rheumatic heart disease.
High Blood Pressure
Health education should focus on the risks, causes and consequences of high blood pressure, and on teaching health behaviors that can help prevent it. Patients who are already hypertensive must be educated about strategies for controlling their high blood pressure, such as regular checkups, medication, stress reduction interventions and lifestyle changes like weight reduction, getting more exercise and eating a more heart-healthy diet.
Physical activity such as moderate exercise for 30 minutes a day, five times a week, can go a long way toward reducing the risk of developing high blood pressure, stroke and other forms of cardiovascular disease. Brisk walking and exercise programs must be encouraged. Education on the importance of moving to keep healthy should present a variety of options, such as doing household chores (vacuuming, mowing the lawn, etc.), walking, aerobic exercises, jumping rope, bicycling, swimming, dancing and jogging.
Decreased intake of salt, saturated fat, trans fat, and cholesterol, along with increased intake of fiber, fruit, vegetables, grain products, fish and lean meat products can reduce the risk of developing high blood pressure and cardiovascular disease. Health educators should teach community members about recommended dietary guidelines, such as eating four to five servings of fruit and vegetables a day, two servings of protein a day, baking rather than frying foods, etc. It is important to emphasize that heart-healthy eating does not have to be expensive or require “special” foods. It can simply be a regular diet based on affordable, nutritious food groups that are readily available in the community.
Coronary Heart Disease
Coronary heart disease occurs when there is hardening and narrowing of the coronary arteries that supply the heart with oxygen and nutrients (atherosclerosis). One of the major contributors to atherosclerosis is high blood cholesterol. The nurse educator should teach simple preventive strategies such as the importance of having one’s cholesterol checked regularly, consumption of a low-fat/low-cholesterol diet, body weight reduction and regular exercise.
Stroke is a condition in which a blood vessel that supplies the brain with oxygen and nutrients is clogged by a blood clot, resulting in the death of cells in the affected part of the brain within minutes. This may lead to dysfunction such as paralysis or weakness of the side of the body controlled by the affected nerve cells in the brain. Stroke affects different people in different parts of the body, depending on the type of stroke. Brain injury-related stroke, for example, often affects speech, behavior, motor activity and the senses. Because dead brain cells are not replaced, the effects of stroke are often permanent.
Preventive strategies that nurses should cover during community health education include stress reduction, blood pressure control, brisk walking or other physical activity for 30 minutes or more several times a week, and reducing fat and cholesterol in the diet. Patients with surgical wounds or fractures should be treated with blood thinners to reduce their risk for formation of blood clots in the circulatory system.
To counter tobacco companies’ racially targeted advertising messages, nurses must educate African American communities by presenting the facts about the health risks of smoking, along with effective strategies for quitting the habit. It is especially critical to bring this information into the schools, from elementary to university levels. Studies have found that every day, approximately 5,000 young people ages 11 to 17 smoke a cigarette for the first time and 2,000 of them will continue to smoke in adulthood.
The following is an example of a brief smoking cessation message for health educators: