Effects on Heart Disease Related Risk Factors Knowledge Among African Americans .

Educational Intervention: Effects on Heart Disease Related Risk Factors Knowledge Among African Americans
by
Linda Smith

MSPH, Walden University, 2009
BSN, University of Nebraska Medical Center, 1991
Proposal Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Philosophy
Public Health
Walden University
August 2015
Abstract

African Americans are disproportionately burdened with the maximum preventable death rates because of high blood pressure, heart disease, and stroke. African Americans also have higher percentages of poor cardiovascular health metrics as compared to the European Americans. These disparities are attributed to an elevated incidence rate of risk factors associated with cardiovascular disease (CVD) among African Americans. Research addressing CVD risk factor knowledge among African Americans is indicative of the literature suggesting revealing oiresearch findings the fact that this particular ethnic group lacks the desired levels of awareness. A secondary analysis of de-identified data obtained from a total of 107 African Americans, who participated in community-based heart health educational sessions in which participating organizations were randomized to either a intervention or comparison group. Secondary quatitative analysis was employed to describe the association between effects of tailored community-based heart health educational session on knowledge of CVD risk factors, demographic characteristics, and awareness of the American Heart Association’s term, cardiovascular health. Findings: Compared with the comparison group, the treatment group knowledge scores ___________________________________. This study support the use of comminty tailored health educational interventions as a strategy, targeting reduction of CVH disparities and improvement of CVD risk factors knowledge in African American populations.

Dedication
This dissertation proposal is dedicated to my parents, the late Ervie Lee Williams and the late Louella Williams, both of whom planted the seed for me to embark upon this academic journey while providing words of encouragement and belief in my ability to achieve my academic goals. I thank you for your abundant giving of yourself, through your prayers and inspirational words that encouraged me, until you had to succumb to illness. I will always cherish the foundation you provided which propelled me to endure this journey. Also to the late Sydney Sanders, whose belief in my journey was shown by your generous contribution which assisted me in being able to continue my academic journey.
Acknowledgments
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Table of Contents

Abstract 2
Dedication 4
Acknowledgments 5
List of Tables 9
List of Figures 10
Chapter 1: Introduction to the Study 11
Introduction 11
Background of the Problem 13
Problem Statement 15
Purpose of Study 18
Research Questions and Hypotheses 19
Theoretical Foundation 20
Nature of Study 21
Definition of Terms 21
Assumptions, Limitations, Scope, and Delimitations 23
Significance of the Study 24
Summary and Transition 25
Chapter 2: Literature Review 27
Introduction 27
Search Strategy 29
Relationship of Literature to the Problem 30
Cardiovascular Health: A National Priority 31
Healthy People 2020 31
Cardiovascular Health: An Approach in CVD Prevention 31
Cardiovascular Health: Prevention Concepts 32
Concepts of Prevention in Cardiovascular Health 32
Primary and Primordial Prevention 32
High-Risk and Population-Wide Approaches to Prevention 33
Culturally Tailored Intervention 33
Theoretical Framework 34
Cardiovascular Health 35
Ideal Cardiovascular Health 36
Cardiovascular Health: Prevalence in United States 37
Cardiovascular Health: Relationship to Cardiovascular Disease Events 37
Cardiovascular Health: Disparities 38
Cardiovascular Health: Trends and Projections 39
Challenges to Cardiovascular Health Promotion 40
Low Prevalence of Cardiovascular Health 40
Geographical Variations in Cardiovascular Health 43
Cardiovascular Health: Prevalence of Health Behaviors 43
Disparities: Ideal Cardiovascular Health Metrics and African Americans 44
CVD Mortality Disparities and African Americans 45
Epidemiological Perspective: CVD Risk Factors and African Americans 46
Prevalence of Modifiable Risk Factors 47
Disparities in Risk Factor Knowledge 48
National Programs for CVD Prevention 50
Community Health Programs and Interventions 50
Community Interventions: Health Promotion and African Americans 52
Nurse-led Interventions 55
Summary and Transitions 59
Chapter 3: Research Method 61
Introduction 61
Research Method and Design 61
Design 62
Sample and Setting 62
Procedures 63
Recruiting Community Health Workers from Targeted Churches 63
Training of Community Health Workers 63
Recruiting Participants for the Intervention and Control Groups 65
Assessment of Knowledge, Anthropometric and Physiologic Measures 65
Community Health Worker Intervention Group 66
Control Group 66
Data Collection Instruments 67
Knowledge of Cardiovascular Risk Factors 67
Health Literacy Measure 67
Depression 67
Clinical Measures 68
Questions and Hypothesis 68
Data Analysis 69
Reliability and Validity 70
Reliability 70
Validity 70
Ethical Considerations 71
Dissemination of Findings 71
Transition and Summary 71
References 73
Appendices 97
Appendix L: Copyright Agreement for Lifestyle & Risk Reduction Sheet 97
Appendix M: Confidentiality Agreement 100
Confidentiality Agreement 100

List of Tables
Table 1:
List of Figures
No figures

Chapter 1: Introduction to the Study

Introduction
Cardiovascular disease (CVD), commonly attributed as the heart disease, is among the most prime sources of early death in the United States, leading to an estimated 800,000 deaths every year American Heart Association (AHA), 2011; Centers for Disease Control and Prevention (CDC), 2013a, 2013b). Preventable deaths are classified as those deaths that occur because of heart condition such as ischemic (lack of oxygen flow), stroke, hypertensive (high blood pressure) diseases in persons aged ≤75 years (CDC, 2013c). Declines in preventable deaths that result because of stroke, heart disease, and high blood pressure during the years 2001 to 2010 for all groups; however, avoidable death rates has decreased steadily in the individuals belonging to age group 55-64 years; whereas, the rate of decline was minimal among the 35-54 years age group (CDC, 2013c). African Americans avoidable death rates from stroke, heart disease, and high blood pressure, are nearly twice in comparison to the whites, and are generally considered as the highest incidence rate of preventable death. In 2010, the rate of avoidable deaths for specific groups was as follows: African Americans (107.3), Hispanic (45.3), American Indian/American Native, non-Hispanic (66.9), Asian/Pacific Islander (33.6), and White, non-Hispanic (57.8). For African American men, the rates are precisely 80% elevated in contrast to the black females and white males (CDC, 2013c).
Deaths ascribed to the absence of precautionary care, such as targeting cardiovascular risk factors to prevent a cardiovascular event or efficient and judicious medical care (i.e. treating the cardiovascular conditions), are referred to as avoidable (Macinko & Elo, 2009). According to the United States Census Bureau (2013), individuals of working age (18 to 64) are projected to increase by 42 million between 2012 and 2060. Unless measures are taken to reduce preventable diseases, the costs – in loss of life, quality of life, and medical care – will increase.
Cardiovascular health is a national health priority, as evidenced by the number of national programs introduced in recent years. The Department of Health and Human Services, Health People 2020 goals (USDHHS, 2013), and the National Prevention Council have developed strategies for national prevention plan for enhanced wellbeing and health status in America (National Prevention, Health Promotion and Public Health Council, DHHS of the Surgeon General, 2011). A public initiative includes the Community Health Worker Health Disparities Initiative, developed by the National, Heart, Lung, and Blood Institute. It is comprised of a set of tailored, evidence-based curricula designed to improve heart health specifically for minority groups -African Americans, Filipinos, Latinos, Alaska Natives, and American Indians (USDHHS, National Heart Lung and Blood Institute, and National Institutes of Health, 2014). Finally, the American Heart Association (AHA) 2020 Strategic Impact Goals are also focused on “improving the cardiovascular health of all Americans by 20% while reducing the deaths as a result of cardiovascular diseases and stroke by 20% by the year 2020” (Lloyd-Jones et al., 2010, p. 587).
The AHA has defined the cardiovascular health and proposed using positive terminology such as health behaviors instead of risk behaviors. These four health behaviors are: (a) physical activity, (b) diet, (c) smoking, and (d) managing body weight. The term health factors are used instead of risk factors. The three health factors are: (a) cholesterol, (b) blood glucose, and (c) blood pressure. These health behaviors and factors comprise the seven Cardiovascular Health (CVH) components that are scored on a matrix at levels of low, intermediate, or poor CVH (Huffman et al., 2012; Lloyd-Jones et al., 2010). According to Shay et al. (2012), the ideal is defined as the simultaneous occurrence of the subsequent factors:
• Clinical absence of CVD (e.g., heart attack, heart disease, stroke, heart failure) and all seven CVH components at ideal levels.
• Cardiovascular health behaviors (body mass index <25 kg, non-smoking, adoption of dietary approaches to stop hypertension [DASH] a healthy eating pattern, engaging in physical activity according to suggested levels).
• Cardiovascular health factors (untreated fasting blood glucose <100 mg/dL), non-smoking (which is also a health behavior), untreated blood pressure <120/<80 mm Hg, untreated total cholesterol < 200 mg/dL).
Background of the Problem
Evidence exists supporting the link between ideal CVH and decreased risks and incidences of cardiovascular disease (CVD) (Lloyd-Jones et al., 2010; Dong et al., 2012; Folsom et al., 2011). However, fewer than 1% of adults in the US have ideal CVH status in all seven health components (Shay et al., 2012) and estimates of the prevalence of all seven ideal levels of CVH are lower in African Americans and Mexican adults relative to European Americans (Shay et al., 2012). Low pervasiveness of CVH in adults in the US is consistent in the literature, particularly among African Americans compared to European Americans (Bambs et al., 2011; Fang, Yang, Hong, & Loustalot, 2012; Folsom et al., 2011). In fact, African Americans have the highest prevalence of poor CVH relative to other populations (Bambs et al., 2011; Fang et al., 2012; Folsom et al. 2011). Simultaneously, total cholesterol health factors are reported as being more favorable, and occur more often in African Americans comparative to the European Americans (Bambs et al., 2011; Dong et al., 2012).
Knowledge of CVD risk factors is necessary to make informed decisions regarding participation in or maintaining behaviors that may increase the risk of CVD (Stroebele, et al., 2011). Bandura (2004) noted, “Knowledge of health risks and benefits creates the precondition for change” (p. 144). However, information of CVD risk factors among the individuals, including high blood pressure control and diabetes, is less than optimal. In addition, despite aggressive public health efforts to augment the knowledge and awareness of CVD risk factors in the general public of the United States, ethnic disparities and racial inequalities in CVD awareness and knowledge associated with CVD risk are documented within literature (e.g., Stroebele, et al., 2011; Mosca, Mochari-Greenberger, Dolor, Newby, & Robb, 2010; Pace, Dawkins). Specifically, African American population’s knowledge of CVD risks is inadequate (Mochari-Greenberger, Mills, Simpson, & Mosca, 2010; Stroebele, et al., 2011).
CVD prevention interventions have been shown to increase knowledge of risk modification strategies (excluding obesity), together with positive shifts in the stages of change for CVD risk factors, and a large impact on clinical outcomes among African Americans (Lemacks, Wells, Ilich, & Ralston, 2013; Villablanca et al., 2009). Although, successful interventions carried out at the individual-level as well as population-wide, exist to diminish an individual’s contact to two of the most prevalent risk factors i.e. is High blood pressure and smoking. These two risk factors have been accountable for the largest number of deaths in the US (Danaei et al., 2009). Future efforts aimed at improving individual and community health will be needed to emphasize education and counseling when addressing lifestyle modifications (Ahmed et al., 2013).
In a secondary analysis evaluation, (Frierson, et al., 2013) assessed differences in cardiovascular risk factors and the burden of chronic disease in Caucasians and African Americans conducting secondary data analysis using a cross-sectional study design, known as the Cooper Center Longitudinal Study. This study involved African American (762) and Caucasians (40,051) who had undergone a medical examination during the years 1970 to 2010, at the Cooper Clinic, results indicated a higher prevalence rate of risk factors associated with CVD was observed among African Americans, relative to Caucasians. Interestingly, the presence of the risk factors such as smoking, obesity and physical fitness were absent in the Caucasians; whereas, all three risk factors exisited among African Americans studied. The findings of the study indicated that a large number of disparities exist in the health status and presence of risk factors among African Americans in comparison to the Caucasians (Frierson, et al., 2013).
Problem Statement
Research has shown that identifying individual predictors of successful or unsuccessful adherence and efficacy of preventive interventions expectations can facilitate the development of relevant approaches of preventive medicine (Bambs et al., 2011); individual predictors including genomics, lifestyle behavior modifications, and physical and social environments (Bambs et al., 2011). The support for the use of community-based cardiovascular health interventions, participation in heart health knowledge and heart healthy behaviors programs, and the importance of evaluating strategies in the promotion of health has been documented in the research (Arslanian-Engoren, Eastwood, De Jong, & Berra, 2014; NHLBI Initiative, 2012; Walton-Moss, Samuel, Nguyen, Commodore-Mensah, Hayat, & Szanton, 2014). Data evaluating the relationship between CVD risk factor knowledge, understanding of the health related material, effectiveness of CWHs led educational interventions and the improvement in the clinical measures after the educational interventions exclusively among the African Americans, is scant. Additional research focusing on educational strategies to increase risk factor knowledge (Aycock et al., 2015) and awareness among high-risk groups (Homko et al., 2008), as such, higher rates of CVD exist in African Americans relative to European Americans, are attributing to lower frequency of ideal cardiovascular health metrics (Folsom et al., 2011). Research analyzing cardiovascular interventions involving vulnerable populations is credited for gaining understanding in current literature focused on the intervention research (Walton-Moss, Samuel, Nguyen, Commodore-Mensah, Hayat, & Szanton, 2014).
The reviewed literature provided an in-depth knowledge of prior research and justified the application of a culturally responsive educational interventional approach in understanding African American knowledge of CVD risk factors and awareness of the cardiovascular health, recently defined by the AHA. Evidence supports the use of the secondary analysis method for examining cardiovascular health behaviors and related factors such as dietary intake, smoking cessation, and medication adherence in a cohort of hypertensive African Americans (Ameba et al., 2015; Arslanian-Engoren et al., 2014; Knafl, Schoenthaler, & Ogedgbe, 2012).
Disparities has been seen in CVD morbidity among adults (individuals reporting experiencing or diagnosis of chronic heart disease such as angina pectoris, heart attack and coronary heart disease) in Douglas County, Nebraska, for African Americans 6%, compared to White, non-Hispanic 5.8% (Healthy Communities Institute, 2014). It is unclear as to which factors present as a challenge to CVD prevention efforts aimed at this community. Lack of knowledge of CVD risk factors, lack of awareness of the AHA cardiovascular health factors, less education, which hinders the understanding of the medical related material and the relationship of these factors to demographic characteristics of the targeted population, might be some of the factors presenting as a challenge to CVD prevention strategies among African American. Finally, it unclear whether the community awareness and the availability of tailored educational sources, developed for improving health in minority and underserved communities is effective or not. The need to determine the role of nontraditional healthcare settings is integral in targeting health disparities (Crook et al., 2009).
Therefore, secondary data analysis will be conducted on de-identified data sets (demographic characteristics and heart disease risk knowledge scores) obtained from community-based oragnizations who delivered 1 hour tailored heart health educational sessions, to determine whether improvements are needed in community health programing being offered to primarily determine whether there is a need to expand the site community health education programs. Secondary data analysis was employed to describe associations between the effects of a theorectically based, culturally tailored, educational interventions led by various professionals, such as a community health educator, registered dietician, nurse, and a PhD prepared educator; to address CVD risk factor reduction by possibly increasing short-term knowledge of CVD risk factors which is a precondition for change (Bandura, 2004). This may ultimately provide insight in to the development of culturally tailored and relevant approaches and design of CVD prevention programs targeting at-risk populations.
Purpose of Study
The predefined purpose of this secondary data analysis of quantitative data was to a) describe efficacy of intervention on short-term knowledge acquisition of CVD risk factors; b) compare differences in knowledge scores between the treatment and comparison group; and c) to determine awareness of the American Heart Association term, cardiovascular health among a African American sample.
As part of the efforts to reduce significant health disparities and improve access to care for the various ethnic minority groups, designing and evaluating culturally tailored interventions have become important in the public health system (Nam et al., 2012). Moreover, culturally appropriate strategies aiming to improve lifestyle behaviors are first step for the management of risk factors (Kountz, 2012). Examples of culturally appropriate strategies may include the use of ethnically matched educators and culturally tailored health education geared to the ethnic minority groups (Nam, Janson, Stotts, Chelsa, & Kroon, 2012).
According to Bandura (2004), the individual distinctiveness of cognitive-knowledge and environmental as well as biological aspects influence action. Therefore, an understanding of these factors may assist public health practitioners and educators in designing CVH promotion interventions that target the cardiovascular health of African American adults. These interventions can potentially influence CVD outcomes of this at-risk population and, thus will have a positive impact on the health disparities. Results from this study could provide insight into the effects of culturally relevant education intervention on personal characteristics (knowledge) of CVD risks and awareness of the health associated terminologies, which may contribute to the existing body of knowledge targeting CVH among African Americans. Second, the perceptiveness of the consequences of a culturally tailored educational intervention on CVH knowledge acquisition and, the application of behavioral research may foster the development of culturally tailored interventions (e.g. using ethnically matched educators, selecting educators form the community itself), aimed at improving cardiovascular health in at-risk populations. National Diabetes Education Program, the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure guidelines, the National Cholesterol Education Program Adult Treatment Panel III Guidelines, and the health literacy tool kit of the American Medical Association Foundation was selected by the community partners the source for the health educational materials, aimed at improving heart health, accessibility, and interest in utilizing health educational materials tailored for the African American community.
Research Questions and Hypotheses
RQ1. Do participants who will receive a culturally tailored educational intervention have levels of knowledge than do participants who have not receive the intervention?
Ho1. Participants who will receive a culturally tailored intervention have similar levels of knowledge to participants who have not received the intervention.
Ha1. Participants who will receive a culturally tailored intervention have higher levels of knowledge to participants who have not received the intervention.

Theoretical Foundation
Bandura’s (1971) social cognitive theory (SCT) will provide the basis for the research hypotheses. The SCT will provide insights into patient-related interventions (Bandura, 2004) and will inform the proposed culturally relevant educational intervention, and its effects on increasing knowledge acquisition of CVD and related risk factors, and awareness of CVH as outlined by the American Heart Association. Social cognitive approaches such as educational interventions, “promote effective self-management of health habits that keep people healthy through their life span” (Bandura, 2004, p.144). The SCT addresses determinants including: (a) information of health hazards and benefits of various healthy activities, (b) apparent self-efficiency, (c) outcome expectations, including-costs and benefits of the health practice), (d) goals, including development of a strategy and plan to reach goals, and (e) supposed facilitators and the communal and structural obstacles (barriers) to desired transformations (Bandura, 2004). The application of a personal factor (short-term knowledge acquisition) of CVD risks and related risk factors and awareness of the possible benefits of adopting CVH behaviors and health factors are the variables presented in this dissertation proposal, as knowledge of health risks and benefits are considered a precondition to change (Bandura, 2004).
Nature of Study
This secondary analysis study describes the effects of community heart health educational interventions on short-term knowledge acquisition of CVD risk factors and awareness of the AHA’s term cardiovascular health. The relationship between demographic characteristics, knowledge acquisition, and awareness of the term cardiovascular health in a African Americansample are described, as well. Secondary analysis was conducted using de-identified data collected from from community churches (3) and a clinic (1) as a part of the program evaluating process, in which community partners used a 25-item HDFQ questionnaire to assess CVD risk factor knowledge and demographic characterisitcs, to determine the conternt and educational needs of particpants in planning for future health programs. Each site was introduced to the National Heart Lung and Blood Institute’s Community Health Worker Health Disparities Initiative Heart Health Program as a evidenced based, tailored heart health education source (USDHHS, National Institutes fo Health, National Heart Lung and Blood Institute, 2014).
Definition of Terms
Each field has terms and phrases that may not be readily understood by all readers. However, each person who reads this study must be able to understand all terminology used (Baltimore County Public Schools, 2010). These operational definitions of certain phrases and terms are used throughout this study.
African Americans: For the purposes of this study, the term African American adults will be used to refer to individuals of African descent who are more than 18 years of age (Sawyer, 2008). According to Sawyer, Black and African American are interchangeable terms, for purposes of this study, the term African American will be used.
Avoidable deaths from heart disease, stroke, and high blood pressure disease: “any death occurring in individuals <75 years of age combined with an underlying cause of ischemic heart disease, stroke, high blood pressure, or chronic (greater than 6 months) rheumatic heart disease” (CDC, 2013c).
Cardiovascular disease risk-reducing behaviors: used interchangeably with the cardiovascular health-promoting behaviors of appropriate weight, nutritional diet, and participation in physical activity (Sacco, 2011).
Culturally-tailored intervention: defined by Pasick et al. (1996) as “the development of interventions, training practices and materials to conform to specific characteristics” (p.145).
DASH-like eating plan: “consumption of a diet that is high in fruits and vegetables, moderate in low-fat dairy items, and low in animal protein, along with a significant intake of plant protein from legumes beans and nuts” (Fung et al., 2013).
Health education: “the action of sharing educational information related to health, which may include information about lifestyles to guard against illness, and information promoting engaging in preventive services” (World Health Organization (WHO), 2012).
Health promotion: “a combination of planned activities developed to improve individual and public health, including implementation of behavior change strategies, health education, detection of risk factors, health protection, and health improvement and maintenance” (Kline & Huff, 2007).
Intervention: “planned set of strategies with objectives aimed at bringing about a change or producing recognizable outcomes. These strategies may include policy, regulatory initiatives, single strategy projects, or multi-component programs” (Rychetnik, Frommer, Hawe, & Shiell, 2002).
Knowledge acquisition: knowledge is “information, understanding, or skills that you get from experience or education” (The American Heritage Dictionary, 2014). Acquisition is “something gained” (The American Heritage Dictionary, 2014). For the purpose of this study, knowledge will be defined as information that is gained by a sample of African American adults who attended a culturally tailored educational intervention.
Lifestyle: “lifestyle is the patterns of choices made by an individual which include food, physical activity, substance use, and sexual behavior” (Freudenberg, 2007).
Physical activity: “physical activity is a regimen of routine exercise of 150 minutes of moderate-intensity exercise per week” (American College of Sports Medicine, 2013).
Public health intervention: “action performed with the intention of health promotion, health protection, and the prevention of illness in communities or populations” (Rychetnik et al., 2002).
Risk (health) factors: Bambs et al. (2011) defined these factors as “(a) ideal levels of blood pressure, (b) total cholesterol, and (c) fasting blood glucose”.
Assumptions, Limitations, Scope, and Delimitations
I will assume that potential participants will report honest and accurate information. For this proposed research, potential participants will be requested to supply information regarding their knowledge of heart disease risks and related risk factors and awareness of the health related terms specifically those associated with CVH. It is assumed that the participants in this study may have some awareness and knowledge of CVD, risk factors and risk-reducing behaviors.
Employment of a secondary analysis design limits the generalizability of study findings. As such, data errors may have occurred during the data collection and data entry process limiting the accruracy, reliability, and validity of data ( ). The use of a convenience sample of urban African American adults from the city’s high disparity urban core could limit the generalizability of the results to the general population. Self-reported instruments used to obtain knowledge scores, required the scores to be interpreted as an estimation of knowledge (Lemmens & Huijsman, 2008). The scope of this study will be an examination of short-term knowledge acquisition that may influence the cardiovascular health behaviors of this at-risk group.

Significance of the Study
Researchers are in agreement that community-wide approaches of cardiovascular health promotion are essential aspects for primary prevention of CVD; high-risk populations should be targeted to engage individuals in community prevention efforts (Bryant et al., 2010; Nguyen et al., 2012; Sin, Fitzpatrick, & Lee, 2010; Strasser, 1978). Individual and population-based interventions are needed in support of attaining AHA’s 2020 Impact Goals for cardiovascular health (Bambs et al., 2011). Although faith in the significance of a light diet and the capacity to consume a low-fat diet exists among African Americans (Walter & Satia, 2009), every component of cardiovascular health (with the exception of total cholesterol) indicated, poorer health status for African Americans relative to European Americans (Bambs et al., 2011).
Results from this study may provide insight into knowledge of CVD risks and related risk factors and CVH awareness, contributing to the body of knowledge related to cardiovascular health and at-risk populations, particularly urban African Americans. For instance, results obtained by the help of this research work could be a helpful guide for public health professionals to use in developing and implementing culturally relevant cardiovascular health educational interventions for at-risk groups. The implications of the proposed study in terms of social change is that, health interventions have the potential to positively influence health behaviors (Joseph et al., 2013; Utz et al, 2008; Whitt-Glover, 2013), and results from this study may lead to a better acquisition of knowledge of CVD risks and correlated risk features. This in turn, may ultimately be used to guide the development of public health strategies aimed at improving CVH in African American populations, thus affecting disparities in avoidable death rates from CVD, high blood pressure, strokes, as well as CVH disparities.

Summary and Transition
Ideal cardiovascular health’s association with decreased risks and incidence for CVD are documented (Dong et al., 2012; Lloyd-Jones et al., 2010); yet, low pervasiveness of model cardiovascular fitness persists (Fang et al., 2012; Bambs et al., 2011; Dong et al., 2012). European Americans met more ideal levels of each metric relative to African Americans in all ideal levels of the metric except for total cholesterol (Folsom et al., 2011; Bambs et al., 2011). Multilevel and multidisciplinary approaches to CVD prevention and CVD self-management programs are needed to: (a) prevent development of risk factors in the onset, (b) tailor programs to the needs of individuals, and (c) incorporate a theoretical foundation of behavior change (Fang et al., 2012; Katch & Mead, 2010; Lloyd-Jones et al., 2010). Overall, CVD prevention interventions have shown promise in minimizing the risks for CVD, as evidenced by their capability to keep the participants in healthier lifestyles: (a) physical activity, (b) non-smoking, (c) maintaining appropriate weight, (d) progress toward weight loss, and (e) consumption of nutritional foods (CDC, 2010; Svetkey et al., 2008). In contrast, this increased knowledge may not result in sustained heart healthy behaviors (Konicki, 2012). There is, however, considerable variation in how knowledge of CVD risk translates to behavior change among African Americans. Thus, the use of a culturally tailored approach to health promotion-to address knowledge of CVD risk to influence health behaviors is emerging. Consideration of the cultural needs and experiences of individuals is an important aspect in working with diverse populations, as “culture is a major factor in explaining and intervening in human behaviors” (McCullough Chavis, 2011, p. 472).
Chapter 2 is a literature review of key concepts pertaining to avoidable deaths related to heart disease and strokes including cardiovascular (heart) disease (CVD) risk factors, and national goals for preventing CVD, highlighting the American Heart Association’s concept, CVH in the United States and in the State of Nebraska. Another concept contained in Chapter 2 is the use of programs and interventions targeting CVD risk factors and related CVD preventive behaviors. Chapter 3 describes the secondary analysis methodology for the study and a description of the data collection procedures.

Chapter 2: Literature Review

Introduction
In 2012, heart disease was selected as one of the leading causes of death for African Americans in Douglas County, Nebraska (DCHD, 2013). Disparities in CVD risk factors-diabetes, stroke, obesity, and physical inactivity-were, and still are, apparent. According to Healthy Communities Institute (2014), data for Douglas County, Nebraska indicated the percentage of African Americans adults diagnosed with strokes was 3.4%, compared to White, non-Hispanics at 1.8%. Diabetes diagnoses in African Americans were 20.0% and only 9.0% in White, non-Hispanics and 39.3% of African Americans were diagnosed with obesity compared to 28.9% for White, non-Hispanics (Healthy Communities Institute, 2014). In addition, among African Americans in Douglas County, behavioral data indicated that as compared to the White, non-Hispanics, physical activity at recommendation levels for African Americans was 36.5% but for White, non-Hispanics was 54.3% (Healthy Communities Institute, 2014). Finally, utilization of 5 or extra vegetables and fruits for each day was rated at 23.7% for African Americans and 37.7% for White, non-Hispanics (Healthy Communities Institute, 2014). These disparities between African Americans and their White, non-Hispanic counterparts, reported for Douglas County, Nebraska indicate a need to understand knowledge of CVD risk and risk factors and awareness of CVH and related potential benefits in the targeted community.
One goal of this proposed research is to serve as an initial step targeting the knowledge of CVD risk and related risk factors and awareness of the CVD related health terminologies and physiological measures, among African Americans. The researcher will use Bandura’s social cognitive theory (2004) to evaluate the effectiveness of a CHW-delivered culturally tailored educational intervention to increase knowledge of CVH and related health behaviors and health factors.
Chapter 2 will present a detailed empirical research on the problem regarding cardiovascular disease (CVD) as it relates to the CVH among African Americans. Specifically, avoidable deaths from heart disease are discussed. The emphasis will be on (a) CVH, cardiovascular health definition and metrics, and prevalence; (b) cardiovascular health behaviors and health factors; (c) knowledge of the cardiovascular health, health behaviors, and health factors; (d) epidemiology perspective on health factors for cardiovascular health; (f) challenges to cardiovascular health promotion efforts; and (f) health promotion: community programs and interventions. Next, discussion of the social cognitive theory will be carried out that will be used to explain how short-term knowledge acquisition of cardiovascular health could occur. Evidence exists to support the use of the social cognitive theory in empirical research involving African Americans and include (a) culturally tailored interventions, (b) health behaviors, (c) physical activity, and (d) the DASH eating plan (Quinn & Guion, 2010; Utz et al., 2008; Whitt-Glover et al., 2013). Finally, global and national attention to the CVD epidemic is warranted, as CVD and related conditions such as diabetes impede socioeconomic advancements, specifically among disadvantaged segments of the population (WHO, 2012). Thus, there is a dire need to emphasize the recently defined concept of CVH as one approach in the prevention of CVD, thus potentially impacting the prevalence of CVD risk factors in African American and at risk communities.
Challenges remain despite the existence of effective interventions for high blood pressure and smoking; both have contributed as the leading cause of deaths in the US. Sedentary lifestyle, nutritional habits and metabolic risk factors associated with the chronic conditions are responsible for a significant rate of mortality in the US (Danaei et al., 2009). African Americans compared with European Americans have a higher prevalence of preventable deaths because of from heart condition, elevated blood pressure and stroke (CDC, 2013c). African Americans have also been linked to disproportionate risk factors of the CVD such as (a) diabetes, (b) high blood pressure, (c) obesity, (d) sedentary life style, (e) inadequate intake of fruit and vegetables, and (f) poor low-density lipoprotein cholesterol control (Kershaw et al., 2011; Covelli, Wood, & Yarandi, 2012; Go et al., 2013; Taylor et al., 2010).
In relation to this, the current research work will highlights the national approach to CVD prevention aimed at enhancing the cardiovascular health for all US population (Lloyd-Jones et al., 2010; USDHHS, 2012). Therefore, the researcher reviewed the empirical literature that addresses national attention to (a) CVD prevention, (b) avoidable deaths related to heart disease and stroke, (c) CVH and status of CVH in the US, (d) knowledge of the associated risk factors, (e) CVH behaviors and factors for which the African Americans are at risk, and (f) the relationship of the variables to the study.
Search Strategy
The main topics searched for this review were Black adults, African American’s cardiovascular health, CVD, risk factors knowledge, behaviors, and interventions. A comprehensive electronic search of literature in the EBSCO host database was undertaken. The databases accessed in this search included (a) CINAHL Plus with full text, (b) ProQuest, (c) SAGE Journal Online, (d) Academic Search Complete, (e) PsycINFO, (f) SOCINDEX, (g) PUBMED, (h) Science Direct, (i) Google Scholar, and others to access peer-reviewed journals, reports, and publications. Key search terms were used singularly or combined and included: American Heart Association and Cardiovascular health, cardiovascular disease (CVD), cardiovascular health and African Americans, coronary heart disease (CHD), CVD mortality and African Americans, African Americans and CVD risk factors, knowledge, prevention, risk factors, African Americans and strokes, coronary artery disease (CAD), health behaviors, heart disease, lifestyle behaviors, health promotion, perceptions, health disparities, cardiovascular health disparities, barriers, beliefs and attitudes, cultural, social ecological factors, African Americans, Blacks, minorities, hypertension, high blood pressure, stroke, culturally tailored interventions and African Americans, African Americans and educational interventions, African Americans and cardiovascular health interventions, health literacy, social cognitive theory, social learning theory and African Americans, social cognitive theory, secondary data analysis and African Americans and African Americans. Secondary sources included textbooks addressing health promotion in African American populations and quantitative research methods.

Relationship of Literature to the Problem
Deaths which occur as a result of the lack of preventive care measures and inaccessibility of the timely and efficient medical care services can be avoided (CDC, 2014). However, the CDC noted continued declines in preventable death rates that occur because of stroke, heart conditions, and high blood pressure during years 2001 to 2010 for all groups. Although avoidable death rates have been minimal in certain groups, but these declines are not true for African Americans who have indicated the most elevated age-adjusted toll of preventable death as a result of heart related diseases (CDC, 2013a, 2013b).

Cardiovascular Health: A National Priority
The national priority to address cardiovascular physical condition in the US is evidenced by the CDC’s Division for Heart Disease and Stroke Prevention’s release of a Public Health Action Plan to Prevent Heart Disease and Stroke (2013a). This directive highlighted CVD (heart disease and strokes) as a public health priority. Moreover, it identified various approaches that could be effective in controlling this public health problem. Acknowledging the reality of the CVD crisis and envisioning the future of optimal conditions that can result by means of effective public health actions is required (CDC, Division for Heart Disease and Stroke Prevention, 2013a).
Healthy People 2020
The “Healthy People 2020” goal is to “improve cardiovascular health and quality of life through prevention, detection, and treatment of risk factors for heart attack and stroke; early identification and treatment of heart attacks and strokes; and prevention of repeat cardiovascular events” (USDHHS, 2012, p. 1). The AHA, whose goals have broadened from reduction of CVD to the adoption of improvement in cardiovascular health across all populations, shares this emphasis (Lloyd-Jones et al., 2010).
Cardiovascular Health: An Approach in CVD Prevention
One of the most pivotal health apprehensions in the US is the low prevalence of ideal cardiovascular health. The AHA defined cardiovascular health as meeting a total of seven components, physical activity, four non-smoking health behaviors, basal mass index (BMI), and diet. Cardiovascular health also focuses on three other health behaviors which are blood cholesterol, fasting blood glucose (sugar), and blood pressure at ideal stage of a metrics in adult populations (Folsom et al., 2011; Dong et al., 2012; Fang et al., 2012; Shay et al., 2012; Bambs et al, 2011), particularly for minority populations (Fang et al., 2012; Shay et al., 2012). African Americans have the highest incidence rate for poor cardiovascular health (Shay et al., 2012; Fang et al., 2012), and “disparities in cardiovascular health cannot be eliminated without preventing the emergence of differences in the rates of the risk factors for CVD” (U.S. Commission on Civil Rights, 2010, p. 50).
Cardiovascular Health: Prevention Concepts
Concepts of Prevention in Cardiovascular Health
The success rate of prevention of any disease in a population is measured on the basis of increasing health measures in that population and the decline in the health disparities across different communities or ethnicities within the population. The success of the prevention is not measured on the basis of standard criteria for “self care” (Starfield, Hyde, Gervas, & Health, 2008, p. 582). The concepts of prevention in CVH referenced in the literature include primary, secondary, and primordial prevention (Lloyd-Jones et al., 2010; Kones, 2011; Weintraub et al., 2011; WHO, 2007). Primary prevention and primordial levels of prevention are associated with sustaining reduction in mortality (Fang et al., 2012). The proposed dissertation study will address primary and primordial levels of prevention, since these are referenced in the proposed dissertation.
Primary and Primordial Prevention
Primary prevention of CVD is concerned with prevention and impediment of the primitive events that might occur among the individuals who have not been medically diagnosed with any heart related condition (Kones, 2011). Strasser (1978) defined primordial prevention by expanding the concept of primary prevention to describe efforts to prevent the penetration of risk factors into populations. Hence, primordial prevention focuses on the avoidance of risk factors (Berry et al., 2012; Lloyd-Jones, et al., 2010).
High-Risk and Population-Wide Approaches to Prevention
Rose (as cited by McLaren, McIntyre, & Kirkpatrick, 2010) coined population strategy prevention as the relationship between high-risk strategy (individuals at highest risk) and population-wide strategy (risk distribution in the whole population) across populations. Although McLaren et al. (2010) argued that particular assumptions underlying Rose’s expressed advantages of a population approach cannot be applied anymore. But, still the concept bears significant value because of curtailing of the social disparities and improvement in the health of population (McLaren et al., 2010). Notably, it is argued that a number of clinical events could be avoided by discovering and caring for individuals at high risk for actions resulting from substantially eminent risk-factor height (Lloyd-Jones et al., 2010).
Culturally Tailored Intervention
Support for culturally-relevant interventions are evidenced in the literature (Covington et al., 2010; Nam et al., 2012; Perra-Medina et al., 2011; Peterson & Cheng, 2011; Utz et al., 2008) and are described as tailored measures shown to improve lifestyle behaviors. They are the first step in managing risk factors such as diabetes (Kountz, 2012). Interventions must be tailored for culture of the targeted population, specifically African Americans, as well as other minority groups in order to satisfy their care needs.
Theoretical Framework
The current study is guided by a single framework: Bandura’s Social Cognitive Theory SCT (2004). The SCT provided a framework to explain the interactions between an educational intervention involving interactive learning and cognitive influence-knowledge acquisition in a sample of African Americans residing in a high disparity urban area. The SCT evaluate the outcomes of a culturally tailored education intervention on increasing cardiovascular health knowledge in a sample of Black adults. Bandura’s SCT puts forth that the knowledge regarding the health risks and advantages can act as the precursors for change. Bandura noted, “If individuals lack knowledge about how their lifestyle habits affect their health, they have little reason to put themselves through the travail of changing the harmful habits they enjoy” (Bandura, 2004, p. 144). Therefore, the relationship between African American adults’ knowledge acquisition and an education intervention approach using the SCT to address cardiovascular health knowledge, provide insights into cardiovascular health promotion targeting African Americans, which may contribute to the cardiovascular health research focused on tailored interventions aimed at health disparities.
Bandura’s (1971) social learning theory (SLT), another term for SCT, is considered one of the most influential theories of learning and human development (McCullough Chavis, 2011). SLT is widely based on the basic concepts of traditional learning. The SLT emerged as an approach to addressing the needs of the population, since the theory considered issues faced by individuals in a social context, hence allowing the social elements to be taken into consideration in learning (McCullough Chavis, 2011). The applicability of SLT as an approach to change human behaviors was realized in the 1950s. SLT gained popularity in the social and behavioral sciences as a mental health intervention in the late 1950s in response to interest in an insight-oriented approach. According to Bandura (1997), individuals learn from direct experiences, which occur in several ways, including vicarious experience and by observing and imitating others. Bandura contributed to the behavior theory by exploring the role of cognition with emphasis on vivid learning. SLT postulates that individuals can learn new information and behaviors by observing others (McCullough Chavis, 2011).
Finally, Bandura (2001) noted that cognitive factors can predict human behavior and guide effective interventions. Success through the complexities of challenges and hazards are attainable when individuals (a) make good judgments about their capabilities, (b) expect consequences from the course of action, (c) weigh the socio-structural benefits and contraindications, and (e) govern their behavior accordingly (Bandura, 2001).
Cardiovascular Health
In expanding its impact goals, the AHA defined a novel idea regarding the cardiovascular health, and developed a metrics to identify and observe the status of cardiovascular health in the Americans (Shay et al., 2012). The AHA also devised terminology for health factors related to the cardiovascular health instead of risk factors for CVD; and health behaviors, which encourage cardiovascular health instead of risk factors that raise risks for increasing CVD and stroke or precursor illnesses for instance high blood pressure and diabetes (Lloyd-Jones et al., 2010). The metric is comprised of defined components of CVH behaviors and health factors scored on a spectrum as having poor, intermediary, or idyllic cardiovascular health as defined in the AHA 2020 Strategic Impact Goals (Shay et al., 2012): (a) smoking; (b) BMI; (c) physical movement; (d) fasting blood glucose; (e) blood pressure; (f) total cholesterol; and (g) diet and health factors. In highlighting the importance of nonsmoking and smoking cessation in health preventive measures, smoking is listed in health factor and health behaviors components. Thus, the advantages focused on the promotion of the health affiliated with each of the seven health factors and health behaviors are documented. Cardiovascular health is described as possessing the standard levels of all of the seven listed features (Lloyd-Jones et al., 2010). As defined by the AHA (2012), a score health value is obtained on a health metrics to guide determination of cardiovascular health. The aim of the AHA is to transform individuals and populations from poor to ideal cardiovascular health (Lloyd-Jones et al., 2010).
Ideal Cardiovascular Health
Ideal cardiovascular health, a construct defined by the AHA, is the synchronized presence of all four idealistic health factors, which follow:
• never smoked or absence of smoking within past year
• ideal body mass index (BMI)
• participation in the recommended physical activity
• dietary intake, conducive to cardiovascular health (i.e. Dietary Approaches to Stop Hypertension [DASH])
Lloyd-Jones et al. (2010) noted that ideal cardiovascular health is the simultaneous existence of all four ideal health factors, which follow:
• never smoked or absence of smoking within past year
• untreated total cholesterol < 200 mg/dL
• untreated blood pressure <120/<80 mm Hg
• No diagnosis of fasting blood sugar or diabetes <100 mg/dL along with the absence of symptoms of CVD for instance coronary heart failure, stroke and heart disease.
Cardiovascular Health: Prevalence in United States
The presence of limited or decreased ideal cardiovascular health, as defined by the AHA among Americans is consistent in the literature (Bambs et al., 2011; Dong et al., 2012; Fang et al., 2012). Data from 2009 Behavioral Risk Factor Surveillance Systems of 356,441 participants in the US without a history of heart condition or stroke, revealed about 3.3% of participants had ideal cardiovascular health. (A perfect score was defined as meeting all seven factors at ideal levels.) However, poor cardiovascular health (zero to two ideal cardiovascular metrics) occurred in nearly 9.9% of participants (Fang et al., 2012). In the same study, Fang et al. (2012) found significant variations in cardiovascular health metrics are reported across states. The percentages of the adult individuals with ideal cardiovascular health ranged from low, at 1.2% in Oklahoma, to high at 16.2% in West Virginia.
Cardiovascular Health: Relationship to Cardiovascular Disease Events
Folsom et al. (2011) investigated the incidence rate of ideal cardiovascular health, as defined by the AHA in Atherosclerosis Risk in Communities (ARIC), in a cohort study from 1987 to 1989 along with 20-years of incidence rates of CVD. Participant exclusions were at baseline, a history of heart malfunction, coronary heart illness (a part of CVD), or stroke, the inability to classify by history. In the same study, Folsom et al. looked at CVD incidence rates during 18.7 years (median duration) of follow-up, with (21.1 years maximum). The total number of CVD events that occurred during this time period was 3,063. However, no CVD events were reported in the 17 participants who met all seven factors rated as ideal levels. CVD incidence rate for those with intermediate cardiovascular health was 7.5 for about 1,000 person-years with a confidence interval of 95% (6.4 to 8.4), and for the individuals with poor cardiovascular health, the incidence rate of CVD was 14.6 with a confidence interval of 95% (14.0 to 15.2). Disparities in overall occurrence time of CVD between African Americans were measured as 16.5 per 1,000 person years and European Americans were 12.2 per person years as noted by Folsom et al., (2011). Huffman et al. found similar results when (2012) they analyzed the data from years 1988-1994 and 1999-2008 National Health and Nutrition Examination Surveys (NHANES) among ARIC participants, and illustrated the prevalence of ideal cardiovascular health (all seven cardiovascular health metrics scored as ideal) among only 0.1% (n=17).
Cardiovascular Health: Disparities
According to Fang et al. (2012), the pervasiveness of cardiovascular health by age indicated the ideal cardiovascular health percentages were lowest in the 65-year-old age group; poor cardiovascular health was highest in this same group. Those aged 18 to 34 years of age indicated the poor cardiovascular health. The highest percentage of ideal cardiovascular health was found in adults 35 to 54 year olds.
Fang et al. (2012) found notable disparities in the cardiovascular health by gender, racial/ethnic, and education. Women fared better (4.6%) in ideal cardiovascular health than did men (1.9%). Ideal cardiovascular health was noted for non-Hispanic Whites (3.7%), Hispanics (2.0%), Asian/Pacific Islanders/Native Hawaiians (4.8%), African Americans (1.6%), and American Indian/Alaska Natives (1.5%). In contrast, poor cardiovascular health was noted for non-Hispanic Whites (9.2%), Hispanics (11.2%), Asian/Pacific Islanders/Native Hawaiians (7.7%), African Americans (15.1%), and American Indian/Alaska Natives (12.2%). In addition, higher levels of ideal cardiovascular health occurred among colleges and postgraduate degree participants (Fang et al., 2012). In addition to this, another study has indicated that the presence of family history regarding the heart conditions like stroke can be indicative as a weak risk factor for the development of CVD (Aycock, et al., 2014).
Cardiovascular Health: Trends and Projections
Huffman et al. (2012) examined 1988-2008 NHANES data obtained from 33,059 participants with an absence of CVD (i.e., self-reported history of heart attack, angina, stroke, or heart failure) in adults aged 20 years and older (mean age was 44.4 years). Huffman et al. examined current trends in composite cardiovascular health metrics and estimated future levels of cardiovascular health behaviors and factors in the US to evaluate whether the AHA 2020 projected goals will be met. Cardiovascular health efforts were challenged. Declines in the occurrence rate of smoking, high blood pressure (men) were reported; yet, significant increases in the overall incidence rate of obesity and blood glucose, minimal changes in health diet scores, and decreased trends in physical activity were also apparent (Huffman et al., 2012).
In addition, adverse population level shifts in each metric was acknowledged as evidenced by increased body mass index and abnormal blood glucose levels matched by simultaneous reductions in prevalence of normal weight and normal glucose (Huffman et al., 2012). However, Huffman et al. cautioned that their projections could have overestimated the future prevalence of impaired prevalence (intermediate cardiovascular health) and explained this was because certain individuals are likely to develop diabetes mellitus at the fasting glucose level threshold of 126 mg/dL and will not advance these projected mean values. Huffman et al. (2012) concluded that if current trends continue, the AHA 2020 goal of improving cardiovascular health by 20% by 2020 will not be reached.

Challenges to Cardiovascular Health Promotion
Low Prevalence of Cardiovascular Health
Low prevalence of cardiovascular health, as defined by the AHA, in the USis substantiated (Fang et al., 2012; Folsom et al., 2011; Huffman et al., 2012; Shay et al., 2012). Shay et al. (2012) examined prevalence of the new concept, cardiovascular health based on age, sex, and race/ethnicity, in adults in the US using data obtained from 2003 to 2008 NHANES and found that ideal cardiovascular health in all seven metrics was noted in less than 1% of participants; however, of the cardiovascular behaviors, a high prevalence (60.2%-90.4%) in nonsmoking (most prevalent ideal cardiovascular health component) was reported. In contrast, the lowest prevalence (0.2% to 2.6%) for ideal healthy diet scores existed among participants (Shay et al., 2012).
Bambs et al. (2011) conducted a study of participants in the Heart Strategies Concentrating on Risk Evaluation study (HeartSCORE) study of community-based African American and European American participants. These researchers found that only 0.1% (one individual) out of 2,981 had ideal cardiovascular health (met all seven components ideal cardiovascular health), and less than 10% had five or more components of ideal cardiovascular. In middle-age cohorts, prevalence of ideal cardiovascular health was low. Significantly, fewer ideal cardiovascular health components were found among African Americans (2.0) than European American (2.6). More importantly, following adjustments by sex, age, and income level, African Americans had 82% fewer odds of having five or better components of ideal cardiovascular health than did European American (Bambs et al., 2011). Interestingly, in each component of cardiovascular health, African Americans were significantly lower than European Americans in all except the total cholesterol component (Bambs et al., 2011). This finding is consistent in the literature (Bambs et al., 2011; Dong et al., 2012; Folsom et al., 2011). As reported by Dong et al. (2012), the prevalence of ideal total cholesterol was lesser for European Americans (35.3%) and elevated among African Americans (46.0%).
Dong et al. (2012) examined the relationship of ideal cardiovascular health metrics and cardiovascular risk among 2,981 community-based multiethnic cohorts (African Americans, European Americans, and Hispanic Americans). Each participant was without a history of a heart attack or stroke at baseline in the Northern Manhattan Study; however, none of the participants exhibited all seven ideal cardiovascular health factors. Among the participants, 4.4% had five to six cardiovascular health factors, while the majority (62.4%) had two or three ideal factors. In the same study, disparities in the prevalence of ideal cardiovascular health were noted, with five to six ideal cardiovascular health factors among European Americans (7.7%), compared to African Americans (4.3%), and Caribbean Hispanics (3.2%). Researchers noted that similarities in these disparities remained even after adjusting for age and sex (Dong et al., 2012). For instance, disparities existed in the prevalence of ideal levels of blood pressure, fasting glucose (blood sugar), non-smoking behavior, ideal BMI, and physical activity. In fact, African Americans’ ideal cardiovascular metrics was lower than were European Americans’ scores. Furthermore, ideal diet definitions and diet components were reported in only 0.4% of total cohorts, and equally poor in all three racial/ethnic groups (Dong et al., 2012).
In their study, Dong et al.’s (2012) median 1-year follow up of 2,981 participants showed 722 participants suffered a CVD event, including a stroke, heart attack, or vascular death. The incidence rate of CVD was 24.0 per 1,000 person-years in the total cohort. (Person-years was defined as “the incidence rate expressed as the number of new cases per population at risk in a given period” [R. Sacco, personal communication, March 31, 2014]). The incidence rate of CVD in the total cohort was lower among individuals with higher numbers of ideal cardiovascular health metrics, after adjustment for age, sex, and race/ethnicity (Dong et al., 2012).
Shay et al. (2012) noted variations in the prevalence of cardiovascular behaviors by age. Shay et al. indicated that, amongst the younger adults (aged 20 to 39 years), the maximum prevalence of ideal levels were noted in blood pressure, cholesterol, and fasting glucose (blood sugar). A prevalence was particularly noted among African American women, compared to middle age (aged 40 to 64 years) and older (aged 65 and above) groups. However, some of the young men as well as the women had ideal BMI, and greater than two-thirds of the middle age and older adults were found to be overweight or obese. In addition, poor physical activity levels were noted in older (age 65 and above) participants, particularly, non-Hispanic, White women. Highest prevalence of ideal healthy diet scores were noted with older adults (age 65 and above), in comparison to young and or middle age participants (Shay et al, 2012).
Shay et al. (2012) also noted variations in prevalence of cardiovascular health behaviors by race/ethnicity with the maximum prevalence in BMI exhibited in African American women and with the lowest and intermediate prevalence of BMI exhibited in non-Hispanic White women. Notably, the same study indicated ideal physical activity levels was more often reported by young adults (aged 20 to 39 years), specifically African American men; however, across the higher age groups, prevalence was lower (Shay et al., 2012). Of particular interest, more than 99% of young men (aged 20 to 39 years) participants reported as exhibiting intermediate or poor Healthy Diet Score ranges; none of the young men scored an ideal Healthy Diet Score. Finally, Shay et al. reported, ideal healthy scores overall were at lower prevalence or poorly met CVH. This finding is consistent in the literature (Bambs et al., 2011; Dong et al., 2012; Folsom et al., 2011).
Geographical Variations in Cardiovascular Health
Fang et al.’s (2012) 2009 BRFSS data examined geographical variations in cardiovascular metrics, in a population of 356,441 adults and found significant variations in cardiovascular health status of populations by states. In all, prevalence of ideal cardiovascular health was reported in 3.3% of participants; 9.9% of participants had poor cardiovascular health. In the same study, cardiovascular health factors indicated the utmost occurrence rate of ideal levels for blood pressure, total cholesterol, and fasting glucose in the 20 to 39 age group, which was specifically found among African American women when compared with the middle-aged (40- 64 years of age) and older (65 and older) participants. Despite this finding, 13.4% to 48.7% of young men and women’s cardiovascular health factors ranged from intermediate to poor (Fang et al., 2012).
Cardiovascular Health: Prevalence of Health Behaviors
In Fang et al.’s (2012) study, ideal smoking levels were the highest prevalence rate of all of the ideal cardiovascular health components among men and women, which is consistent in the literature (Shay et al., 2012). However, fewer than half of participants had ideal BMI. Overweight or obese was reported for more than two-thirds of middle-aged (40- 64 years of age) and older (65 and older) participants. More importantly, the highest prevalence of intermediate and poor BMI was noted in African American women, compared with European American women who had the lowest prevalence of intermediate and poor BMI (Shay et al., 2012). Another group of researchers have also found a low prevalence of current and former smoking, high cholesterol, and high blood pressure as factors; however, increased prevalence of obesity and abnormal glucose was noted (Huffman et al., 2012).
Disparities: Ideal Cardiovascular Health Metrics and African Americans
Significant disparities exist between African Americans and European Americans for prevalence of ideal cardiovascular health components (Bambs et al., 2011; Fang et al., 2012; Folsom et al., 2011). Ideal cardiovascular health (all seven health metrics in the ideal range) existed in only 0.1% (n=17) of ARIC participants. Five to seven of ideal health metrics were reported in 12.2%. Variations were noted according to age, race and sex as follows: 15.2% among 45 to 54 year olds and 8.8% among 55 to 64 year olds for African American men 3.6%, African American women 4.2%, for European American men 10.5%, and European American women 18.7% (Folsom et al., 2011).
The frequency of ideal cardiovascular health metrics at suboptimal levels among African American populations is supported (Folsom et al., 2011; Bambs et al., 2011; Fang et al., 2012). Dong et al.’s (2012) analysis of the four health behaviors indicated the definition of an ideal diet was met by only 0.4% of total participants and diet components of ideal cardiovascular health diet was poor across all race/ethnic group participants. Specifically, African Americans lagged behind European Americans in ideal BMI (30.3% and 47.2% respectively) and ideal physical activity (37.6% and 45.2%), and although ideal nonsmoking behaviors were high among participants, African Americans exhibited the lowest levels of ideal nonsmoking behaviors (Dong et al., 2012).
CVD Mortality Disparities and African Americans
African Americans experience disproportionate burdens in CVD mortalities (Agency for Health Research and Quality [AHRQ], 2007; CDC, 2010) and a prevalence of CVD mortality risk factors (Lloyd-Jones et al., 2010; USDHSS, National Heart Lung & Blood Institute, & National Institutes of Health, n.d.). Higher risks of CVD mortality are experienced in African Americans at an earlier age (Hurley, Dickinson, Estacio, Steiner, & Havranek, 2010). Disparities in the prevalence of CVD risk factors among African Americans have been attributed to an engagement in behaviors such as dietary risk behaviors and inadequate fruit and vegetable intake (Paschal, Lewis-Moss, Sly, & White, 2010). Other dietary risk factors include inadequate or high fat (Di Noia, & Contento, 2010; Kershaw et al., 2011), current smokers (Kershaw et al., 2011), and physical inactivity (AHA, 2009). CVD risk factors, including high blood pressure, are pronounced in African Americans (Kershaw et al., 2011; Mujahid et al., 2011). Research is emerging examining (a) CVD mortality rates, (b) risk factors-high blood pressure, (c) links to race/ethnicity, (d) disparities between African Americans and European Americans, and (e) socioeconomic status, and (f) geographic variations-metropolitan-level segregation (Allen, Purcell, Szanton, & Dennison, 2010; Homko et al., 2008; Hurley et al., 2010; Kershaw et al, 2011).
CVD and related conditions such as diabetes impede socioeconomic advancements, specifically among disadvantaged segments of the population (WHO, 2010). Therefore, it is imperative that public health professionals align with these efforts to improve cardiovascular health in all populations, specifically regarding at-risk minority groups, such as African Americans. In this study, I will attempt to align with national approaches targeting CVD prevention to improve cardiovascular health in all Americans (CDC, Division for Heart Disease and Stroke Prevention, 2013c; Lloyd-Jones et al., 2010; U.S. Department of Health and Human Services, 2012).

Epidemiological Perspective: CVD Risk Factors and African Americans
Epidemiological studies have demonstrated the uniqueness of the interactions and impact of risk factors-body mass index (BMI) on health of populations, particularly in African Americans (Covelli, Wood, & Yarandi, 2012; Edwards et al., 2011; Taylor et al., 2010). For instance, a previous epidemiology study (Covelli et al., 2012) examined, biological measures (blood pressure, salivary cortisol, and height) and risk for essential hypertension (high blood pressure) in urban African American adolescents (n= 106, aged 14-18 years). Covelli et al. (2012) found high and continual interactions of biological measures (African American race/ethnicity, prehypertension (41% of participants), cortisol and over-responsive blood pressure, cortisol, and a family history of hypertension are attributable to the development of elevated blood pressure. Lloyd-Jones et al. (2010) suggested that, regardless of being a young adult or middle-aged, occurrence of severe levels of risk-factors levels, can significantly elevate the long-term and lifetime risks for CVD and stroke. Hence, this warrants prevention targeting at all levels of risk (Doug et al. 2012), as well as defining ideal cardiovascular health metrics resulted from evidence obtained from White cohorts (Lloyd-Jones et al., 2010).
Prevalence of Modifiable Risk Factors
Modifiable (within the individual’s control) risk factors are accountable for numerous premature and preventable deaths. Examples of modifiable risk factors are obesity or being overweight; both can reduce life expectancy. Modifiable risk factors can be grouped in three categories: (a) lifestyle risk factors, which includes tobacco use and physical inactivity; (b) dietary risk factors include excess salt consumption, inadequate consumption of fruit and vegetables; and (c) metabolic risk factors, which augments the threat of increasing CVD (heart problems and strokes) thus, reducing life expectancy. Examples of metabolic risk factors comprise of increased blood pressure or elevated cholesterol, being obese or overweight (Danaei et al., 2009). Although declines in tobacco use are noted, as it is among the leading causes of avertable mortality and morbidity. Tobacco use contributes to the substantial burden of lung cancer and chronic lung disease (Huffman et al., 2012).
Despite the existence of effective interventions for high blood pressure and smoking, both have contributed to the highest mortality in the US. In addition, nutritional habits, lifestyle, and metabolic risk factors for the persistent medical conditions are responsible for increasing the rate of mortality in the US (Danaei et al., 2009). High blood pressure, overweight/obesity, diabetes and physical inactivity are modifiable risk factors that are pronounced among African Americans (AHA, 2009; Covelli et al., 2012; Fryar, Chen, & Li, 2012; Go et al, 2013; Mathieu et al., 2012).
Data from the National Health and Nutrition Examination Survey indicated about 47% of US adults possessed at least a single risk factor out of the three risk factors for CVD in 2009-2010. These risk factors include uncontrolled high levels of low-density lipoproteins (LDL) cholesterol, uncontrolled high blood pressure, or current smoking (Fryar et al., 2012). Finally, declines in the levels of minority populations who experienced at least one of the three risk factors have been observed from 1999–2000 through 2009–2010, specially in the Mexican-American and non-Hispanic White adults; although, this decline has not been evident among the non-Hispanic, African American adults (Fryar et al., 2012).
Disparities in Risk Factor Knowledge
The literature is inconsistent reporting CVD knowledge among African American populations, which exist at suboptimal levels (Mochari-Greenberger, Mills, Simpson, & Mosca, 2010; Homko et al., 2008). In contrast, African Americans having knowledge of CVD risk factors are reported (Daniels et al., 2012; Winham & Jones, 2011). Winham and Jones studied knowledge of CVD among African American young men and women, aged 18-26, and found the majority of participants possessed knowledge regarding the risk factors for the heart related diseases. The participants indicated CVD risk factors as being overweight, have high blood pressure and a family history of heart disease. The participants also reported knowledge of CVD risk reducing behaviors, which included exercising, weight reduction, stress reduction, and abstinence of smoking. The researcher found few studies that examined the effects of a culturally tailored educational intervention on knowledge of the American Heart Association, a new concept cardiovascular health and related the seven health behaviors and health factors collectively, among African American adults residing in an urban community. The need to examine African Americans exists, as their preventable death rates from heart disease, stroke, and high blood pressure is almost two times that of European Americans (CDC, 2013a).
Therefore, research addressing CVD, risk factors for CVD, and interventions pertaining to CVD can be used to gain insight regarding single or combinations of the cardiovascular health metrics components (Shay et al., 2012). Nevertheless, efforts to promote and attain ideal cardiovascular health in minority populations will be challenging (Dong et al, 2012); however, interventions targeting health behaviors and health factors among African Americans and minority populations have shown promise (Duru, Sarkisian, Leng, & Mangione, 2010; Perra-Medina et al., 2011; Peterson & Cheng, 2011; Treadwell et al., 2010). In addition, nurse-led interventions addressing health prevention in the general and diverse populations have reaped positive health results such as, markedly decrease in body mass index (BMI) (Buchholz, Wilbur, Miskovich, & Gerard, 2013).
Aggressive public health efforts to augment public understanding and awareness of CVD risk factors in the US exist. However, ethnic differences in CVD awareness and knowledge of CVD risk and CVD risk factors are recognized in the literature (Homko et al., 2008; Mosca et al., 2010). A survey conducted by the AHA at the national level, discovered that results of the initial 1997 survey to a 2009 survey, showed that understanding of heart disease and heart attack as the foremost causes of mortality has tripled amongst the African Americans, which has been noted as an improvement. Furthermore, research reveals that individuals at high risk for CVD are expected to have limited CVD risk factor awareness and reduced perceptions of these risks. Assessment findings reveal a high risk for CVD exist, particularly among inner city residents (Homko et al., 2008). Awareness by racial and ethnic groups remains a problem. African American, Hispanic, and Asian women are not able to recognize heart disease and heart attack as the most prevalent cause of death, in comparison to the European American women (Mosca et al., 2010). Educational interventions to increase risk factor knowledge and awareness of these serious risks among at-risk populations are needed (Homko et al., 2008). However, knowledge of the educational strategy alone may not be a viable strategy towards behavior change. Therefore, I will employ an interactive learning group strategy.
National Programs for CVD Prevention
National efforts toward CVD prevention have been undertaken and include numerous programs such (a) focused on clinical and community prevention (Million Hearts), (b) the National Program to Reduce Cardiovascular Risk (NPRCR), (c) National High Blood Pressure Education Program (NHBPEP), (d) National Cholesterol Education Program (NCEP), and (e) the NHLB Obesity Education Initiative (OEI). In addition, technological interventions (i.e. smart phone application, text messaging) are emerging, including educational support or added interventions as one strategy to combat certain CVD risk reduction. These innovative interventions offer promise in affecting health (i.e. weight loss, physical inactivity) (Stephens & Allen, 2013).
Community Health Programs and Interventions
Health disparities persist as a priority health concern for African Americans, which necessitates public health professionals to collaborate with African American churches (local and national), and with neighboring communities (Cook, 2010). Cardiovascular health behaviors and health factors are addressed as single or a combination of variables in research evaluating interventions among African Americans. Researchers seek to improve knowledge of diabetes and cardiovascular risk factors including physical activity, diet including the DASH diet, obesity, management (self-care) related to diabetes control, and high blood pressure (Daniels et al., 2012; Kountz, 2012; Peterson & Cheng, 2011; Quinn & Guion, 2010; Resnick et al, 2009; Whitt-Glover et al., 2013; Zenk et al, 2009).
Other studies, pre-or post-educational CVD prevention interventions, have been initiated with high-risk populations, such as racial and ethnic minority women over the age of 40 and Black college students (Joseph et al., 2013; Villablanca et al., 2009). Overall, research is consistent in reporting improvements in knowledge of diabetes (Kountz, 2012), CVD risk factors (Konicki, 2012; Villablanca et al., 2009) and in some instances, knowledge of effective CVD risk modification strategies (Villablanca et al., 2009). Previous studies have reported improvement in body weight, blood pressure, and diet intake (Resnick et al., 2009; Whitt-Glover, 2013) and CVD risk scores (Ma et al., 2009). Although improvements have been achieved with some programs, at least in the short-term, significant changes have not been reported in other programs (Kountz, 2012). In contrast, studies have reported increased knowledge of CVD risk factors is not linked to heart health sustaining behaviors (Konicki, 2012).
The Heart and Soul Physical Activity Program was a pilot study behavioral, church-based physical activity program conducted in an urban African American church. This pilot study’s aim was to incorporate the church-based Heart and Soul Physical Activity Program into a study to evaluate the impacts of spirituality, as well as social support, to increase physical activity in African American women (Peterson & Cheng, 2011). In this study, African American women, aged 35-65, who were physically inactive attended a (two-hour) group sessions, which was conceptualized in the domains of social support, including tangible, belonging, appraisal, and self-esteem. Physical activity and social support increased during the six weeks.
Church-based interventions have been successful in health promotions efforts aimed at positively affecting health and health behaviors (physical activity and CVD risk factor knowledge) among African Americans (Daniels et al., 2012; Peterson & Cheng, 2011) and in other populations. Research suggests that the social context of the church environment offers a social support that is essential to the success of health behaviors changes. The social background of the church setting can be perceived as the place that provides the intrinsic shared sustenance needed for successful promotion of changed health behavior in African American women (Peterson & Cheng, 2011).
Community Interventions: Health Promotion and African Americans
Interventions targeting population-wide behavior change to entire communities are needed and occur often. However, determining specific needs of the targeted underserved populations (i.e. such as racial and minority populations, children, youths and the elderly) it is an essential factors when designing interventions aimed at underserved populations (Pearson et al., 2013; Peterson & Cheng, 2011). The AHA Community Guide supports implementation of community-wide interventions that are culturally and socially appropriate (Stuart-Shor, Berra, Kamau, & Kumanyika, 2012). Finally, the persistent health disparities impacting African Americans necessitates the need for collaboration between public health professionals, African American churches (local and national), and neighboring communities (Cook, 2010).
Numerous interventions and programs addressing CVD risk factors (obesity, diabetes, high blood pressure, cholesterol, and depression) and health behaviors (physical activity, diabetes, and diet management) among African Americans have been conducted in community and church-based settings (Daniels et al., 2012; Kountz, 2012; Lemacks et al., 2013; Murphy & Williams, 2013; Peterson & Cheng, 2011; Resnick et al., 2009; Whitt-Glover et al., 2013). The feasibility of such programs are established with African Americans in the US (Peterson & Cheng, 2011; Resnick et al., 2009) and ethnic populations (South Asians) in other countries, specifically Canada (Jones et al., 2013).
Schneider, et al. (2012) carried out a research study in which a selected mind body intervention together with a Transcendental Meditation (TM) program was implied within the African American individuals in a selected community. The results of the study indicated that such an intervention can be helpful in reducing the risk factors for the myocardial infractions, mortality due to CVD and stroke among the heart patients. These interventions improved the awareness level of the patients by reducing the CVD risk factors. Hence, community based interventions can be successfully implemented in as a secondary preventive measure of the CVD (Schneider, et al., 2012).
Interventions have addressed cardiovascular health behaviors and health factors single variable with African Americans. Primarily, researchers sought to improve knowledge of diabetes, physical activity, diet, obesity, management (self-care) related to diabetes, and high blood pressure (Daniels et al., 2012; Kountz, 2012; Peterson & Cheng, 2011; Resnick et al., 2009; Zenk et al, 2009). Studies report participant satisfaction with programs aimed at improving knowledge and control of diabetes (Kountz, 2012; Utz et al., 2008). In addition, prior studies have reported improvement in body weight, blood pressure, and physical activity (Lemacks et al., 2013; Peterson & Cheng, 2011; Shlay et al., 2011) achieved with some programs and interventions, at least in the short-term (Joseph et al., 2013). With other programs, significant changes were not evident (Kountz, 2012).
The Heart Healthy and Ethnically Relevant (HHER) Lifestyle Trial was a randomized trial of a community-based cardiovascular risk reduction intervention conducted in two federally funded community health care centers (Perra-Medina et al., 2011). The study involved 266 financially disadvantaged African American women aged 35 to 64, patients of South Carolina community health centers. Participants were randomized to the trial’s standard care (n=130) or comprehensive interventions (n=136). Interventions comprised a standard care intervention, which included motivational stage-based behavioral counseling by the primary care provider, goal setting with assistance from a nurse; community resource guide containing free or low cost programs, including facilities; and ethnically tailored educational materials. Participants of the comprehensive intervention received standard care in addition to the following: 12 motivational stage-matched, ethnically tailored care extending over one year, introductory telephone check-ups, and up to 14 brief, motivationally tailored telephone-counseling calls from research staff for over one year. At the 6-month period, improvement in leisure-time physical activity was more likely in the comprehensive intervention group (44%) than in the standard care group (22%). Diet and physical activity, both showed significant improvements between baseline and the six-month interval, with a change attenuating slightly by 12 months (Perra-Medina et al., 2011).
Lemacks et al.’s (2013) systematic review of the literature on articles published from January 2000, through December 2011, revealed interventions aimed at improving nutrition and physical activity behaviors in adult African Americans, show promise in decreasing risk for chronic diseases and improved clinical outcome measures. The researchers indicated clinical relevant outcome measures such as (a) weight loss, (b) decreased waist circumferences, (c) blood pressure, (d) fasting blood sugar, (e) percentage of body fat, (f) hemoglobin A1c in the prior three months (U.S. National Library of Medicine, National Institutes of Health, 2014), (g) blood lipids (fats), (h) high-density (HDL), and (i) low-density lipoprotein (LDL) (Lemacks et al., 2013). However, in the same study, the researchers noted one study that was published in two different articles, as dietary and physical outcomes did not show noteworthy outcomes in two medical findings: decreasing waist circumference and BMI.
Nurse-led Interventions
Lofton (2012) conducted a nurse-led intervention with 128 African American, self-reported single women between the ages of 45-64 (Baby Boomers) to help the women understand the dangers of HIV/AIDs and sexually transmitted diseases (STDs) and infections among African American women in the US. Lofton has indicated that, this age group and ethnicity were chosen because the incidences of HIV/AIDs are rising among older, African American women. In addition, “In the US, African American women have the maximum incidence of STDs of all female ethnic groups (CDC, 2009 as cited in Lofton, 2012, p. 1). The location was chosen because, according to Lofton, “The southern region of the country has the highest rate of HIV in the U.S. and African Americans die more often from the disease that their white counterparts” (p. 4).
The women completed a demographic and a sexual history questionnaire. Instruments used included (a) General Self-Efficacy Scale, (b) Brief HIV-Knowledge Questionnaire, (c) Health Protective Sexual Communication Scale, and (d) Theory of Choice Questionnaire. Women from four organizations from a rural section of southern Louisiana participated in the nurse-led intervention. After completion of the questionnaires, the nurse explained to the women the dangers of unprotected sex and the signs and symptoms of sexually transmitted diseases and infections. For data analysis, the researcher used a Non Equivalent Solomon-Four–Group, an analysis of variance (ANOVA), an analysis of covariance (ANCOVA), a t-test, and Pearson product-moment correlation coefficient (r) (Lofton, 2012).
The results of the analysis indicated that single African American women baby boomers who received the nurse-led educational intervention scores improved in sexual health knowledge, self-perceived risk awareness and personal choice position. However, the nurse-led intervention (treatment) was not effective in improving self-efficacy levels; which may indicate the intimate partner may be in control related to sexual practices in the relationship (Lofton, 2012).
Lofton (2012) recommended, “Nurse Educators must expand and promote cultural competence that is consistent with the growth of minority populations . . . Nurses must continue to create and implement culturally sensitive educational interventions that target high risk populations” (p. 78).
Evdokimoff (2012) explained, “Rehospitalization rates of 20% within 30 days of hospital discharge and 27% within 60 days are one of the highest strains on the federal Medicare budget” (p. 1). To address this problem, Evdokimoff conducted a quasi-experimental comparative design, nurse-led intervention. “The study sample consisted of 70 adults, 65 years of age and older, with a need for skilled nursing services, dwelling in a community serviced by the participating agencies” (p. 86). Evdokimoff based her intervention on the four pillars of Eric Coleman’s Care Transition InterventionSM, which included nurse-led instructions on medication usage, bandage care when applicable, possible red flags problems), and regular communication with nursing facility staff and the lead nurse. Results indicated, “While there was not a significant difference in rehospitalizations between the intervention and comparison groups, there was a greater percentage of the comparison group participants hospitalized at sixty days” (Evdokimoff, 2012).
Constantine (2013) conducted a descriptive, retrospective design involving a nurse-led intervention to improve palliative care with a select group of participants receiving medical intensive care. Constantine stated, “Twenty percent of all Americans die in an intensive care unit (ICU) or shortly thereafter” (p. 1). Constantine conducted the study in a rural Appalachian Mountain area of West Virginia. She used the nine palliative measures of the Communication and Care Bundle and a pre and post-test to determine the effectiveness of the intervention. Constantine explained that even though this was a nurse-led intervention, to be successful, all stakeholders were involved. One-hundred twenty-eight families participated with each family representing a patient in ICU.
An independent t-test was used to evaluate the data. The patients’ ICU length of stay was an average of 10.69 days during the pre-intervention time period and an average of 4.89 days in the post-intervention time period. This change represents a significant difference (p < 0.001) in length of stay between the pre-intervention and post-intervention time periods. There was no significant difference (p = 0.155) in mortality between the pre-intervention and post-intervention time periods. (p. 58)
Harbman (2011) explained she was compelled to conduct a nurse-led pilot study because “Patients with acute myocardial infarction (AMI) are at high risk for reinfarction and death, with the highest rate of death and reinfarction occurring within 30 days of AMI” (p. 1). Harbman used a prospective cohort design to compare achievement of target scores from patients who had a nurse-led intervention against those patients who did not have the benefit of a nurse-led intervention after suffering AMI. Sixty-five patient participants were included in the study. “Data on practice activities and implementation of secondary prevention by the NP [nurse practitioners] were collected before discharge from hospital and one week, two weeks, six weeks and 3 months after discharge” (2011, p. 3). For data analysis, Harbman used a t-test, multiple regression analysis, and logistic regression analysis. Results indicated the following:
Examination of NP practice activities as predictors of successful outcome achievement revealed that successful achievement of recommended triglyceride levels was associated with the NP practice activity of lipid teaching, and shorter weeks to cardiac rehabilitation was related to NP practice activity of physical activity assessment. (p. 115)
Noble, McCrone, Seed, Goldstein, and Ridsdale (2014) explained that no studies existed to explain the emergency care visits of patients suffering from epilepsy. Noble et al. called such hospital visits costly and unnecessary. Because of the frequency of emergency room visits in this care group, Noble et al. conducted a nurse-led intervention among 85 adult participants with a diagnosis of epilepsy. The study was conducted in London, England. The participants were randomly divided into two groups with one group receiving one-year’s nurse-led intervention, which included instructions on when an epileptic seizure constituted an emergency room visit. All participants completed pre and post-tests. “Logistic regression tested for the significance of any differences between the groups” (p. 5). No significant differences were found between the two groups except regarding length of hospital stay with the experimental group requiring shorter hospital time than the control group. Recommendations included involving significant others in future studies as they are the ones who ultimately make the decision to transport to the hospital when a patient suffers an epileptic seizure (Noble, McCrone, Seed, Goldstein, and Ridsdale, 2014).
Another group of researchers have indicated that the nurse led heart failure programs (HFPs) can improve the adherence to the medicine and also reduce the level of hospital readmission. The researchers carried out a review consisted of 413 consecutive patients admitted to the hospital during the time period of 2008 to 2009 for heart failure. All of these patients were called upon for their participation in the nurse led HFP. The results of the study indicated that the intervention improved the patients’ survival rate and also enhanced the physical conditions of the patients (Bdeir, et al., 2014). Similarly, another study was carried out to improve the awareness of the individuals regarding the diabetes and CVD. The main objective of the study was to measure the management of CVD, by the help of nurse or CHWs led community based interventions. The outcomes of the study elucidated that the interventions carried out by nurses or CHWs are cost effective and should be preferred by community health care facilities for future interventions in African American communities (Allen, Himmelfarb, Szanton & Frick, 2014).
Summary and Transitions
African Americans, especially those considered vulnerable and at risk, are disproportionately burdened with low prevalence of ideal cardiovascular health relative to European Americans (Bambs et al., 2011; Dong et al., 2012; Shay et al., 2012) and unequal burdens of multiple CVD risk factors (Covelli et al., 2012). In fact, African Americans are more likely to report one potential risk factor, when in actuality, two or more CVD risk factors are present (Hamner & Wilder, 2008; Winham & Jones, 2011). Knowledge of cardiovascular health factor levels and heart healthy levels of HDL and LDL are often reported as insufficient among African Americans relative to European Americans (Hamner & Wilder, 2008; Homko et al., 2008; Mochari-Greenberger et al., 2010). However, inconsistencies in knowledge of CVD risk factors have been noted. Studies indicate that African Americans have knowledge of certain CVD risk factors (Winham & Jones, 2011; Winston et al., 2014); however, improved awareness of cardiovascular risk factors will not result in the adoption of, and the sustaining of healthy lifestyle behaviors (Konicki, 2012). In contrast, studies indicate that African Americans engage in CVD preventive behaviors such as the avoidance of unhealthy foods, weight loss, and increased fruit and vegetable intake (Mochari-Greenberger et al., 2010; Whitt-Glover et al., 2013). In addition, Mochari-Greenberger et al. has investigated the CVD awareness, precautionary action, and obstacles to the prevention among women revealed that 59% of the African Americans cited physician encouragement as the reason for engaging in preventive action (as compared to 54% of Hispanics and 43% of Whites/others). Culture beliefs not only influence perceptions of health and illness; but also can influence recognition and interpretation of symptoms, healthcare system utilization, and the making of healthcare decisions as well (Homko et al., 2008).
Although only the provision of education is not effective for behavior change, it is an initial step in moving towards behavior change. It is paramount that interventions that are implemented are effective in addressing health knowledge, behaviors, and attitudes of African Americans (Lewis-Moss, Paschal, Sly, Roberts, & Wernick, 2009). Research examining culturally tailored interventions and the social cognitive theory among African Americans is evidenced in the literature (Joseph et al., 2013; Utz et al., 2008). Therefore, this dissertation is proposed as a strategy, that could increase individual knowledge of heart disease risk, and CVD preventive behaviors, which could ultimately result in a change in actual risk. Hence, improving the opportunity to live a CVD-free life, delay the onset of CVD, or lessen the severity of CVD (Hamner & Wilder, 2008).

Chapter 3: Research Method
Introduction
This chapter will focus on the presentation of the purpose, research design, methodology, and the rationale for implying the selected research design and methodology for this dissertation study. In this chapter, I discuss the recruiting strategies to engae the community partners, eligibility criteria, setting, and characteristics of the participating participants. The chapter focuses on the process used to randomize community partners into a treatment or comparions group arm of study in order to compare the effects of community educational interventions on CVD risk factor knowledge, demographic characteristics, and awareness of the term, cardiovascular health between treatment and comparison groups. A discussion of the procedures involving the coordination of community heart health sessions with four community partners, in which the National Heart Lung and Blood Institute’s Community Health Worker Health Disparities Intitiative Heart Health program was selected by the community partners as a source for curricular content. The Data Use Agreement and retrieval of data sets from the community partners are described. And finally, an overview of the data analysis process is provided, followed by a discussion of the measures undertaken to ensure participants’ rights and protection, and plan for dissemination of the dissertation study results.
Research Design and Rationale
Secondary data analysis is implied as the central research method in this study. It allows the researchers to carry out a research study by utilizing the data of any previously conducted study or by extracting the data from any database. Secondary data analysis is a effective and time saving method of analysis, in which research questions are answered that have not been previously addressed in the parent study. High quality of data sets and extracted data can be easily analyzed by the help of secondary data analysis (Goodwin, 2012). IRB approval was obtained from Walden University to conduct this secondary analysis dissertation study.
A modified randomized static group comparison design (Maruyama & Ryan, 2014) was employed.
Sample and Setting
Four community partners that were comprised of three churches and one clinic centrally located within an predominantly urban African American community were recruited for the dissertation study. A total of 107 African Americans affiliated with a community partner aforementioned, in which the community partner was randomized into a intervention or comparison group in which the community sponsored a 1-hour heart health educational session. In response to recruitment, potential community partners expressed interest in conducting health education aimed at heart health disparites in the African American community. The Community Health Worker Health Disparities Initiative of the National Heart, Lung, and Blood Institute (NHLBI) culturally tailored heart health curricula was selected by community partners, to evauate heart health educational needs of African Americans and consideration of using the curricula for future programing. Thus, to ultimately aide in the planning of future heart health programing aimed at heart heart disparites. The main aim of this secondary analysis study was to describe the relationship between effects of community tailored tailored educational interventions on CVD risk factor knowledge, demographic characteristics, and awareness of the term cardiovascular health, between a intervention and comparison group of African American who participated in community health sessions offered in the community. The inclusion criteria for the selection of the churches included the (a) must be located within the urban area, (b) a congregation of more than 50 percent of the African Americans; (c) an established ministry must be present within the church. The researchers in the parent study applied the purposive approach for the selection of churches and a community clinic after discussing the study with the pastors of the churches and director of clinic. Three pastors of belonging to three different churches were selected where the congregation consisted of 95 to 100 percent African American. All four sites were randomly assigned to the intervention group or the control group. For the study purpose two groups were formulated; namely the intervention group and the control group.
Procedures (Note: I am still addressing this area & the latter sections.)
Recruitment of Community Partners
Upon receiving Walden University IRB approval, the primary investigator (PI) initiated recruitment of churches, clinics and organizations serving the targeted community. For potential community partners, community health professionals (community health educators, registered dietician, community liasons, and nurses), were asked to identify potential community partners for recruitment. In addition, the PI conducted a internet search to obtain names and addresses of potential partners. On the initial contact, the PI introduce self as a doctoral student and public health nurse consultant, involved with the National Heart, Lung, and Blood Institute (NHLBI) Community Health Worker Health Disparities Initiative Heart Health Program (USDHHS, NHLB, National Institutes of Health, 2014). The purpose of the contact was explained as an inquiry as to existence of heart health health program, and current evaluation of such a program. Based on the response from the entity contact person, the PI met with contact person of the entity to discuss the research project and data collection procedures, including a Data Use Agreement that will be required from all community partners. The PI reviewed and explained the use of a site specific Data Use Agreement (Appendix__) as it relates to the data collection process, data collection tools selected by the site, role of the researcher, and information applicable to the use of data sets. Per request of the community partners, the data collection instruments (demographic data forms and a knowledge questionnaire) were reviewed and selected by the community partners to obtain data from African American participants, for the purpose of evaluating the need to expand their health educational programs. Upon receiving signed consent from the authorized representative of the specified organization, each signed Data Use Agreement was scanned into the PI’s personal computer, a copy was emailed to the IRB and a carbon copy of the signed Data Use Agreement was submitted to the signer as well. While awaiting IRB approval, coordination of the heart health session consisted of the PI addressing inquiries from the potential community parners inquiry about the NHLBI’s culturally tailored heart health education curricula for African Americans. The NHLBI’s website addressing the Community Health Worker Health Disparites was provided each potential community partner. After a review of the NHLB content, each site opted to use a condensed version of the NHLB’s tailored heart health program curricula to keep the presentation within undr a 1-hour time frame to optimize participant attendance. For the selection of the community health workers, the pastors were asked to identify the suitable individuals that can be considered appropriate for providing educational intervention to the intervention group. the main inclusion criteria for the selection of the CHWs was that; (a) must African American; (b) must speak English (c) must be above the age of 18 years (d) must be familiarized with the surrounding community of the church; (e) must be able to identify one of the CVD risk factor out of ABCD on the basis of self report. The researchers then interviewed the selected candidates keeping in mind the inclusion criteria. 12 individuals were then selected for the training and educational workshops on the basis of their availability. These individuals were then randomly allocated within the intervention and the control group.
Data Collection Instruments
The community partners selected to use demographic data (Appendix ____) form to collect demographic characteristics-age, marital status, education, employment, and income. The Heart Disease Fact Knowledge Questionnaire (HDFQ) (Wagner, Lacey, Chyun, & Abbott, 2005) a 25-item questionnaire, was administered to participants either prior to (comparison group) or after (intervention group) participating in a community partner sponsored heart health educational session, to evaluate heart disease risk knowledge, the association between diabetes and heart disease, and risk reduction strategies for heart disease (2015 Nigeria Medical Journal). Data sets obtained from all community partners included participant responses from demographic data forms and the HDFQ.
Questions and Hypothesis
RQ1. Do participants who will receive a culturally tailored educational intervention have levels of knowledge than do participants who have not receive the intervention?
Ho1. Participants who will receive a culturally tailored intervention have similar levels of knowledge to participants who have not received the intervention.
Ha1. Participants who will receive a culturally tailored intervention have higher levels of knowledge to participants who have not received the intervention.

RQ2. Do participants who will receive a culturally tailored educational intervention have higher levels of knowledge than do participants who have not received the intervention after controlling for the participant’s demographic characterisitics?
Ho2. Participants who will receive a culturally tailored educational intervention have similar levels knowledge to participants who havenot received the intervention after controlling for the participant’s demographic characteristics (age, gender, marital status, education, employment, and income).
Ha2. Participants who receive a culturally tailored educational intervention have higher levels of knowledge to participants who have not received the intervention after controlling for participant’s demographic characteristics (age, gender, marital status, education, employment, and income).
Data Analysis
Data was analyzed using descriptive and inferential statistics. Descriptive statistics will include means, standard deviations, frequencies and percentages. Hypothesis 1 (simple knowledge differences between the groups) was tested using a t test for independent means. Hypothesis 2 (knowledge differences between the groups regarding the CVD related terminologies and physiological measures) was assessed using a paired t-test.
Reliability and Validity
Reliability
“Reliability is the degree to which an assessment tool produces stable and consistent results” (Phelan & Wren, 2006, para. 1). Two types of reliability exist: internal and external. McLeod (2013) explained that external reliability is the amount of variability from one use of an instrument to another use of the same instrument. McLeod also noted that internal reliability is the consistency of the results across items on the same instrument. Test-retest reliability occurs when the same test is given to a group of individuals at two different times with the same results. Parallel forms reliability occurs when different forms of the same test are given to a group of individuals with the same results. Inter-rater reliability is a measure of reliability that occurs when different raters or judges agree upon the assessment reached by the instrument. Internal consistency reliability is the level to which diverse test items on the same test measure a particular construct (McLeod, 2013; Phelan & Wren, 2006).

Validity
The construct (knowledge) will be operationally defined and quantified, and it is considered as the core of measurement (Kimberlin & Winterstein, 2008). For instance, the ability to improve heart health in the community may be assessed by measuring the knowledge of heart disease risk factors that attribute to the development of CVD among the targeted community. Thus, there is a need for interpretation of results of the knowledge questionnaire, in this case, to measure level of knowledge of heart disease risk factors (Kimberlin & Winterstein, 2008).

Ethical Considerations
Perrmission to conduct this study was obtained from Walden University Institutional Review Board (IRB) prior to recruitment and data collection efforts. The primary investigator (PI) will secure and safeguard the physical transport of data to the double locked physical residence occupied by the PI. Data will be placed in a fireproof file box to safeguard and prevent unauthorized viewing of data. All data related to the dissertation study will be securely stored for a minimum of 5 years and according to Walden University’s policy. In addition, at the end of 5 years, all dissertation research paper and electronic materials will be disposed of according to the policy.

Dissemination of Findings
I plan to disseminate the findings to (a) public health professionals, (b) government agencies, (c) academia, (d) churches, and (e) health systems via any publications that result from the study after the dissertation has been successfully defended. In addition, I will contact community partners and venues to obtain other sources for disseminating results.
Transition and Summary
This chapter discusses the design and methods that was used to conduct this secondary analysis dissertation research. The study process began with a discussion about the purpose, recruitment, and identification of potential community partners, ethical considerations, data collection instruments and procedures, and data analysis. Finally, a discussion regarding the reliability and validity, ethical considerations and plan for dissemination of findings are provided.
Chapter 4 discuss results obtained in collecting and analyzing data. The relationship between the hypothesis and theoretical framework are provided. All other relevant data related to participants are described as well. Finally, Chapter 4 contains a summary of the results and the significance of this dissertation study.
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