Lower Cardiovascular Disease Risk in Midlife Black Women: History
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Subjects: Health Care Sciences & Services
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Holly Jones

Midlife Black women suffer disproportionately from cardiovascular disease (CVD) and stroke in comparison to White women of similar age and demographic. Risks factors  for CVD and stroke are largely considered to be modifiable yet, CVD prevention and awareness campaigns have been less effective among Black women. Decreased awareness of personal CVD risk is associated with delays in the presentation of women to the emergency room or health care providers for symptoms of myocardial infarction. The Midlife Black Women’s Stress and Wellness (B-SWELL) program was co-designed with the community to increase awareness about CVD risk factors, stress, and healthy lifestyle behaviors among midlife Black women.

  • women’s health services
  • cardiovascular diseases
  • community based participatory research
  • African American women

1. Introduction

Midlife Black women in America have a 69% higher death rate from heart disease and double the death rate from stroke compared to White women [1]. It is estimated that 49% of adult Black women have some type of heart disease and 40% have hypertension, a major precursor to heart disease. Black women are also more likely to suffer from chronic medical conditions and disability or adverse outcomes resulting from such conditions [2]. Heart disease and many of its related conditions are largely modifiable and preventable through healthy lifestyle behaviors. National campaigns such as those supported by the American Heart Association (AHA), have failed to increase awareness of relative heart disease risk in women of color, particularly Black women [3][4]. Reasons proposed for the failure to improve cardiovascular disease (CVD) awareness in Black women include a lack of tailored and targeted awareness campaigns and limited access to cardiovascular screenings [5].
A lack of awareness is associated with delays in the presentation of women to the emergency room or health care providers for symptoms of myocardial infarction [6]. Lower rates of awareness and poor lifestyle behaviors contribute to the poor health outcomes and comorbidity observed in midlife Black women. It is suggested that disparities in the effectiveness of awareness campaigns may be related to socially constructed ideas about the meaning of heart disease and prevention [7]. Thus, the adoption of healthy lifestyle behaviors is a choice which may require targeted interventions that leverage cultural norms, beliefs, and behaviors [8].

Life’s Simple 7

The Midlife Black Women’s Stress and Wellness (B-SWELL) program uses the AHA’s Life’s Simple 7 (LS7) to highlight key lifestyle behaviors shown to lower heart disease risk. LS7 was introduced in 2010 to target key modifiable behaviors related to heart disease risk. The LS7 behaviors are exercise, losing weight, eating better, stopping smoking, controlling cholesterol, managing blood pressure, and reducing blood sugar [9]. LS7 was selected for this research because its metrics are easy to use and amenable to self-evaluation. Individuals can rate their performance for each key behavior using a scale of 0 (poor) to 2 (ideal). Since its inception, the LS7 metrics have been associated with lower risk for heart failure, diastolic dysfunction, stroke, and mortality related to CVD [10][11]. The LS7 metrics have also been used to assess for cancer risk, metabolic syndrome, and all-cause morbidity [12][13].

2. Phase 1

2.1. Partnership and Recruitment

During phase 1, the PI worked closely with a community research advisory board (C-RAB) working group to develop the B-SWELL materials (Figure 1). This iterative process would span one year. In this way, trust was established and the C-RAB members gained familiarity with this study’s purpose and expected outcomes. An initial outline for each module and its content was developed by the principal investigator (PI). Following development, the content was passed along to the C-RAB working group. Each member of the working group reviewed the materials, providing critique and recommendations for improvement or further development. Feedback focused on the informational content of the B-SWELL materials, clarity of the content, and cultural relevancy. Updates were provided intermittently to the larger C-RAB group to solicit feedback and discussion. This cyclical process was successful in the development and refinement of the B-SWELL content and materials.

Ijerph 19 01356 g001

Figure 1. Collaborative research activities.

2.2. B-SWELL Materials

The final B-SWELL prototype consisted of eight modules containing culturally adapted content and materials. The first module, ‘Heart Disease and You’, provides an overview of CVD risk for midlife Black women, introduces the LS7 behaviors (exercise, eating better, losing weight, stopping smoking, managing blood pressure, controlling cholesterol, and reducing blood glucose), and discusses the relationship between stress and CVD. The remaining seven modules were dedicated to the LS7 healthy lifestyle behaviors and titled: ‘Reducing Heart Disease Risk with Exercise’, ‘Heart Disease and Nutrition’, ‘Heart Disease and Weight Loss’, ‘Heart Disease and Smoking’, ‘Blood Pressure and Heart Disease’, ‘High Cholesterol and Heart Disease’, and ‘Diabetes and Heart Disease’. Content in each module provided in depth information about the respective LS7 behavior, the relationship to CVD, and stress to increase personal knowledge and awareness.

3. Phase 2

B-SWELL Pilot

The B-SWELL pilot was co-facilitated by community researchers. As facilitators, the community researchers were tasked with maintaining the flow of the program; monitoring participant engagement; creating a safe environment in which each participant could speak, be heard, and feel comfortable sharing experiences; and promoting the B-SWELL agenda. During the pilot trial, checks were in place to maintain fidelity of the intervention. Facilitators were given a guide that contained an ordered list of session activities and pre- and post-session checklists. Open-ended questions were included in the guide to encourage self-reflection and identify areas in need of improvement (Table 1). Sessions of the B-SWELL pilot were audio recorded. The principal investigator reviewed the audio recordings regularly to evaluate sessions facilitated by community researchers and provide feedback. In turn, community facilitators were asked to perform self-evaluations using the facilitator guide.
Table 1. Facilitator questions for reflection.
Questions for Post-Session Self-Evaluation
  • What do you think went well with this group session?
  • Describe any problems you had (i.e. participant agitated, no engagement, technical difficulties, etc.)
  • What do you think you could have done to make this session better?
  • Describe areas where you might need more training.
  • Describe areas for improvement.

4. Community Participatory Research Methods and Relationship between the PI and the C-RAB

Using community participatory research methods and a strong working relationship between the PI and the C-RAB, content for the B-SWELL program materials was successfully developed consisting of culturally tailored, original materials and adaptations of existing AHA LS7 materials. Intertwined in this process was the desire to culturally adapt the LS7 materials to address the existing health disparities affecting midlife Black women. Community engagement and participation were essential to achieve these aims. The C-RAB consisted of community researchers that were invested in their community and representative of the targeted population, midlife Black women. Although time intensive, the cyclic process used to develop the B-SWELL materials resulted in an intervention that can be embraced by midlife Black women. The B-SWELL has unique attributes that will increase the likelihood of sustainability and transferability.
A true collaboration was formed that placed community researchers on equal footing with academic researchers. The C-RAB members provided honest and direct feedback that ranged from critique of concepts to the images of Black women and colors used in the modular design. The ideas and recommendations from the C-RAB provided rich, salient characteristics to the B-SWELL materials that embodied situations and experiences of midlife Black women. Community participatory research methods are inclusive, allowing research to be conducted with its participants rather than on its participants [14]. Ideally, community-focused research projects should arise from problems relevant to the population studied thus promoting engagement and participation [15]. When ideas for research projects arise outside of the community, such as what occurred with the B-SWELL program, the community should be engaged at the earliest point of development and refinement to improve the chance of success. The methods and approaches in community engaged research promote reflection, participation, and collaboration and are conducive to a cyclical pattern of discovery [16][15]. Community engaged research is grounded in social justice and, thus, is ideal for investigating issues associated with health disparities and high-risk or marginalized populations [15][17]. 

5. Conclusions

The final B-SWELL intervention modules and content were developed using community engaged and participatory research methods. The benefits of collaborative research have been recognized, yet the numbers of community-based collaborations in research projects remain small compared to the large number of researcher-led interventions and projects. Acknowledgement of the expertise derived from lived experiences and recognizing the value in the community perspective are key if researchers hope to effectively address existent health disparities and social inequities. Community programs are proposed to be more sustainable and successful when developed in collaboration with representative members of the targeted community or population thus, a community-focused approach was ideal for the development and refinement of the B-SWELL program.

This entry is adapted from the peer-reviewed paper 10.3390/ijerph19031356

References

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