Perceptions of a Cardiovascular Risk Reduction Intervention for Sexual Minority Adults

Abstract

Sexual minority (SM) adults have a higher prevalence of risk factors for cardiovascular disease (CVD), largely attributable to increased exposure to minority stressors. There are no evidence-based CVD risk reduction interventions tailored to the needs of SM adults. We conducted a qualitative descriptive study to explore SM adults’ perceptions and preferences for a culturally tailored, minority stress-informed intervention for CVD risk reduction. SM adults without CVD were interviewed and presented with a 10-week proposed intervention that combined elements of existing interventions for minority stress and CVD risk reduction. Participants were asked about preferences regarding intervention delivery methods, setting, and duration. Interviews were deductively coded into cognitive, behavioral, and socio-environmental themes informed by the Social Cognitive Theory. Themes were also inductively coded based on participant responses. The sample included 22 SM adults with a mean age of 52 (±7.16) years; approximately 55% were female-identified and 59% were non-Latinx White. Cognitive themes included recognition of stress associated with minoritized identities and self-efficacy for behavior change. Behavioral themes included stress management skills and maintaining a healthy lifestyle (e.g., exercise). Socio-environmental themes included barriers (e.g., time commitment) and facilitators (e.g., financial incentives) for participating in the proposed intervention. All participants were interested in an intervention that would improve their cardiovascular health. A majority indicated they preferred a 12-week, virtual, synchronous, group intervention. All participants endorsed the proposed intervention with particular emphasis on stress-reduction components. This study provides important knowledge that should be considered in designing tailored interventions for CVD risk reduction among SM adults.

Background

Cardiovascular disease (CVD) is the leading cause of death worldwide accounting for approximately one-third of all deaths annually.¹ There is growing evidence that sexual minority (SM; e.g., gay, lesbian, bisexual) adults experience significant cardiovascular health (CVH) disparities compared to heterosexual adults.^2,3 Prior work has shown that SM adults have a higher prevalence of several modifiable risk factors for CVD compared to their heterosexual counterparts. For instance, SM men and women have a higher prevalence of tobacco use relative to their heterosexual peers.^2–4 In addition, lesbian women and bisexual people have been shown to have a higher body mass index (BMI) than their heterosexual counterparts.^3,5 Recent studies have also shown that bisexual men and women have higher odds of hypertension compared to heterosexual adults of the same sex.^6,7 Given these CVH disparities, the National Institutes of Health and the American Heart Association have called for the development of behavioral interventions to improve the CVH of SM populations.^3,8

It is well-established that psychosocial factors (e.g., depression, anxiety) are associated with worse cardiovascular outcomes in adults.^9–11 Further, there is an extensive body of research that has documented a higher prevalence of depression and anxiety among SM adults,^12–14 which may place them at greater risk of CVD. In addition, SM individuals are exposed to societal marginalization that increases their exposure to unique psychosocial stressors related to their minority sexual orientation. These stressors are commonly referred to as minority stressors.^15,16 Minority stressors have been thoroughly examined within the context of mental health, substance use, and HIV risk among SM adults and related interventions have been shown to be effective in reducing the impact of minority stress on these outcomes.^17–20 However, a small but growing body of research has found that minority stressors are associated with increased risk of CVD among SM adults, such as a higher prevalence of tobacco use, hypertension, and physical inactivity.^21–23 Thus, interventions focused on reducing minority stress pathways to CVD among SM adults may be effective at improving their CVH.

In the general population, it is recognized that culturally tailored interventions are effective at reducing CVD risk in minoritized groups, such as racial and ethnic minority adults.^24–28 However, to date, there are no evidence-based interventions to reduce CVD risk among SM adults.³ Given the unique stigma-related stressors that affect SM individuals and based on existing intervention research, we hypothesize that a culturally tailored intervention to reduce the impact of minority stress on CVD risk in SM adults will be effective at preventing CVD in these individuals. Before developing such an intervention, it is crucial to understand the perceptions of SM adults regarding CVH and possible acceptable intervention strategies. Therefore, the purpose of this study was to explore SM adults’ perceptions and preferences for a culturally tailored, minority stress-informed intervention to reduce their CVD risk.

Methods

This qualitative descriptive study follows the Consolidated Criteria for Reporting Qualitative Studies (COREQ) standards.²⁹ Review and approval for this study and all procedures was obtained from the Institutional Review Board of the Columbia University Irving Medical Center. The study was designed and conducted by a research team that included four PhD-prepared investigators with complementary expertise in SM health, CVH, qualitative research methods, and interventions for reducing the impact of minority stress on SM individuals’ health. The team also included three graduate research assistants with prior experience conducting SM health research and who were trained in qualitative research methods by the PhD-prepared investigators. Having a diverse team reduced the risk of bias and ensured multidisciplinary perspectives.

Theoretical Framework.

Social cognitive theory (SCT) informed the interview guide (Appendix A), codebook development, and deductive content analyses (Figure 1). SCT posits that enhancing an individual’s knowledge and skills to perform a given behavior improves self-efficacy, which in turn increases likelihood that the new behavior will be maintained.³⁰ The SCT was selected as a guiding framework in order to account for the multitude of aspects that can influence behavior and behavior change, including cognitive, behavioral, and socio-environmental factors.³⁰ These factors were considered particularly important to address in a culturally tailored, minority stress-informed CVD risk reduction intervention for SM adults and were operationalized in the interview guide. Specifically, cognitive factors addressed in this study were recognition of CVD as an issue that impacts SM adults and self-efficacy for behavior change (defined as the belief in one’s ability to make a change to improve their health).³⁰ Behavioral factors referred to one’s skills or behaviors that may improve, maintain, or worsen one’s CVH (e.g., “self-management” skills like engagement in physical activity, maintaining a healthy diet, and stress management).³⁰ Finally, socio-environmental factors included barriers and facilitators to making a change in their CVH, as well as participants’ preferences for a CVD risk reduction intervention.

Figure 1.

Social Cognitive Theory applied to the cardiovascular health of sexual minority adults.

Sample

Between July and November 2021, SM adults were recruited via online advertisements on Facebook and ResearchMatch, a national health volunteer registry created by several academic institutions and supported by the U.S. National Institutes of Health as part of the Clinical Translational Science Award program. ResearchMatch has a large population of volunteers who have consented to be contacted by researchers about health studies for which they may be eligible.

Prior to enrolling in the study, individuals completed an online screener that assessed demographic characteristics and medical history to determine eligibility. The online screener assessed age (in years), race (American Indian or Alaska Native; Asian or Pacific Islander; bi-racial or multi-racial; Black or African-American; White) ethnicity (Latinx vs. non-Latinx), and education (less than high school; high school or GED; some college/2-year college; Bachelor’s degree; graduate or professional school). Geographic location was categorized based on participants’ state of residence (Midwest; Northeast; South; West). Following recommendations for assessing sexual orientation identity, participants were asked: “Which of the following best represents how you think of yourself?” Responses were straight/heterosexual, lesbian, gay, bisexual, queer, same-gender loving, or another (please specify).³¹ To identify if individuals were gender minority (e.g., transgender, non-binary), we used the recommended 2-step approach that first assessed sex assigned at birth (responses included female, male, intersex, or other [please specific]) followed by gender identity (responses included woman, man, transgender woman, transgender man, non-binary, genderqueer, or another [please specify]).³¹ Participants whose sex assigned at birth aligned with their gender identity were classified as cisgender (i.e., non-transgender).³¹ The online screener also assessed whether individuals had a history of CVD (i.e., coronary artery disease, heart attack, heart failure, stroke).

Eligibility Criteria

Based on responses to the screener, English-speaking, SM-identified, community-dwelling cisgender adults between the ages of 35–64 living in the United States who reported no history of CVD were purposively sampled. We excluded participants with a history of CVD because the focus of the intervention was on primary and secondary prevention of CVD. We did not exclude individuals based on self-report of existing CVD risk factors (e.g., tobacco use, hypertension). Although CVD diagnosis most commonly occurs after the sixth decade of life,³² we chose to focus on midlife as it is a critical period for CVD prevention. The onset of CVD risk factors, such as hypertension and diabetes, is common during midlife.^33,34 Therefore, risk of future CVD events (e.g., heart attack) increases substantially in the years following mid-life. We also excluded gender minority persons because of their unique CVD risk factor profile (e.g., use of gender-affirming hormones) compared to cisgender adults.³⁵

Procedures and Measures

Semi-structured, one-on-one interviews were conducted via telephone or videoconferencing to explore SM adults’ perceptions regarding minority stress and CVH, as well as their preferences for an intervention for CVD risk reduction. After providing electronic informed consent, a research assistant administered a structured interview to assess participants’ self-reported CVD risk factors. Current tobacco use was assessed by asking participants if they currently smoked cigarettes “every day,” “some days,” or “not at all.” Responses to current tobacco use were dichotomized (yes vs. no). We used the 2-item Exercise Vital Sign, a valid and reliable measure of physical activity, to assess participants’ average moderate and vigorous activity per week.³⁶ Physical activity was classified based on recommendations for adult aerobic physical activity from the Centers for Disease Control and Prevention,³⁷ which consist of greater than or equal to 150 minutes of moderate or vigorous exercise in an average week (yes vs. no). We used an item from the National Health Interview Survey to assess sleep duration. Participants were asked: “On average, how many hours of sleep do you get in a 24-hour period?” Following recommendations from the National Sleep Foundation,³⁸ responses were dichotomized to create a variable for short sleep duration which was defined as sleeping less than 7 hours per night (yes vs. no). Further, using established recommendations, participants were classified as meeting criteria for obesity (body mass index [BMI] greater than or equal to 30 kg/m²) based on their self-reported height and weight.³⁹ In addition, three separate items from the National Health and Nutrition Examination Survey were used to assess if participants had ever been told by a healthcare professional that they had hypertension (also called high blood pressure), diabetes, and high cholesterol. Responses to the three items were dichotomous (yes vs. no). The 2-item Patient Health Questionnaire (PHQ-2) was used to assess depressive symptoms.⁴⁰ Cronbach’s alpha for the PHQ-2 in the present sample was 0.86. Participants with PHQ-2 scores of three or greater were classified as meeting criteria for probable depression.⁴⁰

A semi-structured one-on-one interview lasting approximately 45–60 minutes was conducted by a trained research assistant. Participants were asked about their CVD risk behaviors and perceptions of a proposed intervention that included elements of 2 existing interventions: one to reduce the impact of minority stress among SM adults and one focused on CVD risk reduction (Table 1).^17–19,41 Consistent with the SCT, the proposed intervention addressed cognitive, behavioral, and socio-environmental factors that influence behavior change in individuals. Minority stress reduction components of the sample intervention were adapted from an evidence-based 10-session skill-building intervention to improve the mental and sexual health of SM adults.^17–19 CVD risk reduction components of the proposed intervention were adapted from an extensively tested behavioral intervention to reduce CVD risk among racial and ethnic minority adults.⁴¹ The existing minority stress and CVD risk reduction interventions served as a guide for creating a culturally responsive CVD risk reduction intervention to the specific needs of SM adults, for whom such an intervention is yet to be developed. Although the minority stress components have been previously tested in SM adults, the CVD risk reduction components have only been tested in other marginalized groups. Therefore, rather than developing an untested CVD risk reduction intervention, we sought to adapt one that had been previously successful at reducing CVD risk in marginalized people.

Table 1.

Sample intervention.

Week	Topic	Cardiovascular health content	Minority stress reduction content
1	Introduction to Promoting Heart Health in Sexual Minority People	A day in your life; Smoking & alcohol consumption	Motivating engagement in the intervention
2	Physical Activity	Sample walking program	Explaining emotional impact of minority stress
3	Controlling Blood Pressure	Places to get blood pressure checked; Blood pressure log; Your food choices	Tracking stress related experiences
4	Cholesterol	Reading food labels; Alternate recipes	Increase awareness of minority-stress related experiences
5	Healthy Weight & Healthy Eating	Tips to maintain healthy weight, healthy serving size; grocery list; Tips to save time & money; Tips for eating out heart healthy	Cognitive correlates of minority stress & developing alternative appraisals
6	Diabetes	Places for glucose checks; “Am I at risk for type 2 diabetes?”	Addressing emotion avoidance tendencies maintained by minority stress
7	Increasing Physical Activity	Fun physical activities	Connecting minority stress to emotion-driven behaviors
8	Motivation & Assertiveness	Tips to motivate you to be physically active	Assertiveness training
9	Barriers & Problem Solving	Heart healthy lottery; Tips for getting enough sleep	New reactions to stress
10	Conflict Resolution	Light weights & stretch bands for home use	Self-affirmation

Recruitment continued until data saturation occurred, meaning that subsequent interviews were unlikely to generate new knowledge.⁴² Data saturation was reached after completing 22 interviews, which is concordant with recommended standards of qualitative research.⁴³ All interviews were audio-recorded, de-identified, and transcribed by a third-party transcription service. The accuracy of each transcript was verified by 2 research assistants. Participants were compensated $50 for their time.

Several strategies were used to enhance rigor of data collection, including clear eligibility criteria (as described above), using an iteratively-developed codebook to guide our coding, and holding weekly team meetings to debrief and maintain fidelity to the interview guide.⁴⁴

Data Management and Analysis

We assessed frequencies, means, and distributions of demographic variables to characterize the sample, support the transferability of study findings, and contextualize themes. We conducted directed deductive content analysis using a codebook comprised of initial a priori codes informed by the SCT³⁰ and our intervention adaptation. Responses that were not anticipated in the a priori codes (i.e., those that were not coded to constructs of the SCT) were analyzed using inductive coding.⁴⁵ Deductive content analysis was selected because this study had a very specific objective and questions that needed to be addressed to inform a CVD risk reduction intervention for SM adults.⁴⁵ All transcripts were double-coded by 2 members of the research team. Any discrepancies between coders were resolved by group consensus. Deductive codes were mapped to SCT constructs and similar inductive codes were organized into categories. Intercoder reliability was performed by 2 independent reviewers on all transcripts to calculate a κ coefficient for the deductive codes. NVivo12 Software was used to manage and analyze data. We use the following descriptors to indicate the percent of participants that endorsed each code: “most” or “a majority” (represent about 75% of participants), “half” (represents about 50% of participants), and “some” or “a few” (represent about 25% of participants).

Results

The study included 22 SM individuals with a mean age of 52 years (±7.16; range 39–64). Participant characteristics are described in Table 2. Overall, current tobacco use was low (n = 3). The most common CVD risk factors were high cholesterol (45%), probable depression (45%), hypertension (27%), short sleep duration (27%), physical inactivity (23%), and obesity (23%). Only one participant reported having a history of diabetes. Participants met criteria for 0–4 CVD risk factors. Approximately 86% of participants reported having one or more CVD risk factor and 68% met criteria for two or more CVD risk factors. Intercoder reliability was near perfect (mean κ = 0.98; range, 0.88–1.00) for deductive codes, which were organized according to the SCT (Figure 1). Each theme was discussed by all participants.

Table 2.

Participant characteristics.

Demographics	Total (n=22)
Age (years), mean (SD)	51.8 (7.16)
Female gender, n (%)	12 (55%)
Sexual identity, n (%)
Lesbian	7 (32%)
Gay	8 (36%)
Bisexual	7 (32%)
Queer	0 (0%)
Same-gender loving	0 (0%)
Race, n (%)
American Indian or Alaska Native	0 (0%)
Asian or Pacific Islander	3 (14%)
Black or African-American	4 (18%)
Bi-racial or multi-racial	2 (9%)
White	13 (59%)
Latinx ethnicity, n (%)	1 (4%)
Education, n (%)
Less than high school	0 (0%)
High school/GED	0 (0%)
Some college/2-year college	4 (18%)
Bachelor’s degree	7 (32%)
Graduate or professional school	11 (50%)
Geographic region, n (%)
Midwest	4 (18%)
Northeast	8 (36%)
South	7 (32%)
West	3 (14%)
Health insurance coverage, n (%)	19 (86%)
CVD Risk Factors
Current tobacco use, n (%)	3 (14%)
Does not meet aerobic physical activity recommendations, n (%)	5 (23%)
Short sleep duration (<7 hours per night), n (%)	6 (27%)
Obese (BMI ≥ 30.0 kg/m2), n (%)	5 (23%)
Hypertension, n (%)	6 (27%)
Diabetes, n (%)	1 (0.5%)
High cholesterol, n (%)	10 (45%)
Probable depression, n (%)	10 (45%)

Cognitive Factors

Based on most frequent responses, we identified two primary cognitive factors that must be included in a CVD risk reduction intervention for SM adults, namely recognition of stress associated with minoritized identities and self-efficacy.

Recognition of stress associated with minoritized identities.

A majority of participants stated their sexual orientation identity was “moderately” to “very important” to their daily lives but reported that it was only one dimension of their identity. For example, one participant described their sexual orientation identity as: “…very important, but…I feel like it’s important because society thinks that it’s important. It’s not entirely part of my own personal definition. I don’t say I do this because I’m a lesbian. It’s just kind of… it’s a way that I am different, I guess, but I don’t feel like it defines me, if that makes sense. I feel like I’m being told that it defines me rather than I feel like it defines me.” Additionally, participants consistently reported experiencing minority stress related to their sexual orientation identity, with one participant simply stating, “…it’s just, it’s stressful living in a straight world being a gay person.”

Most participants endorsed other minoritized identities (e.g., race, gender) and described how their multiple minoritized identities interacted to create a unique intersectional experiences. Additionally, many participants commented on the prejudices they now face due to older age. However, one participant described age as a protective factor against anti-SM violence stating, “I don’t really have much of a problem anymore… I’m an old f*g so people tend not to play with me...” In contrast, a few female-identified participants reported their gender was a source of stress, while many participants of color indicated their race was a more salient minoritized identity for them than their sexual orientation identity. One participant asserted, “This has changed as I’ve gotten older, but… my identity as an Indian American is more important to me than my LGBT identity.”

Self-efficacy.

Most participants indicated they were “very likely” to make changes in health behaviors if so advised. For instance, they were willing to make moderate changes to their diet or physical activity. They were, however, unwilling to make changes that were considered time-intensive or that compromise their values (e.g., veganism). “If the modifications were small and incremental, then …I would be able and willing. If it was a dramatic change, then … I would be quite resistant.”

Regarding the proposed intervention, some were concerned about costs associated with the intervention. Interested participants identified the need to improve their CVH and reduce stress as motivators for participating in an intervention. Despite the high prevalence of CVD risk factors in this sample, a few participants indicated their current state of good health was a reason for not wanting to participate in an CVD risk reduction intervention. “It’s been on the periphery. I haven’t been diagnosed with any heart ailments or stress. It would be awesome if I never had that [problem] and just my own lifestyle keeps me healthy.”

Behavioral Factors

Behavioral factors refer to factors that would improve, maintain, or worsen one’s CVH (e.g., stress management, physical activity, diet). Relevant themes under this domain were stress management skills and maintaining a healthy lifestyle.

Stress management skills.

Many participants reported using avoidant strategies to manage their stress. Although a few of these strategies could be considered maladaptive (e.g., compartmentalizing and using alcohol or drugs), participants deemed most of these as adaptive at least in the short-term. Their long-term effectiveness was not described. Approximately half of participants reported using complementary and alternative therapies (e.g., yoga, mindfulness) for stress management, while the other half found these strategies to be ineffective or inconvenient to their daily routines. Other strategies that were deemed adaptive included were physical activity, positive mantras, painting, journaling, music, and simply taking breaks from known stressors, such as avoiding social media or stressors at home.

“My main [thing] is I just don’t engage... So I’d get away from the stress if it’s stressful… [like if] it’s my partner...I’ll take a walk, that’s a good time to take the dog for a walk …so, certainly kind of walk away is part of it...”

A majority of participants explained that they relied on physical activity to manage stress. While they recognized its physical health benefits, most participants mentioned improving mental health as the main reason for staying active. Some engaged in anaerobic strength training, but the majority discussed aerobic physical activity, such as walking, running, and bicycling.

“… daily exercise and movement play a huge role in [stress management]. Not only in improving a lot of the physical soreness and tightness and diminishing mobility but also with mindset. I’ve kind of brought two of those things together. For movement, I’m doing low impact aerobics. And then for … getting in a head space that is just more restful and mindful and calm and peaceful, I’ve been also doing beginner yoga…”

Maintaining a healthy lifestyle.

The majority of participants mentioned diet followed by physical activity as important for maintaining a healthy lifestyle. In particular, they mentioned choosing healthier food options (e.g., increasing fruit and vegetable intake, portion control). In addition, many participants indicated they avoided unhealthy behaviors (e.g., tobacco and alcohol use) and attempted to get enough sleep. “I exercise, try to get enough sleep…I do try to eat healthy, I try to like get in more fruits and vegetables, like make a deliberate focus…, and drinking enough water.”

Socio-Environmental Factors

Of the multiple socio-environmental factors described in the SCT (e.g., social support, normative beliefs, and incentive motivation), participants mostly discussed barriers and facilitators to improving their CVH. Table 3 and Figure 2 summarize participants’ intervention modality preferences for a CVD risk reduction intervention, as described below.

Table 3.

Participants’ intervention modality preferences for a cardiovascular disease risk reduction intervention.

Intervention Modality	Summary of Preference	Salient Quote
Delivery method	When asked about preferred delivery method, responses were mixed. Some participants indicated they preferred a group intervention, others preferred a one-on-one intervention, and a few said they had no preference.	“I think you can gain from other people who have similar experiences, and sometimes you’re more motivated when you’re with other people than by yourself.” “…generally I usually don’t do things in groups. The older I get, the more I just don’t like people…”
Delivery setting	Participants were largely ambivalent about the delivery setting. They noted the pros and cons of both virtual and in-person formats; however, a majority of participants indicated they preferred a virtual and synchronous format due to its convenience.	“I like both ideas…the online option is something that could be really plausible. It’s more convenient to not have to leave home to do it. But then again, the option of going in person, you’re able to communicate with other people who are doing the same thing. There’s that interaction thing. I would probably be torn between the two really. But I see advantages of both.”
Individual session duration	Almost all participants preferred sessions less than an hour. Many participants preferred 60-minutes to fully delve into the content of the session.	“…an hour probably [is best], because after that I would say, ‘Okay, done, enough…I need a break.’”
Intervention duration	Participants were shown a 10-week sample intervention; however, the majority recommended a longer intervention (12-weeks) as it would permit sufficient time for developing sustainable lifestyle changes.	“I would say that it’s like the minimum. I think I would need at least 8 weeks to like feel like it’s making a change, it’s making a permanent change or a significant change. I think 8 to 12 weeks is a good like number, like 12 weeks, I think beyond that like going into like 16 weeks is, it’s like asking a lot you know like because what if you hate it, whatever it is, like 16 weeks is like ugh.”

Figure 2.

Participants’ intervention modality preferences for a cardiovascular disease risk reduction intervention.

Barriers.

The most common barrier to achieving a healthy lifestyle was the time commitment. A major concern of some participants was adherence to a healthy lifestyle, both generally, and specifically regarding the proposed intervention. One participant indicated “Finding that time [is a barrier] because it means taking time away from things that I enjoy or would rather do.” Regarding physical activity, another participant stated “actually time is one big [barrier] for exercise. So right now… I work from home so I can make time for exercise, but in the near future it would be very difficult for me to do exercise regularly.”

Facilitators.

Facilitators or motivating factors for participating in the intervention included financial compensation or incentives, such as free groceries or pre-prepared meals. Many stated that sharing evidence-based information would motivate them and increase their trust in the intervention. Tracking CVH metrics, such as blood pressure, cholesterol, and weight, before and after the intervention, was stated as another motivator. One participant stated, “I’m a numbers person, so if I see the number and [the] progress that I made, it’ll really motivate me.” In addition, the presence of social interaction and stress reduction were also motivators for participating in the proposed intervention for some, with one participant stating, “social interaction would motivate me to join…perhaps make me less irritable around my colleagues.”

Table 3 summarizes participants’ preferences for intervention modality preferences including delivery method (e.g., group vs. one-on-one), delivery setting (e.g., in-person vs. virtual), individual session duration, and intervention duration (e.g., 10-week vs. longer duration). Briefly, one-third of participants preferred a group intervention, one-third preferred a one-on-one intervention, and one-third had no preference for intervention delivery. Regarding delivery setting, the majority of participants preferred a virtual intervention. When asked about the duration of individual intervention sessions, the majority indicated that 60-minute sessions would be most appropriate. The majority of participants also preferred an intervention longer than the 10-week proposed intervention as many thought longer participation in the intervention would increase their ability to maintain lifestyle changes.

Proposed Intervention

Intervention components endorsed.

Overall, after being shown the proposed intervention (Table 1), participants’ impressions of the proposed intervention were overwhelmingly positive. All participants viewed the combined elements of existing interventions for minority stress and CVD risk reduction favorably. Most participants expressed enthusiasm about stress management strategies provided by the minority stress-based intervention. Regarding CVH content, participants were most interested in intervention content related to “controlling blood pressure,” “cholesterol,” and “healthy weight and healthy eating.” As reported by one participant, “It seems to cover a lot of different aspects… some of the stress management related activities sound interesting to me… anything with cholesterol is good too because I do have that problem. And the blood pressure.”

Intervention components not endorsed.

Criticisms of the proposed intervention focused largely on how some participants felt that not all components were applicable to them. Many were not interested in participating in sessions related to conditions with which they had not been diagnosed, such as sessions on diabetes or high cholesterol. As one participant indicated, “…fortunately [I] don’t have any problem with diabetes…the rest of it seems pretty interesting to me… I [also] don’t have any problem with… smoking and alcohol.”

Discussion

The purpose of this study was to explore SM adults’ perceptions and preferences of a culturally tailored, minority stress-informed CVD risk reduction intervention. Consistent with the SCT, findings uncovered several cognitive, behavioral, and socio-environmental factors that should be addressed in the development of an intervention to prevent CVD risk among SM adults. These data provide important knowledge for intervention development.

Cognitively, we found that some participants minimized the significance of their sexual orientation identity in their lives. There are several potential explanations for this. First, the lower perceived significance of sexual orientation identity to their lives may be related to a sense of internalized homophobia and/or due to their generational understanding of their identity as the sample was middle-aged. Second, considering intersectionality, it is likely that participants who endorsed having multiple minoritized identities experienced stress related to one or more of those other identities more strongly than their sexual orientation identity. This is supported by statements from participants who identified their older age and gender as more salient identities than their sexual orientation identity. In addition, although more than two-thirds of participants reported multiple CVD risk factors, they generally lacked awareness of existing research indicating SM adults have higher CVD risk than heterosexual adults. These findings are crucial to informing future interventions because, as described in the SCT and the minority stress model, awareness of one’s elevated risk of poor health outcomes (e.g., CVD, depression) is vital for actively engaging in behavior change and for attributing stressors to outside sources of stigma and discrimination, rather than to something for which one is responsible. Participants in the present study were middle-aged and were therefore at increased risk of developing CVD due to their age. Within the SCT, knowledge of the problem and insight into its personal relevance are critical components for behavior change.³⁰ In the general population, it is known that many people with CVD risk factors lack insight into their elevated risk,^46–48 and lack of awareness is associated with reduced heart-healthy behaviors (e.g., physical activity and healthy diet).⁴⁹ Similarly, SM individuals may not be able to attribute experienced stressors to societal stigma against their identities until they may engage in the type of intervention proposed here. Therefore, the tailored intervention needs to include content describing CVH disparities among SM adults and clarifying the intervention’s goal to reduce those disparities by addressing minority stress within the initial session. This approach is already built into the minority stress risk reduction intervention.^17–19 Failure to emphasize and raise awareness of the elevated CVD risk among SM adults could result in reduced intervention engagement.

Behaviorally, participants reported using several stress reduction strategies that have been shown to be effective at reducing psychological and behavioral risk factors for CVD in prior interventions.^50,51 Participants indicated they were willing to make changes to improve their CVH if the changes were not too time-consuming. They were also interested in participating in a CVD risk reduction intervention, primarily due to their advancing age rather than their sexual orientation identity. Although approximately 68% of participants had two or more CVD risk factors, many participants indicated their current state of good health made it unnecessary for them to participate in the proposed intervention. This suggests a lack of awareness of CVD risk but also that participants may be at different stages of readiness to engage in behavior change due to their perceived risk of developing CVD. Nevertheless, participants were generally supportive of the proposed intervention components, particularly stress reduction strategies. However, several participants asked if they could skip sessions focused on CVD risk factors they did not believe applied to them. Findings demonstrate the need to increase participants’ awareness of the importance of primary and secondary prevention for CVD across one’s life course. Rather than focusing on CVD risk factors that participants already exhibit, it is important to educate participants that a CVD risk reduction intervention can be helpful to prevent CVD risk factors that have yet to develop. This could be an important ingredient for the proposed CVD risk reduction intervention that could enhance participants’ readiness for behavior change. Further refinement of this proposed intervention needs to address these behavioral factors informed by the SCT.

Socio-environment factors also play an important role in behavior change.³⁰ Participants most often discussed time as the biggest barrier to maintaining a healthy lifestyle or taking part in an intervention. However, most participants paradoxically preferred a 12-week intervention, when presented with our shorter 10-week proposed intervention, because it was considered more comprehensive and more likely to result in lasting behavior change. In fact, their preference was in alignment with similar behavioral interventions for CVD risk reduction, which were 12 weeks in duration or less,^24,25 and aligned with the current configuration of the minority stress-based intervention.^17–19 Consistent with the SCT, these socio-environmental factors will inform further development of the proposed intervention and will address the identified barriers and facilitators for participating in a CVD risk reduction intervention. In particular, the intervention must address barriers to participation and maintenance of behavior change.

Findings from our study provide valuable information for clinicians’ efforts to address CVD risk in SM adults. Although SM middle-aged adults in the present study had high levels of education and health insurance coverage, they generally lacked awareness of their CVD risk and the importance of prevention efforts to reduce their CVD risk. This suggests that their clinicians may not be emphasizing the importance of CVD risk reduction during routine health visits. Findings indicate that clinicians should provide SM middle-aged adults with tailored education about their current and future risk of CVD. It is also important for clinicians to be educated about the growing evidence of increased CVD risk among SM adults. This could improve their efforts to screen prevent, and manage CVD risk factors in SM patients. Providing clinicians with an intervention that addresses both CVD risk and minority stress, and that was created with input from the SM community and tested for acceptability, feasibility and efficacy would be highly beneficial for clinical practice.

As such, this study is an important step in informing future interventions for CVD risk reduction tailored to SM adults. Given that the participant sample was diverse in terms of gender, race, sexual orientation identity, and geography, our results have important implications for the design of future patient-centered interventions for SM adults. Further, it is important that future interventions incorporate the perspectives of healthcare professionals and community groups serving the SM community. Future qualitative work is needed to better understand how such an intervention can be feasibly and sustainably implemented within clinical and community-based settings.

Despite its strengths, this study has several limitations. There were no interview questions focused on participant preferences regarding who should deliver the intervention (e.g., nurses, psychologists, physicians, SM-identifying community health workers). Considering who will deliver an intervention tailored for marginalized people is an important factor that may impact participation rates in an intervention. However, our prior intervention work with SM individuals indicates that identities of interventionists are not important if they are LGBTQ-affirming and competent in intervention content and delivery style.^52,53 Further, although the interview guide was informed by prior evidence and the SCT, which allowed us to uncover the most important topics for future interventions, this also inherently narrowed the focus of the interviews conducted. However, interviewers provided participants with several opportunities to express their thoughts outside of the interview guide, lowering the threat of this limitation. Additionally, the participant population was highly educated (~82% college graduates) and had high rates of health insurance (86%). Regarding risk factors, this sample was more likely to take part in adequate exercise, had a lower prevalence of diabetes, and may be healthier than the general population of SM adults. Together, these factors may limit the generalizability of results. Lastly, individuals who respond to online advertisements about SM health research may be different from their counterparts, introducing selection bias. Social desirability may have also influenced responses regarding participants’ opinions about the proposed intervention.

Conclusion

This study explored SM adults’ perceptions and preferences for a culturally tailored, minority stress-informed intervention for CVD risk reduction in a purposive sample of diverse individuals. Given that the participant sample was diverse in terms of gender, race, sexual orientation identity, and geography, our results have important implications for the design of future patient-centered interventions for CVD risk reduction among SM adults. By exploring the cognitive, behavioral, and socio-environmental factors that influence the CVH of SM individuals, this study provides a greater understanding of factors that impact behavior change and that must be addressed to develop a culturally tailored intervention for CVD risk reduction. Further, future interventions must incorporate the perspectives of healthcare professionals and community groups serving the SM community. Lastly, upon demonstration of efficacy, future research is needed to understand how such an intervention may be scaled and implemented within clinical and community-based settings.

Public Health Significance:

To our knowledge, this study is the first qualitative study describing sexual minority adults’ perceptions and preferences for a culturally tailored, minority stress-informed intervention for cardiovascular disease risk reduction. Findings provide the groundwork for a future intervention that will reflect the values and health needs of the sexual minority community, which is likely to increase its population resonance.