The Cardiovascular Disease Epidemic in African American Women: Recognizing and Tackling a Persistent Problem

African American women have the highest cardiovascular disease burden compared with women of other ethnic groups.¹ Cardiovascular disease affects 47.3% of African American women, and African American women have the highest rates of hypertension, stroke, heart failure, and coronary artery disease observed among women in the United States.¹ Health disparities exist across a wide range of sociodemographic positions in African American women.² Cardiovascular disease rates are related to systemic disadvantages from discrimination, exclusion from health trials, inequities in access to health care resources,³ and social determinants of health.⁴ To be effective, interventions aimed at promoting cardiovascular health in African American women must collectively address the social and environmental challenges that face this population.

In this issue of the Journal of Women's Health, White et al. have presented an integrative review of interventions aimed at reducing cardiovascular disease in African American women.⁵ Inclusion criteria included interventions that improved cardiovascular health literacy and/or reported outcome measures on two or more cardiovascular disease-related health promotion areas. They included 16 peer-reviewed articles that addressed 14 interventions in adult African American women <65 years of age. Cardiovascular disease health promotion areas included components of the American Heart Association's “Life's Simple 7”: tobacco cessation, daily physical activity, good nutrition, and achieving goal body weight, total cholesterol, blood pressure, and fasting blood glucose. Most of the interventions in White et al.'s review targeted behavioral risk factors such as physical activity and nutrition, which are important factors contributing to racial and ethnic disparities in cardiovascular disease.^6,7 No U.S. racial or ethnic group has >30% of its population achieve ideal cardiovascular health practices,¹ and African American women are the least likely to participate in behaviors that reduce cardiovascular disease such as having a healthy diet and regular exercise.⁸ African American women usually have multiple risk factors,⁷ and the greatest benefits are often observed when multiple cardiovascular disease risk factors are addressed concurrently.^7,8

In White et al.'s review, the majority of behavioral interventions were tailored to the African American woman using health behavioral theories.⁵ The most used health behavior theory was social cognitive theory, which changes behavior through “observational learning, reinforcement, self-control, and self-efficacy.”⁹ Social cognitive theory interweaves an individual's experience and environment to change behavior. Each study in this review was successful at either improving health literacy or at improving a cardiovascular health promotion area. In whole, these studies combined the strengths of the African American community and culture to address the social and environmental needs of African American women (Fig. 1). The African American community defined pertinent parts of the African American culture that relate to behavior, such as spirituality, views of self, and foods enjoyed. Community and academic resources were used to develop interventions that address individual needs: childcare, transportation, urban/rural needs, flexibility for timing of clinic visits and health promotion activities, safe places to exercise, and healthy food availability. Importantly, the African American communities recognized the barriers to cardiovascular health promotion and identified ways to overcome these barriers.

FIG. 1.

Tailored care for African American women with CVD. Successful modes of treatment identified in White et al.'s integrative review.⁵ CVD, cardiovascular disease.

The results of this review are consistent with those from other studies that have demonstrated a positive impact of tailored health behavior interventions in improving risk factors in African American communities.⁶ The Centers for Disease Control and Prevention Racial and Ethnic Approaches to community health (REACH) program has funded communities to develop interventions that successfully result in reduced cardiovascular disease risk.¹⁰ To be maximally effective, tailored interventions must prioritize African American women as individuals and appropriately manage their unique needs.

Recognizing and Tackling a Persistent Problem

Cardiovascular health inequities are partially explained by social and economic factors.² The African American woman's position in the society is a consequence of chronic institutional and cultural oppression.² Perceptions of hopelessness, inequality, police brutality, and social justice generate minority stress that increases susceptibility to cardiovascular disease risk factors.¹¹ Limited education leads to low income from discriminatory employment and poor compensation practices.² This contributes to inadequate health insurance, which is a major barrier to health care access in African American women. Racial residential segregation, a byproduct of economic stratification, also places African American women at increased risk of exposure to damaging environments.⁴ Irrespective of education level, African Americans are at higher risk of poor health outcomes compared with whites.¹¹ Health care clinician bias also contributes to worsened outcomes.¹²

A multifaceted approach to cardiovascular disease prevention that acknowledges and integrates culturally tailored strategies may be more successful in reducing racial and ethnic disparities.³ The individual experiences of each women must be addressed to successfully deliver care. Health care programs designed for improving cardiovascular health among African American women should address social and environmental factors.²

Conclusions

To successfully combat the cardiovascular disease epidemic in African American women, health promotion programs must simultaneously address multiple cardiovascular disease risk factors that are frequently coexisting in this population. Health care providers must be educated on how to adapt their practices to accommodate vulnerable populations. Successful government reforms must address the gaps in income, education, and residential environments while also providing equity in social justice and advancements for the personal growth and development of African American women.

Funding Information

K.B. received support from the National Heart, Lung, and Blood Institute K01HL142848, University of Arizona Health Sciences, Strategic Priorities Faculty Initiative Grant, and University of Arizona, Sarver Heart Center, Women of Color Heart Health Education Committee.