Abstract
Objective:
To assess cardiovascular disease (CVD) and CVD risk factors and their association with socio-demographic characteristics and health beliefs among African-American (AA) adults in Minnesota.
Methods:
A cross-sectional analysis was conducted of a community-based sample of AAs enrolled in the Minnesota Heart Health Program Ask About Aspirin Study from May 2019 to September 2019. Socio-demographics, health beliefs, and self-reported CVD and CVD risk factors were collected. Prevalence ratio (PR) estimates were calculated using Poisson regression modeling to assess the association between participant characteristics and age/sex-adjusted CVD risk factors.
Results:
The sample included 644 individuals (64% women) with a mean age of 61 years. CVD risk factors were common: hypertension (68%), hyperlipidemia (47%), diabetes (34%) and current cigarette smoking (25%); 18% had CVD. Those with greater perceived CVD risk had a higher likelihood of prevalent hyperlipidemia (PR 1.34, [95% CI 1.14-1.57]), diabetes (PR 1.61 [1.30-1.98]) and CVD (PR 1.61 [1.16-2.23]) compared to those with lower perceived risk. Trust in healthcare provider was high (83%) but was not associated with CVD or CVD risk factors.
Conclusions:
In this community sample of AAs in Minnesota, CVD risk factors were high as was trust in healthcare providers. Those with greater CVD risk perceptions had higher CVD prevalence. Consideration of socio-demographic and psychosocial influences on CVD and CVD risk factors could inform development of effective cardiovascular health promotion interventions in the AA Minnesota community.
Keywords: cardiovascular risk, cardiovascular disease, psychosocial factors, social determinants of health, African-Americans
Introduction
Minnesota (MN) has the lowest age-adjusted heart disease mortality in the United States.1 Yet, disparities in cardiovascular disease (CVD) exist in MN, with African-American (AA) adults ages 35-64 years having nearly double the rate of cardiovascular (CV) mortality compared to their White counterparts.2 Furthermore, AAs have higher rates of CVD risk factors than Whites including physical inactivity, poor diet, hypertension, diabetes, and obesity.3 Thus, there is a crucial need for primary prevention efforts to alleviate the burden of cardiometabolic factors which place AAs in MN at higher risk for CVD. There are several examples of small and large-scale, community-based interventions that target health behaviors to improve CV health by lowering blood pressure, increasing physical activity and promoting healthy eating among AAs.4–7 However, there is little integration of these programs within AA communities in MN; prior studies have focused solely on one sector of the Black community, namely, African immigrants/refugees.8,9
A recent analysis suggested that AAs in the Minnesota Heart Survey (MHS) have a lower CV mortality rate compared with those in the Atherosclerosis Risk in Communities Study (ARIC, recruiting primarily in the southern United States) largely due to lower risk factors at baseline.10 A more contemporary study of AAs enrolled in the Minnesota Heart Health Program (MHHP) Ask About Aspirin Study revealed a higher CV risk factor burden among participants at baseline than those within the MHS.11 However, there is limited knowledge on psychosocial factors associated with CVD and CVD risk factors among AAs in MN. To address this gap, we assessed self-reported CVD and CVD risk factors and their association with sociodemographic characteristics and health beliefs among AA adults enrolled in the MHHP Study.
Methods
Study Population and Data Collection
In the MHHP Study, trained community health workers recruited study participants, ages 45-79 years from May to September 2019 in the Minneapolis-Saint Paul (MSP), MN metropolitan (urban) area. Enrollment sites included community health fairs, churches, community centers, gyms and senior housing apartments. After obtaining verbal consent, community health workers administered a 10-minute survey including socio-demographics, CVD history and risk factors and beliefs about health and prevention. All participants were offered a $10 gift card for participation. The University of Minnesota Institutional Review Board reviewed and approved this study.
A total of 795 participants enrolled in the MHHP Study. This analysis included 644 adults who self-identified as either Black or AA. Excluded participants consisted of those who did not identify as Black or AA (n=149), were outside the pre-specified age range of 45-79 years (n=1), or reported sex other than male/female (n=1).
Study Variables
CVD and risk factors
Prevalent CVD and CVD risk factors were assessed by self-report. Positive CVD history included any “Yes” response to the following: Have you ever been told by a doctor or other health professional that you had i) coronary artery disease (CAD) or a heart attack; ii) a stroke; iii) peripheral artery disease (PAD) or blockages in your leg arteries or decreased blood flow to your legs; iv) revascularization or a procedure to open up or bypass blocked arteries in your heart, leg, or neck? The survey included questions to assess CVD risk factors by querying, “Have you ever been told by a doctor or other health professional that you had i) high blood pressure; ii) high blood cholesterol; iii) diabetes?” and to those who smoked more than 100 cigarettes in a lifetime “Do you smoke at present?” These questions were based on other national and statewide surveys evaluating self-reported CVD risk factors.12–14
Psychosocial factors
Sociodemographic factors included age, sex (male/female), marital status and educational attainment. Age was assessed as both continuous and categorical (45-49, 50-59, 60-69, 70-79 years) variables. Marital status was categorized as single, married, separated/divorced or widowed. Educational attainment level was classified as less than a high school degree, high school graduate, some college, or college/graduate school completion. Four health belief items were assessed: (1) self-awareness of actions on health (“Your decisions and actions can have a positive effect on your health”); (2) trust in healthcare provider (“You completely trust your doctor’s decisions about which treatments are best for you”); (3) importance of CVD prevention (“Preventing a heart attack or stroke is very important to you”); and (4) CVD risk perception (“Your chances of getting a heart attack or stroke in the next few years are great”). Response options for each item used a 4-point Likert Scale (strongly disagree to strongly agree) with an additional response of “don’t know”. There were three missing responses to question 3 (importance of CVD prevention) and two missing responses to question 4 (CVD risk perception); these were coded as “don’t know” responses. Affirmative (strongly agree, somewhat agree) and negative (somewhat disagree, strongly disagree, “don’t know”) responses were combined to form a dichotomous variable.
Statistical Analysis
Descriptive data were stratified by sex and presented as n (%) for categorical data and mean (standard deviation [SD]) for age. Sex differences in the descriptive data were tested using chi squared and student t test for categorical and continuous data respectively. Poisson regression modeling with robust error variance was used to evaluate associations between participant characteristics and CVD risk factors, adjusting for age and sex. Poisson regression was also used to examine prevalence ratios (PRs) between participant characteristics and self-reported CVD. This analysis included the following models: an unadjusted model; model 1 adjusted for age and sex; and model 2 adjusted for model 1 plus CVD risk factors (cigarette smoking, hypertension, hyperlipidemia and diabetes). For all models, those with affirmative responses to the health belief questions were compared to those with a negative or “don’t know” response. All analyses were performed using Stata version 16 (Stata Corp, College Station, Texas, USA).
Results
Study Sample
Table 1 displays the participant socio-demographic characteristics and health beliefs overall and by sex. The mean (SD) age of the participants was 61.2 (8.6) years; 64% were women. The sample was well educated with 67% attending or graduating from college or graduate school. Marital status differed by sex. Compared with women, more men were married (42% vs 31%) and fewer were separated/divorced or widowed (21% vs 33%). CVD risk factors were common including hypertension (68%), hyperlipidemia (47%) and diabetes (34%). One quarter of participants reported current cigarette smoking with a prevalence greater among men compared with women (32% vs 22%). In total, 18% of participants had self-reported CVD (22% men, 17% women). The proportions of participants with CAD, stroke and PAD were 6%, 7% and 8% respectively.
Table 1.
Participant Socio-demographic Characteristics and Health Beliefs by Sex
| Variable | Total (N=644) |
Men (N=232) |
Women (N=412) |
P-value |
|---|---|---|---|---|
| Age (years) | 0.23 | |||
| 45-49 | 70 (11) | 25 (11) | 45 (11) | |
| 50-59 | 204 (32) | 85 (37) | 119 (29) | |
| 60-69 | 249 (39) | 83 (36) | 166 (40) | |
| 70-79 | 121 (19) | 39 (17) | 82 (20) | |
| Mean (SD) | 61.2 (8.6) | 60.4 (8.3) | 61.7 (8.7) | 0.08 |
| Ethnicity | ||||
| Hispanic | 6 (1) | 2 (<1) | 4 (1) | 1.0 |
| Non-Hispanic | 638 (99) | 230 (>99) | 408 (99) | |
| Marital status | <0.01 | |||
| Married | 225 (35) | 97 (42) | 128 (31) | |
| Single | 231 (36) | 86 (37) | 145 (35) | |
| Separated/Divorced | 134 (21) | 43 (19) | 91 (22) | |
| Widowed | 51 (8) | 6 (3) | 45 (11) | |
| Education level | 0.06 | |||
| Less than high school | 66 (10) | 32 (14) | 34 (8) | |
| High school graduate | 149 (23) | 54 (23) | 95 (23) | |
| Some college | 269 (42) | 99 (43) | 170 (41) | |
| College/graduate school graduate | 160 (25) | 47 (20) | 113 (27) | |
| CVD risk factors | ||||
| Current cigarette smoking | 163 (25) | 74 (32) | 89 (22) | 0.004 |
| Hypertension | 434 (68) | 148 (64) | 286 (69) | 0.14 |
| Hyperlipidemia | 301 (47) | 107 (46) | 194 (47) | 0.81 |
| Diabetes | 219 (34) | 88 (38) | 131 (32) | 0.12 |
| Self-reported CVD | ||||
| Any CVD | 119 (18) | 51 (22) | 68 (17) | 0.09 |
| Coronary artery disease | 41 (6) | 17 (7) | 24 (6) | 0.45 |
| Stroke | 48 (7) | 24 (10) | 24 (6) | 0.04 |
| Peripheral artery disease | 48 (8) | 20 (9) | 28 (7) | 0.40 |
| Revascularization procedure | 50 (8) | 25 (11) | 24 (6) | 0.01 |
| Health beliefs (somewhat agree/strongly agree) | ||||
| Self-awareness of actions on health: Your decisions and actions can have a positive effect on your health. | 637 (99) | 229 (99) | 408 (99) | 0.71 |
| Trust in healthcare provider: You completely trust your doctor’s decisions about which treatments are best for you. | 535 (83) | 186 (80) | 349 (85) | 0.16 |
| Importance of CVD prevention: Preventing a heart attack or stroke is very important to you. | 635 (99) | 228 (99) | 407 (99) | 1.0 |
| CVD risk perception: Your chances of getting a heart attack or stroke in the next few years are great. | 249 (39) | 92 (40) | 157 (38) | 0.31 |
All values are presented as number (percentage) of participants except for age which is shown as mean and standard deviation (SD). CVD indicates cardiovascular disease.
Nearly all participants agreed that their actions could affect health (99%) and that CVD prevention was important to them (99%); 83% reported trust in their healthcare provider and 39% had a perception that their risk of a CV event was high. There was no evidence of a difference in the health belief responses by sex.
CVD risk factors: prevalence and associations with socio-demographics and health beliefs
All self-reported CVD risk factors were strongly associated with age (Table 2). The proportion of participants reporting current cigarette smoking decreased with age while hypertension, hyperlipidemia and diabetes all increased with age. After age and sex-adjustment, single respondents were more likely to report current smoking (adjusted PR 2.22, CI 1.58-3.14) and have hyperlipidemia (adjusted PR 1.25, CI 1.03-1.51) compared with married participants. Smoking prevalence decreased with increased education level; 9% of college graduates smoked compared with 41% of those with less than a high school degree (adjusted PR 0.24, CI 0.14-0.42). No other CVD risk factors were significantly associated with education level.
Table 2.
Age- and Sex-Adjusted Associations of Self-reported Cardiovascular Disease Risk Factors with Socio-demographics and Health Beliefs
| Variable | Total | Cigarette Smoking (N=163) |
Hypertension (N=434) |
Hyperlipidemia (N=301) |
Diabetes (N=219) |
||||
|---|---|---|---|---|---|---|---|---|---|
|
| |||||||||
| Age, years | N (%) | PR (95% CI) | N (%) | PR (95% CI) | N (%) | PR (95% CI) | N (%) | PR (95% CI) | |
|
|
|||||||||
| 45-49 | 70 | 23 (33) | Ref | 26 (37) | Ref | 16 (23) | Ref | 12 (17) | Ref |
| 50-59 | 204 | 62 (31) | 0.90 (0.61-1.34) | 127 (62) | 1.68 (1.22-2.32) | 88 (43) | 1.89 (1.19-2.99) | 59 (29) | 1.67 (0.95-2.91) |
| 60-69 | 249 | 60 (24) | 0.74 (0.50-1.10) | 179 (72) | 1.93 (1.41-2.65) | 133 (53) | 2.34 (1.50-3.65) | 95 (38) | 2.24 (1.30-3.84) |
| 70-79 | 121 | 18 (15) | 0.46 (0.27-0.79) | 102 (84) | 2.26 (1.65-3.10) | 64 (53) | 2.31 (1.46-3.67) | 53 (44) | 2.57 (1.48-4.48) |
| Sex | |||||||||
| Women | 412 | 89 (22) | Ref | 286 (69) | Ref | 194 (47) | Ref | 131 (32) | Ref |
| Men | 232 | 74 (32) | 1.43 (1.10-1.86) | 148 (64) | 0.95 (0.85-1.06) | 107 (46) | 1.00 (0.84-1.19) | 88 (38) | 1.24 (0.99-1.54) |
| Marital status | |||||||||
| Married | 225 | 36 (16) | Ref | 145 (64) | Ref | 97 (43) | Ref | 68 (30) | Ref |
| Single | 231 | 81 (35) | 2.22 (1.58-3.14) | 157 (68) | 1.06 (0.93-1.20) | 124 (54) | 1.25 (1.03-1.51) | 87 (38) | 1.29 (1.00-1.66) |
| Separated/Divorced | 134 | 36 (27) | 1.87 (1.24-2.81) | 90 (67) | 0.98 (0.85-1.13) | 51 (38) | 0.84 (0.65-1.10) | 47 (35) | 1.11 (0.82-1.50) |
| Widowed | 51 | 10 (20) | 1.77 (0.92-3.42) | 40 (78) | 0.97 (0.82-1.16) | 29 (57) | 1.12 (0.84-1.51) | 16 (31) | 0.87 (0.55-1.37) |
| Education Level | |||||||||
| Less than high school | 66 | 27 (41) | Ref | 51 (77) | Ref | 35 (53) | Ref | 27 (41) | Ref |
| High school graduate | 149 | 54 (36) | 0.87 (0.62-1.24) | 99 (66) | 0.88 (0.75-1.03) | 77 (52) | 1.00 (0.76-1.31) | 58 (39) | 1.02 (0.71-1.45) |
| Some college | 269 | 67 (25) | 0.58 (0.41-0.83) | 176 (65) | 0.90 (0.77-1.04) | 113 (42) | 0.83 (0.63-1.09) | 86 (32) | 0.87 (0.62-1.23) |
| College/graduate school graduate | 160 | 15 (9) | 0.24 (0.14-0.42) | 108 (68) | 0.87 (0.74-1.02) | 76 (48) | 0.90 (0.68-1.19) | 48 (30) | 0.77 (0.53-1.11) |
| Health beliefs | |||||||||
| Self-awareness of actions on health | |||||||||
| Disagree/Don’t Know | 7 | 3 (43) | Ref | 3 (43) | Ref | 3 (43) | Ref | 2 (29) | Ref |
| Agree | 637 | 160 (25) | 0.63 (0.25-1.57) | 431 (68) | 1.46 (0.60-3.56) | 298 (47) | 1.03 (0.46-2.32) | 217 (34) | 1.12 (0.34-3.73) |
| Trust in healthcare provider | |||||||||
| Disagree/Don’t Know | 109 | 37 (34) | Ref | 68 (62) | Ref | 44 (40) | Ref | 28 (26) | Ref |
| Agree | 535 | 126 (24) | 0.80 (0.59-1.09) | 366 (68) | 0.96 (0.83-1.13) | 257 (48) | 1.09 (0.85-1.40) | 191 (36) | 1.23 (0.87-1.73) |
| Importance of CVD prevention | |||||||||
| Disagree/Don’t Know | 9 | 3 (33) | Ref | 7 (78) | Ref | 2 (22) | Ref | 1 (11) | Ref |
| Agree | 635 | 160 (25) | 0.83 (0.31-2.22) | 427 (67) | 0.83 (0.62-1.12) | 299 (47) | 2.06 (0.59-7.22) | 218 (34) | 3.04 (0.49-18.90) |
| CVD risk perception | |||||||||
| Disagree/Don’t Know | 395 | 96 (24) | Ref | 257 (65) | Ref | 161 (41) | Ref | 106 (27) | Ref |
| Agree | 249 | 67 (27) | 1.17 (0.89-1.52) | 177 (71) | 1.05 (0.94-1.16) | 140 (56) | 1.34 (1.14-1.57) | 113 (45) | 1.61 (1.30-1.98) |
All prevalence values are presented as number (percentage) of participants with each risk factor. Separate models were run for each risk factor and participant characteristic. PR indicates prevalence ratio; CVD, cardiovascular disease.
CVD risk factor prevalence did not vary by health beliefs except for those who agreed that their CVD risk was high. Increased CVD risk perception was associated with a higher prevalence of hyperlipidemia (PR 1.34, CI 1.14-1.57) and diabetes (PR 1.61, CI 1.30-1.98) compared with those who did not agree that their CVD risk was high.
CVD: prevalence and associations with socio-demographics, health beliefs and CVD risk factors
Overall, the prevalence of self-reported CVD increased with the number of CVD risk factors for each age group (Figure 1). In general, CVD prevalence increased with age in all risk factor categories. However, the highest prevalence of CVD was in the youngest age group (ages 45 to 49 years) with ≥3 CVD risk factors. All participants with 0-1 risk factors had low CVD prevalence, <10% across age groups. In participants with 3 or more risk factors, CVD prevalence increased to ≥20% regardless of age and was >30% in the total sample. Using age as a continuous variable, CVD prevalence increased by 16% for every 5 years in the fully adjusted model (PR 1.16, CI 1.05-1.29, Table 3). Men had a higher unadjusted prevalence of CVD than women (22% vs 17%), but the difference was not statistically significant in any of the models. Participants who were separated or divorced had a higher prevalence of CVD compared with those who were married (26% vs 15%), a significant factor even after adjustment for age, sex and CVD risk factors (PR 1.63, CI 1.08-2.46, Table 3). Higher education level was associated with lower CVD prevalence after adjustment for age and sex (PR 0.71, CI 0.51-0.97, Table 3), but this association was attenuated after adjustment for other CVD risk factors and was no longer statistically significant.
Figure 1. Self-reported cardiovascular disease (CVD) prevalence by number of CVD risk factors among each age group.
CVD prevalence increased with additional CVD risk factors in all age groups.
Table 3.
Associations of Self-reported Cardiovascular Disease with Socio-demographics and Health Beliefs
| Variable | N (N=644) |
Self-reported CVDa (N=119) |
Unadjusted PR (95% CI) |
Model 1b PR (95% CI) |
Model 2c PR (95% CI) |
P-valued |
|---|---|---|---|---|---|---|
| Age, per 5 years | 1.22 (1.11-1.35) | 1.23 (1.12-1.36) | 1.16 (1.05-1.29) | 0.004 | ||
| Age groups (years) | ||||||
| 45-49 | 70 | 5 (7) | Ref | Ref | Ref | |
| 50-59 | 204 | 30 (15) | 2.06 (0.83-5.10) | 2.02 (0.81-5.01) | 1.41 (0.59-3.38) | 0.44 |
| 60-69 | 249 | 52 (21) | 2.92 (1.21-7.04) | 2.95 (1.22-7.10) | 1.78 (0.76-4.18) | 0.18 |
| 70-79 | 121 | 32 (26) | 3.70 (1.51-9.07) | 3.75 (1.53-9.17) | 2.25 (0.95-5.31) | 0.06 |
| Sex | ||||||
| Women | 412 | 68 (17) | Ref | Ref | Ref | |
| Men | 232 | 51 (22) | 1.33 (0.96-1.84) | 1.41 (1.02-1.94) | 1.31 (0.96-1.80) | 0.09 |
| Marital status | ||||||
| Married | 225 | 34 (15) | Ref | Ref | Ref | |
| Single | 231 | 41 (18) | 1.17 (0.77-1.78) | 1.24 (0.82-1.87) | 1.03 (0.69-1.53) | 0.90 |
| Separated/Divorced | 134 | 35 (26) | 1.73 (1.13-2.63) | 1.65 (1.09-2.51) | 1.63 (1.08-2.46) | 0.02 |
| Widowed | 51 | 9 (18) | 1.17 (0.60-2.28) | 0.96 (0.48-1.92) | 0.89 (0.46-1.70) | 0.72 |
| Education level | ||||||
| High school graduate or less | 215 | 51 (24) | Ref | Ref | Ref | |
| At least some college | 429 | 68 (16) | 0.67 (0.48-0.92) | 0.71 (0.51-0.97) | 0.83 (0.61-1.14) | 0.25 |
| Health beliefs | ||||||
| Self-awareness of actions on health | ||||||
| Disagree/Don’t Know | 7 | 1 (14) | Ref | Ref | Ref | |
| Agree | 637 | 118 (19) | 1.30 (0.21-8.03) | 1.20 (0.18-8.01) | 0.89 (0.13-6.08) | 0.90 |
| Trust in healthcare provider | ||||||
| Disagree/Don’t Know | 109 | 16 (15) | Ref | Ref | Ref | |
| Agree | 535 | 103 (19) | 1.31 (0.81-2.13) | 1.09 (0.67-1.80) | 1.10 (0.68-1.78) | 0.70 |
| Importance of CVD prevention | ||||||
| Disagree/Don’t Know | 9 | 3 (33) | Ref | Ref | Ref | |
| Agree | 635 | 116 (18) | 0.55 (0.21-1.40) | 0.54 (0.26-1.13) | 0.52 (0.22-1.26) | 0.15 |
| CVD risk perception | ||||||
| Disagree/Don’t Know | 395 | 53 (13) | Ref | Ref | Ref | |
| Agree | 249 | 66 (27) | 1.98 (1.43-2.73) | 1.84 (1.33-2.54) | 1.61 (1.16-2.23) | 0.004 |
Self-reported CVD defined as coronary artery disease, stroke, peripheral artery disease or revascularization procedure. All values are presented as number (percentage) of participants.
Model 1 is adjusted for age and sex.
Model 2: Model 1 + adjustment for CVD risk factors.
P-values presented for Model 2.
CVD indicates cardiovascular disease; PR, prevalence ratio; CI, confidence interval.
Increased CVD risk perception was associated with a higher prevalence of self-reported CVD across all models (adjusted PR 1.61, CI 1.16-2.23, Table 3). There was no evidence of other significant associations between health beliefs and CVD prevalence. CVD burden was similar in participants expressing trust in healthcare providers compared with those who did not (PR 1.10, CI 0.68-1.78).
Discussion
This study provides a contemporary assessment of CVD and CVD risk factors among AAs sampled from a large metropolitan area in MN and adds new information on their association with health beliefs. CVD risk factors were common among participants, higher than previously described in the MHS.15 Although the sample size was small, the youngest age group had a very high CVD prevalence. In total, CVD prevalence was >30% among participants with 3 or more CVD risk factors. Participants with greater CVD risk perceptions reported a higher prevalence of hyperlipidemia, diabetes and CVD compared with those with lower perceived risk. Trust in healthcare providers was high in this sample (83%) but was not associated with CVD or CVD risk factors. In addition, health beliefs probing self-awareness of actions on health or importance of CVD prevention were not found to be associated with CVD or CVD risk factors.
Middle-aged AA adults suffer from increased CVD mortality compared with White adults of the same age. Two large community cohorts, the ARIC and Reasons for Geographic and Racial Differences in Stroke (REGARDS) studies, both showed approximately 2-fold increased age-adjusted risk for CAD mortality in Black men and women compared with Whites ages 45-64 years old.16 When adjusted for CVD risk factors and social determinants of health (education, income and health insurance), this difference was attenuated. Published data found that CVD mortality was lower in AAs from MN compared with the ARIC cohort. The authors report that CVD mortality was nearly triple for men and 2.5-fold higher in women in ARIC compared with men and women in the MHS.10 There were major limitations in the MHS data including reliance on State and National Death Index records for mortality. There was also no assessment of prevalent CVD at baseline with the assumption that prevalence was low, similar to the 4% found in the ARIC study. Although participants in the current study were older than the MHS participants (mean age 61 years versus 54 years), CVD prevalence was 18%, much higher than the assumed 4% in MHS.
CVD prevalence in the current study was similar to prevalence in other cohorts. According to the National Health and Nutrition Examination Survey (NHANES), total CVD prevalence in adults over 20 years old is 11% for AA men and women.17 In the ARIC cohort, the baseline CVD prevalence was 12% for Black men (mean age 54 years) and 13% for Black women (mean age 53 years) who were 6-8 years younger on average than our sample.18 The individual types of CVD differed in our study compared with national averages. CAD prevalence was lower than expected,17 but stroke was higher and PAD was similar when compared with other population-based samples.19,20 Low CAD prevalence could be due to underreporting of CAD without myocardial infarction or may be a result of non-random sampling.
The MN population has an overall low prevalence of CVD risk factors. In the MHS, among adults with an average age of 53 years, hypertension (29%), hyperlipidemia (29%) and diabetes (5%) were all below national averages while current smoking (17%) was similar.15 There are limited data on the CVD risk factors for Black Minnesotans and our study demonstrated a much higher prevalence compared with the mostly White population in the MHS. One difference between these surveys is that we sampled AA adults in urban settings only, while the MHS enrolled participants from rural areas as well. This would not explain the higher prevalence of CVD risk factors we observed because rural dwelling adults consistently experience worse CV health and increased CVD risk factors compared with urban adults independent of race.21–24 The Jackson Heart Study (JHS) is a contemporary, prospective, community-based cohort of AA adults designed to investigate CVD risk factors.25 We again observed higher prevalence of CVD risk factors in our participants compared to the JHS, including current smoking (25% vs 13%), hyperlipidemia (47% vs 33%) and diabetes (34% vs 19%).26 Hypertension prevalence was marginally higher—68% compared with 63% in the JHS.26 These baseline JHS data were collected in 2000-2004 and mean age was younger than our sample (55 years vs. 61 years).25 Younger age and earlier sampling timeframe may account for the lower prevalence of CVD risk factors in the JHS with stable or modest increases in CVD risk factors among AAs over time.17,27 Similar to our sample, 61% of the JHS participants reported some level of post-secondary education, thus education is less likely a major factor in the observed differences in CVD risk factors.26
As expected, we found that all CVD risk factors increased with age except for smoking which was highest in the youngest age group (45 to 49 years). Although there were few participants in this youngest age group with multiple risk factors, those with 3 or more had a very high prevalence of CVD. It is important to identify this younger AA population with multiple CVD risk factors because they have a much higher risk of a CV event compared with White adults with similar risk factor levels.28 Not only is CV event rate increased, but the case fatality rate for incident CVD is higher for AAs compared with Whites, particularly in younger to middle-aged adults.16,29,30
Several studies have documented lower trust of physicians among AAs compared to Whites.31–34 The high level of trust in healthcare providers reported by our participants (83%) is likely multifactorial, reflective of favorable patient-provider relationships among this sample. Although not evaluated in this study, another factor associated with higher trust of healthcare providers among AAs is race concordance between patient and physician. Race concordance has been associated with longer visits,35 higher level of engagement,36 and higher probability of seeking preventive care37 compared with race discordance.
Over one third of participants reported high self-perceived risk for a heart attack or stroke. This perception was associated with increased prevalence of CVD, hyperlipidemia and diabetes reflecting appropriate insight among high-risk participants. In contrast, data from an urban, primarily AA sample in Pennsylvania showed significantly lower perceived CVD risk compared to calculated risk.38 Patients who understand their increased CVD risk may be more motivated to adopt lifestyle modifications, willing to use medications for risk reduction and to follow evidence-based CVD prevention recommendations. There may be an opportunity to intervene to reduce cardiometabolic risk factor profiles in this population.
Strengths
To our knowledge, this study is one of the first to demonstrate the high CVD risk factor burden among AAs in MN. Community-based sampling allowed for evaluation of individuals regardless of their interaction with healthcare systems. In addition, we documented key health beliefs in this understudied population.
Limitations
Limitations to data interpretation include the use of a convenience sample of AA adults recruited from urban locations in the MSP metropolitan area; thus, it may not be representative of other AA populations including AAs residing in non-urban areas. In particular, this was a highly educated sample with 67% of participants with at least some college experience. The sample size limits the power to detect CVD and CVD risk factors associations in some sociodemographic subgroups. We asked a limited number of questions regarding social determinants of health in an effort to reduce participant burden but anticipate a more in-depth evaluation in future studies.
Conclusions
This study demonstrates a high prevalence of CVD and CVD risk factors in a sample of AA adults in MN, a state known for low rates of CVD. The study adds new information on socio-demographic and psychosocial influences on CVD and CVD risk factors that could inform development of effective CV health promotion interventions in the AA MN community.
Acknowledgements
We thank the Minnesota Heart Health Program (MHHP) Ask About Aspirin Study participants and research team (University of Minnesota) for their long- term devotion to expanding our knowledge of cardiovascular disease risk factors toward the eradication of cardiovascular health disparities in Minnesota.
Funding
This study was funded by the National Heart, Lung, and Blood Institute, National Institutes of Health (Grant No. R01HL126041).
Dr. Brewer was supported by the American Heart Association (Grant No. 19AMFDP35040005), National Center for Advancing Translational Sciences (NCATS, Clinical and Translational Science Awards (CTSA) Grant No. KL2 TR002379) and the National Institutes of Health (NIH)/National Institute on Minority Health and Health Disparities (NIMHD) (Grant No. 1 R21 MD013490-01) and the Centers for Disease Control and Prevention (CDC) (Grant No. CDC-DP18-1817) during the implementation and analysis of this work. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of NCATS, NIH or CDC. The funding bodies had no role in study design; in the collection, analysis, and interpretation of data; writing of the manuscript; and in the decision to submit the manuscript for publication.
Abbreviations
- AA
African-American
- AHA
American Heart Association
- ARIC
Atherosclerosis Risk in Communities
- CAD
coronary artery disease
- CV
cardiovascular
- CVD
cardiovascular disease
- JHS
Jackson Heart Study
- MHHP
Minnesota Heart Health Program
- MHS
Minnesota Heart Survey
- MSP
Minneapolis-St. Paul
- MN
Minnesota
- PAD
peripheral artery disease
Footnotes
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Disclosures
The authors have no conflicts of interest to disclose.
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