Research in Gerontological Nursing

Empirical Research 

“Missing Pieces”: Exploring Cardiac Risk Perceptions in Older Women

Leanne L. Lefler, PhD, APN; Jean C. McSweeney, PhD, RN, FAHA, FAAN; Kimberly K. Garner, MD, JD, MPH

Abstract

Approximately 95% of older women have factors that put them at risk for developing cardiovascular disease, but research indicates many do not perceive themselves to be at risk. We examined older women’s perceived risk for coronary heart disease (CHD) and the factors influencing their perceptions. We conducted a descriptive, qualitative study using in-depth, individual interviews and quantitative measures to assess perceived risk and risk factors. Twenty-four older African American and Caucasian women had a mean 4.46 cardiac risk factors but perceived their own CHD risk as unrealistically low at 1.95 cm (SD = 1.57, on 0-to-8 cm visual analogue scale). Narrative data clustered in themes that represented a lack of fact-based information and multiple misconceptions about CHD and prevention. Major improvements in CHD health are only achievable if risk factors are prevented. This research suggests older women have substantial needs for consistent CHD information and prevention guidance.

[Res Gerontol Nurs. 2013; 6(2):107–115.]

Abstract

Approximately 95% of older women have factors that put them at risk for developing cardiovascular disease, but research indicates many do not perceive themselves to be at risk. We examined older women’s perceived risk for coronary heart disease (CHD) and the factors influencing their perceptions. We conducted a descriptive, qualitative study using in-depth, individual interviews and quantitative measures to assess perceived risk and risk factors. Twenty-four older African American and Caucasian women had a mean 4.46 cardiac risk factors but perceived their own CHD risk as unrealistically low at 1.95 cm (SD = 1.57, on 0-to-8 cm visual analogue scale). Narrative data clustered in themes that represented a lack of fact-based information and multiple misconceptions about CHD and prevention. Major improvements in CHD health are only achievable if risk factors are prevented. This research suggests older women have substantial needs for consistent CHD information and prevention guidance.

[Res Gerontol Nurs. 2013; 6(2):107–115.]

Evidence demonstrates that older women can achieve major improvements in health and life expectancy simply by modifying coronary heart disease (CHD) risk factors (Mosca et al., 2011); however, only 5% of women in the nation have risk factor levels that are optimal for CHD health (Ford, Li, Zhao, Pearson, & Capewell, 2009). CHD is the number-one health problem of women in the United States, with more than 83% of CHD deaths occurring in adults 65 and older and women experiencing even greater mortality than men (38% versus 25%) (Lloyd-Jones et al., 2009). It is well known that individuals with multiple CHD risk factors are at greater risk for early mortality from CHD. In fact, older women with only two risk factors are three times more likely to die from CHD than those with one or no risk factors (Berry et al., 2012). Women are also at great risk for disability from CHD, often experiencing recurrent angina, heart failure, and stroke (Lloyd-Jones et al., 2009), as well as declines in cognitive function (Okonkwo et al., 2010) and physical function from CHD (Baum et al., 2009). Data continue to indicate lack of a heart-healthy lifestyle as the major cause of CHD death and disability rates in the United States (Shay et al., 2012). Current efforts to address unhealthy lifestyles are inadequate (Lloyd-Jones et al., 2010; Mosca et al., 2011; Shay et al., 2012); thus, interventions are critically needed, especially for those segments of the population, such as older women, that could greatly benefit.

The National Heart Lung and Blood Institute (2012) reported that a key contributor to women’s failure to engage in a heart-healthy lifestyle to prevent or modify CHD risk factors is a “personal disconnect,” that is, failure to make a connection between risk factors and one’s personal risk for CHD. Reasons for this disconnect are not well established, and to date, health care providers have been unsuccessful in correcting this (Goulding, Furze, & Birks, 2010; Lefler, 2009; Moore, Kimble, & Minick, 2010; Wang et al., 2009). If women do not believe they are at risk for CHD, they are unlikely to modify risk factors to reduce their risk; therefore, understanding risk perception is vitally important before developing risk-reducing health promotion activities.

Beliefs of risk perception are reported as multifaceted and complex, involving social, cognitive, motivational (Marsch, Bickel, Badger, & Quesnel, 2007; Wang et al., 2009), and emotional factors (Slovic, Finucane, Peters, & MacGregor, 2004; Weinstein, 2000); however, it is unknown which factors are more salient for older adults or for women, or if factors are contextually specific. Before interventions can be developed to help older women acquire accurate perceived risks for CHD, research is needed to identify key factors that influence their perceived risk and explain how the interrelationships of these factors affect formulation of perceived risk and, ultimately, promotion of heart health. Therefore, this study examined older women’s perceived risk for CHD and factors influencing their perceptions as a first step toward developing effective interventions for CHD risk reduction in this group.

Method

Research Design

We conducted a descriptive, naturalistic (Morse & Field, 1995) qualitative study using in-depth, face-to-face individual interviews to capture older women’s’ descriptions, understandings, and beliefs about CHD, including myocardial infarction (MI), and their personal risk for CHD and MI.

Study Sample

We recruited potential participants from a senior health clinic at a large university medical center in a southern state. The sampling frame was a database of 125 women 60 and older who had consented to have their contact information released for possible inclusion in future studies. From this database, we used purposive sampling to recruit both Caucasian and African American women who met our sampling criteria.

To be included, participants had to be English-speaking, community-dwelling women 60 and older with at least one self-reported risk factor for CHD other than age (e.g., cigarette smoking, hyperlipidemia, physical inactivity, overweight or obesity, diabetes mellitus, hypertension). We excluded women if they had an MI, angioplasty, or cardiac bypass surgery because these women would probably perceive greater CHD risk. We also excluded women if they had a self-reported history of dementia or a psychiatric diagnosis because of potential problems with memory and recall. We reached data saturation at 24 women as indicated by considerable repetition of data (Speziale & Carpenter, 2003). Institutional review board approval and written consent were obtained prior to data collection.

Data Collection

We developed the interview guide based on a review of the literature and consultation with cardiovascular research experts. Prior to this study, we pilot tested the interview guide to determine whether the questions were comprehensible and elicited sufficient data to fulfill our aims. Participants completed a short demographic and risk factor/medical history questionnaire after completion of the in-depth, face-to-face interview. We also included a measure of self-perceived risk for “heart attack” that has been used in other studies (Lefler, 2009; Wang et al., 2009) to assess participants’ rating of their own CHD risk: “Compared to other women my age, my risk for heart attack in the next 5 years is ___” We used a 0-to-8 cm horizontal visual analogue scale (VAS) with the polar ends marked low and high for the response format.

Interviews were conducted in a quiet office in the senior health clinic to enhance confidentiality and to afford participant convenience and familiarity. The interview began with a global question about the woman’s health and her understanding of CHD and MI, followed by probes (Morse & Field, 1995) concerning her ideas, experiences, and knowledge of CHD. A probe question also focused on perceived “worry” or CHD risk and the basis for her beliefs. Audiorecorded interviews lasted 1 to 2.5 hours and were transcribed verbatim. Each woman received a $20 grocery store gift card for participation.

Data Analysis

After checking each transcript for accuracy, we entered each transcript into Ethnograph (version 6.0, Qualis Research, Denver, CO), a text-based data management program that numbers each line and allows data labeling and sorting by identified variables. We used interpretative phenomenological analysis (Speziale & Carpenter, 2003), a rigorous scientific process, with the purpose of bringing human experiences to language in order to explain phenomena. The interview data were coded by the first author (L.L.L.) using content analysis (Morse & Field, 1995) with constant comparison (Glaser & Strauss, 1967). After the first author coded three interviews, developed definitions for each code, and prepared a preliminary code book including code labels, definitions, and narrative examples, the second author (J.C.M.) reviewed the transcripts and code book. Labeling and coding differences were discussed until we reached consensus. The remaining interviews were coded and then sorted by codes. The first author randomly presented the raw data aggregates to the other authors to check the relevance of categories, organization of the data, and emerging themes. We then developed overarching themes that represented the women’s voices, beliefs, and understandings about CHD and their perceived risk for CHD.

Several other techniques were used to maximize the validity and reliability of the study, following the guidelines for trustworthiness of Lincoln and Guba (1985). To provide dependability, the first author conducted all of the interviews using the interview guide. Interviews were then transcribed verbatim and checked for accuracy after each interview. The first author enhanced credibility and confirmability by keeping a detailed audit trail of coding and theoretical decisions and reaching consensus with the second author, who served as the qualitative expert.

Results

Sample Description

Twenty-four English-speaking African American (n = 9) and Caucasian (n = 15) women 60 and older who were able to verbalize their beliefs and understandings about CHD comprised the sample. Participants had a mean of 4.46 CHD risk factors, not including age (Table 1). No significant (p > 0.05) racial differences were observed for any risk factor or in the mean number of risk factors.

Demographic Characteristics, Risk Factors, and Comorbid Conditions (N = 24)

Table 1: Demographic Characteristics, Risk Factors, and Comorbid Conditions (N = 24)

Perceived Risk for Heart Attack Scale

The women’s mean self-perceived risk rating for “heart attack” was 1.95 cm (SD = 1.57) on the 0-to-8 cm VAS. The range of scores was positively skewed, from 0 to 6.30 cm; only one woman scored herself substantially above the scale median at 6.30 cm. No significant (p = 0.41) racial differences were found on the self-perceived risk measure.

Narrative Data: Formulation of Individual Perceived Risk

Two themes represented how the participants thought about and arrived at their perceived risk for CHD: Gathering Information and Weighing the Risk. Their perceived risk, in turn, guided their health promotion activities, captured in the third theme: Applying Personal Beliefs Toward Health Promotion. The themes and subcategories substantiating the themes, including examples of raw narrative data, are included in Table 2 and are briefly described below.

Themes Gathering Information and Weighing the Risk: Subcategories and Narrative Data

Table 2: Themes Gathering Information and Weighing the Risk: Subcategories and Narrative Data

Theme 1: Gathering Information

The ways the women learned about CHD and understood its etiology were aggregated to form the theme of gathering information. This theme was composed of four subcategories.

Flawed Understandings. All 24 women expressed a lack of understanding and held inaccurate beliefs about the etiology of CHD and MI. The most often quoted phrases, “I don’t really know much about it [heart attack]” and “I don’t really know what things or conditions would put someone at risk for heart attack,” reflect the majority of the group’s level of knowledge. For example, one typical response about the etiology of CHD: “Well, that was about the arteries, but I didn’t connect the arteries with the heart.” Another woman stated, “ and hypertension, you know like you get angry real fast or something scare you? I believe that’s what causes it [heart attack].”

Putting the Pieces Together. Understanding the etiology of CHD was primarily based on pieces of facts that they “fit” together themselves instead of on information from a health care provider or on medical facts. Most women who lacked specific information about risk factors did not know how they were related to the development of CHD and MI. Twenty-three women named eating the wrong foods as the major cause of CHD, but most were unsure which foods to eat to avoid or prevent CHD, as illustrated by the following quote: “I try to watch my carb intake, my sugar and all that. I don’t drink Cokes®.”

Twenty-one women said a lack of exercise might bring about CHD, and 19 mentioned being overweight as a risk factor. Stress and high blood pressure were also frequently mentioned causes, demonstrating some accurate understanding. Others did not correctly put the pieces together. For example, one woman explained what would predispose someone to an MI:

If you exercise, if you overeat and gain too much weight, and you need to keep a check on your cholesterol, and I think, this is my personal feelings, if you are a Christian and you know the Lord, you can have some peace even in turmoil by going to Him. If the problem is there, I think being upset could cause it [heart attack].

The women said much of their knowledge of CHD came from television commercials, pamphlets, and magazines: “Well, I watch TV a lot and I read quite a bit at the doctors’ offices. You know you can pick up pamphlets and stuff and read, and that is basically how I find out about it [heart disease].”

Personal Experiences. Personal stories and experiences were another major source of information about CHD. All 24 of the women mentioned family and/or friends who had experienced a “heart condition.” Most knew some facts about CHD and developed other pieces of information based on their own or family/friends’ experiences. One woman said:

And my dad never had a heart attack, well, dad did have a bad heart, they had to put a pacemaker in, but I don’t know, anyway his heart had decayed and the back side was gone [describing sequelae from myocardial infarction].

Lack of Health Care Provider Guidance. The women expressed an overwhelming lack of guidance from their health care providers related to CHD prevention. Many said they relied exclusively on their provider to notify them if they should engage in preventive actions. Interestingly, these women had multiple comorbid conditions (as self-identified on the medical history form) and were seen frequently by their health care providers for ongoing treatment of these conditions, yet the link between the comorbid condition and CHD was inadequately understood. According to the participants, health care providers provided few lifestyle recommendations so the women did not perceive a need for making lifestyle changes to reduce their CHD risk. According to one woman, “If he [physician] doesn’t tell me anything’s wrong with me...now if he told me something, well that valve’s not looking good or you don’t have good blood exchange, then I would say, well, we’d better do something about it.”

Others explained that their health care provider had never discussed CHD prevention with them, so they believed their provider had “cleared them,” meaning they were free of risk for CHD. When asked whether her health care provider gave her any information about CHD, one woman said:

No, because they said I was fine and I didn’t need anything. The only thing they said is that we can find that your cholesterol is just a little bit over what it should be, so we want to put you on this 5 mg of cholesterol, just to keep it down he said absolutely nothing wrong with my heart.

Another woman said, after a physician appointment, “I felt pretty good and they cleared me.”

Theme 2: Weighing the Risk

The second overarching theme, Weighing the Risk, reflects how participants formulated their perceived risk for CHD. Overall, the women did not describe CHD as a part of their conscious thoughts; they were mostly unaware of the problem, especially if they felt healthy and did not experience any heart symptoms. Women described a “disconnect” from thoughts or worry about having a heart attack or CHD themselves, although when queried, some said they weighed their risk based on information they had gathered. We identified three subcategories that comprised Weighing the Risk.

Few Risk Perceptions. A lack of understanding was noted regarding the role of risk factors as precursors for MI. Only 7 of the 24 women described any concern about ever developing CHD or having an MI. To place this information in the context of the participants’ actual risk, we listed participants’ risk factors and their rating of their personal perceived risk for MI after each narrative statement (Table 3). Most demonstrated a complete disconnect from a feeling of CHD risk, although two women expressed some concern about the possibility of having a heart attack because they had experienced palpitations in the past: “Well, occasionally you can feel your heart not beat just right. It will skip or do something and you think ‘Oh, is this going to be it’, you know.”

Comparison of Perceived Risk Narratives and Actual Risk Descriptions

Table 3: Comparison of Perceived Risk Narratives and Actual Risk Descriptions

Setting Priorities. Risk for MI was typically considered insignificant compared to other priorities. The women made decisions based on these priorities, for example, caregiving duties or other chronic health problems for which they were being treated:

I just don’t, like I said, I don’t give it a thought. Even though I am worried about a lot of things, having heart attacks is not one of them. I worry about falling, what am I gonna buy at the grocery store, seems to me that’s [heart attack] the least of my worries.

Non-Acceptance, Faith, or Fate. Most women did not believe they needed to worry about having an MI. Fate or faith played a role in their lack of concern or active engagement in CHD prevention. For example, one woman shared, “I don’t think about things that I am just not interested in or don’t want to have. I don’t plan to get it [MI]. So much of it is mental, you know, I think, I really do.” Another women stated, “If it’s God’s will, you know, I’ll be alright; if not then, you know, there ain’t nothing I can do about it. Well you know if it happens it just happens, you know.”

Theme 3: Applying Personal Beliefs Toward Health Promotion

We specifically asked the women about activities they did because of worry or concern about CHD. However, because most women did not express concern and did not perceive CHD risk, we elicited information about activities they undertook for general health promotion. The theme of Applying Personal Beliefs Toward Health Promotion was composed of four subcategories. The related narratives are provided in Table 4.

Theme Applying Personal Beliefs Toward Health Promotion: Subcategories and Narrative Data

Table 4: Theme Applying Personal Beliefs Toward Health Promotion: Subcategories and Narrative Data

Current Actions for Health. The most frequent and important current actions for maintaining health were being “active” or staying busy, avoiding stress, having a positive attitude, and “eating right.” However, when we asked for clarification of activity, most were not describing regular physical exercise. Staying active was instead described as “keeping one’s mind busy” and participating in social and family activities. A positive attitude was depicted as preventive for stress, worry, and anxiety, which was believed to be very important for health. For example, one woman said, “Staying positive and active is good, I do think it’s bad for your health to sit around.” Very few statements matched medical recommendations for preventing CHD.

Barriers to Health Promotion. The women said it was often difficult to be motivated to make healthy lifestyle decisions. Several discussed their struggles with smoking cessation while others noted caregiving responsibilities, lack of resources, and/or comorbid conditions that functioned as barriers to health promotion activities. One woman said, “I do know that I need all the exercise I can get, and I don’t do a whole lot anymore, I’m lazy.” Another woman stated, “And I was trying to quit smoking, it’s hard, but I went to bed one night and I said my prayers and I asked God to take the taste of tobacco from me.”

Several women expressed a need for more education and lay materials to increase their understanding of CHD:

I don’t think there’s enough information out that is clear, that people can understand, you start throwing those big words but it needs to be in lay language where even the ones that don’t do a lot of reading or anything can understand.

Facilitators of Health Promotion. Getting regular “checkups” and listening to their physicians were viewed as key facilitators of good health. Most perceived that these actions were sufficient to keep themselves healthy. The women frequently explained they would engage in health promotion activities if their health care provider specifically instructed them to: “The doctors and the nurses told me I would feel better if I would lose that weight. I’m easy to mind; I say yes ma’am and I just went to working on it.”

Recommendations to Others for CHD Prevention. Women shared recommendations that they believed would help other older women prevent CHD, even as they expressed limited expectations of acquiring it themselves. Avoiding stress was the most frequently recommended preventive action.

Discussion

This study was designed to increase understanding of how older African American and Caucasian women comprehended their personal CHD risk and how they applied this understanding to their health promotion behaviors. The older women in this study had inaccurate and incomplete understandings and beliefs about CHD and CHD prevention. Their narratives documented “missing pieces” of information, which prevented a clear understanding of how CHD risk factors are linked to increased probability for CHD. These inaccurate understandings were reflected in limited awareness, ownership, and acceptance of personal risk for CHD. The women in the study, despite a mean of 4.46 risk factors, rated their CHD risk quite low (mean = 1.95 cm on a 0-to-8 cm VAS). Yet, most of the women in the study would be considered at high risk by the current practice guidelines (Mosca et al., 2011). According to these guidelines and other work (Berry et al., 2012), risk for a coronary event increases with age and exponentially as the number of risk factors increase. Previous research with younger women, compared with the older women in the current study, found that women most often underestimated their risk for CHD (DeSalvo et al., 2005; Lefler, 2009; Moore et al., 2010; Mosca et al., 2006; Wang et al., 2009). Researchers have hypothesized that lack of perceived risk for many disease conditions results from various factors, such as lack of knowledge and/or understanding of the disease process (Alm-Roijer, Fridlund, Stagmo, & Erhardt, 2006; Powers et al., 2011), low health literacy (Peters, Hibbard, Slovic, & Dieckmann, 2007), limited personal experience with the disease (Slovic, Peters, Finucane, & MacGregor, 2005), lack of risk assessments by clinicians (Alm-Roijer et al., 2006), the uncertainty and lack of immediacy of the risk (Marsch et al., 2007), and inaccurate societal representations of disease victims (Lefler, 2004, 2009). Many of the factors identified in this earlier work with younger samples are easily recognized in the narratives of the older women in this study.

This study, particularly targeting beliefs of older women, identified inadequate understanding or health literacy as salient points resulting in an incomplete picture of risk and risk factors and how they can predict CHD events. Although these women had multiple risk factors, in the absence of symptoms, they did not perceive risk or a need to change their behavior to reduce risk for CHD. The few women who reported possible cardiac-related symptoms were the only ones who indicated concern of risk for CHD, which is similar to a recent report (Moore et al., 2010). The older women in the current study and other studies reporting data from younger women (Fleury & Sedikides, 2007; Mochari, Ferris, Adigopula, Henry, & Mosca, 2007; Mosca et al., 2006; Powers et al., 2011) clearly demonstrated a lack of knowledge and understanding of the etiology of CHD. These older women gathered information from personal experiences, random information sources, television and magazines, and occasionally, their health care provider. They used their personal experiences, health care provider guidance (or lack thereof), and factual and nonfactual pieces of information they had gathered to form an understanding of their personal CHD risk. It was clear that much of their knowledge was derived from social and cultural interactions. Unfortunately, many of their sources of CHD information were unsound. Mosca et al. (2006) found that less than 50% of younger women (N = 2,032, mean age = 51) could identify any CHD risk factors without prompting, and most failed to identify the most potent modifiable risk factors—diabetes and hypertension—similar to other research findings (Hamner & Wilder, 2008; Momtahan, Berkman, Sellick, Kearns, & Lauzon, 2004; Powers et al., 2011).

The older women in this study showed little concern about the possibility of having an MI; their priorities were immediate problems and daily life needs. This is similar to Moore et al.’s (2010) study, in which women believed heart disease was “out of sight, out of mind”; that is, they did not perceive CHD a problem because they did not have existing symptoms. Many relied on faith in God or luck for CHD prevention and took little ownership in reducing risk factors or modifying their lifestyle. Previous research suggests that knowledge of personal CHD risk encourages preventive actions, regardless of age (Mosca et al., 2006; Mosca, Mochari-Greenberger, Dolor, Newby, & Robb, 2010). Thus, the misunderstanding of risk factors and CHD personal risk may contribute to the increasing prevalence of CHD risk factors in the population today.

Limitations

Although qualitative studies are not generalizable, these results may be germane to others and should help health care providers gain understanding of older women’s beliefs of risk for CHD and the factors that influence their beliefs. Risk estimations used in this study were not actual biophysical measures, and some women may have fallen in the “at-risk” rather than “high-risk” category. All data were obtained from a small convenience sample, and information was obtained via self-report, which is prone to social acceptability bias.

Study Implications

This study clearly found limited understandings and knowledge of CHD among these older women. Interestingly, the older women relied almost exclusively on their health care provider to counsel and instigate a CHD health promotion or disease prevention program for them. Yet Crosson et al. (2010) found that providers did not believe patients desired health promotion counseling. The providers in Crosson et al.’s study surrendered to patient nonadherence concerning weight management, diet, and exercise; frustrated, they ceased counseling altogether. Undoubtedly, promoting lifestyle changes is a major challenge for health care providers. System-related barriers, such as limited reimbursement for counseling, time constraints, and poor access to care, also impede adequate counseling and education for risk factor reduction. Practitioners and policy makers are challenged to promote and develop interventions tailored to older women to improve knowledge about CHD risk and risk factors to reduce the burden of CHD in this group.

Conclusions

Older women are at substantial risk for death and disability from CHD and its sequelae. Major improvements in health and life expectancy can be achieved by this group if CHD risk factors are prevented or modified; however, this study suggests that older women take limited ownership of their role in reducing risk factors and have substantial needs for CHD guidance and information. The increasing prevalence of risk factors throughout the United States highlights the critical need for health promotion activities and programs directed at risk factor reduction.

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Demographic Characteristics, Risk Factors, and Comorbid Conditions (N = 24)

Characteristic n (%)
Age (years)
  60 to 65 4 (16.7)
  66 to 70 5 (20.8)
  71 to 75 10 (41.7)
  76 to 86 5 (20.8)
Educational level
  Less than high school graduate 5 (20.8)
  High school graduate 5 (20.8)
  Some college 9 (37.5)
  College graduate 5 (20.8)
Annual income
  Less than $10,000 8 (33.3)
  $10,000 to $29,000 5 (20.8)
  $30,000 or more 11 (45.8)
Risk factors/comorbid conditionsa
  Sedentary (no regular exercise) 20 (83.3)
  Hypertension 16 (66.7)
  Positive (first degree) family history 14 (58.3)
  Hyperlipidemia 12 (50)
  Poor diet (no “heart-healthy diet”) 10 (41.7)
  Smoking (smoked “most of life”) 9 (37.5)
  Overweight/obese 8 (33.3)
  Diabetes mellitus 6 (25)
  Stroke 5 (20.8)
  Peripheral vascular disease 2 (8.3)
  Abdominal aortic aneurysm 1 (4.2)
  Chronic kidney disease 1 (4.2)

Themes Gathering Information and Weighing the Risk: Subcategories and Narrative Data

Theme Subcategory Raw Narrative Data
Gathering Information Flawed understandings “But I think a heart attack is caused by pressure on you, I believe that if you get uptight, then you heart gets uptight.”
Putting the pieces together “The heart attack may be in my family. That’s one thing I haven’t figured out yet, why it was, was it the diabetes part?” “They say that blood pressure has a lot to do with it [heart disease], I don’t know why.”
Personal experiences “I don’t know anything except the sister who had a heart attack when she was very young, I think 25, and I remember vividly, she was in bed 6 weeks after that. My grandmother and mother both died of strokes, no, no history of heart attacks.”
Lack of health care provider guidance “I didn’t get it [information about heart disease] from doctors and nurses, just from reading and experiences with my kids.” “I’ve noticed every time I see a doctor that’s the first thing they say when you go in, “Have you fallen since your last visit?”, so, I know that falling is a big problem with the elderly, not heart.”
Weighing the Risk Few risk perceptions “No [not at risk] because my doctor said I was fine. I think if he thought I could be at risk, he would explain to me, so, no, I never think about that.”
Setting priorities “People have more severe medical problems than thinking about their heart. You know, like breast cancer patients.” “I don’t have time, It’s something always more important.”
Non-acceptance, faith, or fate “It’s just so overwhelming that they don’t want to have to deal with it and they can’t do anything about it [heart disease].”

Comparison of Perceived Risk Narratives and Actual Risk Descriptions

Perceived Risk Narrative Actual Risk Description
“No, I don’t feel at risk [for heart attack] about the only thing I know about risk is stuff I read, because my mom and dad had several heart attacks and strokes and stuff and I’m trying to avoid some of the stuff they did.” African American woman with hypertension, diabetes, family history, obesity, some college, self-perceived risk = 0.8 cma
“It’s [information about CHD] not directed at me, personally. I know it’s directed at some women; if it’s directed at you, then you need to listen. I don’t think it is directed at me.” Caucasian woman with hyperlipidemia, sedentary lifestyle, no heart-healthy diet, some college, self-perceived risk = 1.2 cma
“When I am tired and winded, that worries me, that maybe it’s possible that I’ll have a heart attack. But it’s not a whole bunch that I can think of that I’d be concerned about me having a heart attack, you know, and I know it can happen anytime but so far so good.” African American woman with hypertension, diabetes, hyperlipidemia, family history, sedentary lifestyle, obesity, some high school, self-perceived risk = 2.0 cma
“If I am at risk to have a heart attack, I want to know all about it so I know what the symptoms are...my heart, it pounds so, it pounds until it hurts. Why? I’d like to know why.” Caucasian woman with hypertension, hyperlipidemia, family history, past smoker, sedentary lifestyle, some high school, self-perceived risk = 1.1 cma
“And they call me a worrywart.... But if you stop and think sometimes, not to worry but to think about it and then try to do something about it if you can. You know I don’t want to have a heart attack and I don’t want to see anybody else have one.” African American woman with hypertension, stroke, smoker, family history, sedentary lifestyle, high school graduate, self-perceived risk = 4.3 cma
“But I do worry about it because it’s there and everybody has a chance of getting it, and I do not do right. I’m overweight, I don’t exercise as much, and I don’t eat right. So, I know I’m not doing right.” Caucasian woman with hypertension, diabetes, family history, obesity, some college, self-perceived risk = 4.0 cma

Theme Applying Personal Beliefs Toward Health Promotion: Subcategories and Narrative Data

Subcategory Raw Narrative Data
Current actions for health “I try to take as few, as little medicine as I can. I do take vitamins and calcium and an aspirin and omega-3 and try to just eat more fiber. I try to stay active, I have a good family life and go to church regularly.” “I read somewhere that said where beer had collagen and that was good for you and I thought well, I’ll try that for a while.”
Barriers to health promotion “I was walking 2 miles. I don’t do it now because I can’t leave my husband [who has Alzheimer’s disease] to do it.” “They have an exercise room, too, but my insurance would only cover so much. It wouldn’t cover the pool, with my bad knee and all.”
Facilitators of health promotion “One thing, obey your doctor. Now you have to have faith in your doctor, have your mind clear and listen to everything he got to tell you and try to go by his rules.” “Well, for me it would be good to have a visit from somebody that could tell me, the things apply to the heart and what are the most important things you do to sustain good health and to prevent heart attacks. Because those basic things, I don’t really know those.”
Recommendations to others for CHD prevention “I think most people will listen to their doctors if they feel they are really concerned. But doctors usually say you need to have a mammogram and they don’t say you need to have your heart checked, or you need to exercise.”
Authors

Dr. Lefler is Assistant Professor, and Dr. McSweeney is Professor, College of Nursing, University of Arkansas for Medical Sciences, Little Rock, and Dr. Garner is a Health Services Researcher, Geriatric Research and Education Clinical Center, Central Arkansas Veterans HealthCare System, North Little Rock, Arkansas.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This research was supported by grants from the John A. Hartford Foundation Geriatric Nursing Initiative and the American Nurses Foundation. Supporting sources had no other involvement in this research.

Address correspondence to Leanne L. Lefler, PhD, APN, Assistant Professor, College of Nursing, University of Arkansas for Medical Sciences, 4301 W. Markham, #529, Little Rock, AR 72205; e-mail: L.Lefler@uams.edu.

Received: March 20, 2012
Accepted: June 27, 2012
Posted Online: January 08, 2013

10.3928/19404921-20121217-01

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