CARDIOVASCULAR RISK FACTOR AWARENESS IN AMERICAN INDIAN COMMUNITIES:THE STRONG HEART STUDY

Objective: To use data from the longitudinal Kurt Schweigman, MPH; June Eichner, PhD; Strong Heart Study (SHS) to determine the Thomas K. Welty, MD, MPH; Ying Zhang, PhD level of awareness about risk factors for heart disease among 13 populations of American Indians in , , and South/ North Dakota. The aim of this study is to assess 12 awareness of nine major risk factors for heart INTRODUCTION States. Although smoking disease among participants in SHS. varies in American Indian tribal groups Methods: During July 1993 to December (CVD) is the (eg, northern Plains tribes have higher 1995 (phase II of SHS), 3638 participants ages leading cause of death among American rates than southwest tribal groups), the 46 to 80 years (mean age 60) were asked if Indians.1,2 The proportion of premature average number of cigarettes smoked nine known risk factors for cardiovascular disease affect a person’s chances of getting deaths attributed to heart disease is higher per day by American Indians is less than 13 heart disease; 3226 (89%) participants com- among American Indians/Alaska Natives the US average. Zephier et al found pleted the study and met the method reliability than in any other racial group.3 Further- dietary patterns for American Indians to criteria for inclusion. more, American Indians are experiencing be associated with high risk for CVD, Results: Among each of the nine risk factors, an epidemic of CVD, and without due in part to the lack of, or expensive the percentage of correct answers provided by study participants ranged from 70% (family aggressive prevention programs, CVD cost of, fresh fruits and vegetables in 14 history of heart disease) to 90% (being very mortality and morbidity will continue rural American Indian communities. overweight). Participants with to increase.4 Several risk factors for CVD The aim of the current study is to (90% vs 86%, P,.05) and mellitus are modifiable, eg, smoking, physical assess awareness of nine major risk (81% vs 71%, P,.05) were more likely than activity, and diet. Individual behavior factors for heart disease among partici- those without these disorders to know they were heart disease risk factors. For all nine risk can be targeted to reduce and/or elimi- pants in the Strong Heart Study (SHS). factors, the percentage of correct answers was nate modifiable risk factors for CVD; Multivariate logistic regression was used lower (P,.05) among smokers than among therefore, determining what people know to examine the association between nonsmokers. In multivariate logistic regression about risk factors is a worthwhile endeav- heart disease risk factor awareness and analyses, female sex, advanced education, and regional centers, education, sex, age, being from Oklahoma were significantly asso- or. Heart disease risk factor knowledge is 5 American Indian heritage, native lan- ciated with heart disease awareness. the first step in risk factor reduction. In Conclusion: Although overall risk factor some populations, smokers and people guage, and use of traditional (American awareness for heart disease was high, sub- who are overweight are more likely to Indian) medicine. groups were identified who could benefit from identify these respective risk factors for culturally appropriate health education and 6,7 other interventions to motivate health pre- heart disease. However, knowledge vention actions, especially for smoking. (Ethn does not always lead to behavior change METHODS Dis. 2006;16:647–652) that reduces risk.8,9 We are aware of only one other Study Population and Key Words: Awareness, Behavior, Chronic study that describes heart disease risk Data Sources Disease, North American Indians, Tobacco factor knowledge in American Indian Strong Heart Study (SHS) phase I, communities.10 Among American In- conducted during 1989–1991, was the dians, variations in risk factors for CVD first large multicenter study to examine exist both culturally and regionally.11 CVD morbidity/mortality and risk American Indians/Alaska Natives have factors in 13 American Indian tribal the highest prevalence of cigarette groups: Ak-Chin Papago/Pima, Apache, smoking among both youths (28%) Caddo, Cheyenne River Sioux, Coman- From the California Rural Indian Health che, Delaware, Fort Sill Apache, Gila Board, Sacramento, California (KS); Univer- and adults (40%) in the United sity of Oklahoma Health Sciences Center, River Pima/Maricopa, Kiowa, Oglala Oklahoma City, Oklahoma (JE,YZ); Aber- Sioux, Salt River Pima/Maricopa, Spirit deen Area Tribal Chairman’s Health Board, Address correspondence and reprint Lake, and Wichita. These groups reside Aberdeen, South Dakota (TW). requests to Kurt Schweigman, MPH; To- in one of three regional centers: Ar- bacco Program Coordinator; California Ru- izona, southwestern Oklahoma, and This research was done by the Center for ral Indian Health Board; 4400 Auburn 13,15 American Indian Health Research, Univer- Blvd., 2nd Floor; Sacramento, CA 95841; South Dakota/North Dakota. sity of Oklahoma Health Sciences Center, 916-929-9761; 916-929-7246 (fax); kurt. SHS phase II study population Oklahoma City, Oklahoma. [email protected] includes 3638 phase I participants who

Ethnicity & Disease, Volume 16, Summer 2006 647 THE STRONG HEART STUDY - Schweigman et al

clinic staff. Self-administered question- considered by the interviewer not to be The aim of the current study naires aided in the overall SHS clinic reliable (n5283). exam flow. Number of interviewer- is to assess awareness of nine administered questionnaires that were Data Analysis major risk factors for heart translated into native language was not Data were analyzed using SAS version documented; however, we are aware of 8.1 for Windows.21 The association of disease among participants very few. Pyne et al found consistency heart disease awareness with disease status in the Strong Heart Study across responses among interviewer- and (heart disease vs no heart disease, hyper- self-administered questionnaire formats tensive vs normotensive, diabetic vs 17 (SHS). for a quality of well-being scale. nondiabetic) and a lifestyle habit (smoker Furthermore, Schweigman et al found vs nonsmoker) was analyzed by using the no clear advantage in the use of a self- chi-square test. Multivariate logistic re- administered versus interviewer-admin- gression was used to examine the associ- were re-examined between July 1993 and istered questionnaires among SHS par- ation between heart disease awareness 18 December 1995. Self-reported data (eg, ticipants. and regional centers, education, sex, age, sex, date of birth, years of education, Interviewers were predominantly American Indian heritage, native lan- American Indian heritage [blood degree American Indian and members of the guage, and use of traditional (American quantum], traditional [American Indian] participating SHS communities. Train- Indian) medicine. Three of these were medicine use, and ability to speak native ing and quality control of interviewers continuous variables (age in years, edu- 19,20 [American Indian] language) were re- followed SHS protocol. cation in years, and percent of American tained from phase I. Medical chart health Indian heritage), while two were categor- history ascertained congestive heart fail- Reliability of Responses ical variables (South Dakota/North Da- ure, coronary heart disease, myocardial Reliability of participant answers kota as reference group for regional infarction, hypertension, and diabetes was subjectively judged by the inter- centers and women as reference group 15 mellitus. Cigarette smoking was self- viewer immediately after the interview- for sex). The remaining two variables reported from phase II. er-administered demographic and cul- were dichotomous, native language (does To assess awareness about heart tural questionnaire by selecting one of not speak vs does speak but not fluently disease risk factors among SHS phase II the following five categories: very reli- or can fluently speak) and traditional participants, a heart disease risk factor able, reliable, unreliable, very unreliable, medicine use (never or seldom vs often, knowledge questionnaire, developed by or uncertain. Only very reliable and almost always or always). Does not speak the National Center for Health Statistics, reliable responses were used for this native language is the reference group for 16 was administered. For questions about study. Interviews judged to be of lower native language. An odds ratio (OR) ,1 each of nine risk factors associated with reliability were generally the result of indicates greater risk factor knowledge heart disease (being very overweight, impaired cognitive ability, ie, language compared to the referent group and an cigarette smoking, diabetes mellitus, fam- barriers. The risk factor knowledge OR .1 indicates less knowledge com- ily history of heart disease, high blood questionnaire did not contain an option pared to the referent group. P values pressure, high , high-fat diet, for participant reliability. However, all #.05 and ORs whose 95% confidence not exercising regularly, and worry/anxi- nine questions had to be answered to be intervals did not include 1 were consid- ety/stress) participants chose one of included in the study. ered to be statistically significant. the following responses: increases risk, does not increase risk, or don’t know/not Subject Participation sure. Among the 3638 eligible partici- RESULTS pants, 3226 (88.7%) were included in Survey Mode the data analysis. A total of 412 Participant characteristics by region- Seventy-two percent of the heart participants were excluded from the al center are listed in Table 1. Among disease awareness questionnaires were analysis either if they refused to com- the 3226 study participants, 62% interviewer-administered, while 28% plete the risk factor questionnaire were female and 38% were male. The were self-administered. All SHS forms (n5129) or if one or more of the age of participants ranged from 46 to and questionnaires were printed in following applied: respondent did not 80 years, with the mean age of 60 English. Participants who self-adminis- answer questions for all nine of the heart (Table 1). tered the questionnaire were deemed to disease risk factors, other key data items Overall, positive answers for risk have capable cognitive skills by SHS were missing, or the respondent was factor knowledge ranged from 70% for

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of nine protective ORs) (Table 3). Table 1. Participant characteristics by regional center (AZ, OK, SD/ND) and overall Having more American Indian heritage Regional Center (blood degree quantum) is associated Participant Characteristics AZ OK SD/ND Overall with increased risk of not knowing heart Number of participants 1044 1121 1061 3226 disease risk factors for four (being very Age mean, years (SD) 59.4 (7.9) 60.5* (8.1) 59.7 (7.6) 59.9 (7.9) overweight, high blood pressure, not Education mean, years (SD) 10.2 (2.8) 12.4* (2.7) 11.0* (3.0) 11.2 (3.0) exercising regularly and worry/anxiety/ Female sex (%) 67.1* 59.5 58.9 61.8 stress) of the nine risk factors (Table 3). Native language speaker (%) 88.6* 58.7* 75.2* 73.8 Use traditional medicine (%) 7.4 7.5 13.9* 9.6 However, having a higher American Current smoker (%) 16.0* 30.2* 44.2* 30.2 Indian heritage is associated with Have heart disease 3 (%) 30.8 31.2 36.5* 32.8 knowledge of diabetes as a heart disease Have hypertension (%) 52.1 48.2 38.7* 46.3 risk factor (Table 3). Speaking native Have diabetes (%) 70.4* 44.7 46.3 53.5 language is associated with increased * Denotes statistically significant difference (P #.05) among regional centers. risk of not knowing heart disease risk 3 Heart disease was defined as congestive heart failure, coronary heart disease, or . AZ5Arizona; OK5Oklahoma; SD/ND5South Dakota/North Dakota; SD5standard deviation factors for two (cigarette smoking and family history) of the nine risk factors (Table 3). For every year of age, the risk family history of heart disease to 90% disease risk factors than individuals of not knowing cigarette smoking is for being very overweight. Heart disease without hypertension (Table 2). Partic- a heart disease risk factor increases by risk factor awareness was higher, but not ipants with diabetes mellitus had signif- 2% (Table 3). statistically significant, among partici- icantly more knowledge of diabetes as pants without heart disease than those a heart disease risk factor; on the other with heart disease for five of the nine hand, diabetics knew significantly less DISCUSSION risk factors: being very overweight, about family history of heart disease as cigarette smoking, high blood pressure, a risk factor (Table 2). A significantly Overall, risk factor awareness was high cholesterol, and not exercising higher proportion of cigarette smokers high, ranging from 71% to 90%. regularly (Table 2). Participants with were less likely to know heart disease Participants with hypertension (90% vs a health condition related to heart risk factors than nonsmokers for all nine 86%, P,.05) and diabetes mellitus disease (hypertension and diabetes mel- risk factors (Table 2). (81% vs 71%, P,.05) were more likely litus) had significantly more knowledge In multivariate logistic regression than those without these disorders to of the corresponding risk factor than analyses, the three variables that showed know they were heart disease risk individuals without the condition (Ta- the most consistent association with factors. Diabetes is strongly linked to ble 2). A significantly higher proportion heart disease awareness were female sex heart disease. American Indian men and of participants with hypertension knew (nine of nine protective ORs), higher women with diabetes had respectively that diabetes, high blood pressure, and education (nine of nine protective a 2.2-fold and a 3.4-fold increased risk not exercising regularly were heart ORs), and being from Oklahoma (nine for CVD compared to those without

Table 2. Heart disease risk factor (% with awareness) in those with and without medical chart history health condition of heart disease, high blood pressure, diabetes, and self-reported smoking

Heart Disease vs No Hypertension vs No Risk Factor Heart Disease Hypertension Diabetes vs No Diabetes Smokers vs Nonsmokers Being very overweight 90 91 90 90 91 90 88* 91* Cigarette smoking 85 87 87 86 87 86 83* 88* Diabetes 76 76 78* 74* 81* 71* 69* 79* Family history 70 70 70 70 69* 72* 68* 71* High blood pressure 87 88 90* 86* 88 87 84* 89* High cholesterol 83 84 84 83 84 83 79* 86* High fat diet 86 84 85 84 85 84 81* 86* Not exercising regularly 84 85 86* 84* 85 85 80* 87* Worry/anxiety/stress 83 82 82 82 82 82 78* 84*

The percentage of participants with knowledge of a risk factor was based on the number of respondents for each question (missing data were excluded). * Denotes statistically significant difference (P #.05) between those who reported the health condition and those who did not.

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Table 3. Multivariate logistic regression of heart disease risk factor awareness: significant odds ratios by sociodemographic attributes and cultural factors;

*Center Education American Indian *Native Specific Risk Factor Arizona Oklahoma (year) *Sex Age (year) Heritage (%) Language Being very overweight OR .32 .86 2.07 1.01 CI .23–.45 .82–.90 1.63–2.64 1.00–1.01 Cigarette smoking OR .50 .88 1.52 1.02 1.44 CI .38–.66 .85–.91 1.23–1.87 1.01–1.04 1.08–1.93 Diabetes OR .46 .93 1.42 .99 CI .38–.57 .91–.96 1.20–1.68 .99–.99 Family history OR .56 .89 1.53 1.35 CI .46–.67 .86–.91 1.30–1.79 1.11–1.64 High blood pressure OR .38 .85 1.33 1.01 CI .28–.51 .82–.89 1.07–1.65 1.00–1.01 High cholesterol OR .28 .87 1.53 CI .21–.37 .84–.90 1.26–1.86 High fat diet OR .28 .91 1.99 CI .21–.36 .88–.94 1.63–2.43 Not exercising regularly OR .67 .26 .90 1.42 1.01 CI .53–.84 .19–.35 .87–.93 1.16–1.74 1.00–1.01 Worry/anxiety/stress OR .29 .88 1.78 1.01 CI .22–.38 .85–.91 1.47–2.15 1.00–1.01

Only significant odds ratios are shown on the table with all values rounded. * Referent group for center is North/South Dakota, for sex is female, and for native language is those who cannot speak native language. 3 Traditional medicine was part of the multivariate logistic regression model but did not show significant results. OR5odds ratio; CI595% confidence interval (Wald confidence interval). diabetes.22 Age, albuminuria, hyperten- The association between speaking native tobacco users are more likely to use sion, and low-density lipoprotein cho- language and unawareness of smoking ceremonial tobacco. In fact, nonsmokers lesterol are also significantly linked to as a risk factor for heart disease is are more likely than smokers to use CVD in American Indians of both intriguing. American Indians have had ceremonial tobacco.24 Commercial to- sexes.22 Smokers were less likely than (and still do have) a ceremonial and bacco may not be interpreted as harmful nonsmokers to know, or acknowledge, medicinal association with tobacco, to health among American Indian that any of the nine attributes were risk predating European contact.23 Findings native language speakers because of the factors for heart disease (P,.05). In of the Tobacco in Portland Indians Sapir-Whorf Hypothesis. The Sapir- multivariate logistic regression analyses, convenience sample survey do not Whorf Hypothesis states that intracul- the three variables that showed the most support the hypothesis that commercial tural communication is invariably inter- consistent association with heart disease twined with culture and that language knowledge were female sex (nine of nine not only describes our surroundings, protective ORs), higher education (nine but also how we experience it.25 Native of nine protective ORs), and being from Those with a greater degree of language speakers could mistakenly be Oklahoma (nine of nine protective American Indian heritage associating ceremonial use of tobacco ORs). Those with a greater degree of with harmful commercial use. Since American Indian heritage have increased have increased risk of not speakers of their native language are risk of not knowing heart disease risk knowing heart disease risk less likely to know that smoking is a risk factors for four of the nine risk factors factor for heart disease, and since (being very overweight, high blood factors for four of the nine risk American Indians/Alaska Natives have pressure, no regular exercise, and worry/ the highest smoking prevalence, perhaps anxiety/stress), but they are more aware factors (being very overweight, bilingual education on the health effects of diabetes as a heart disease risk factor. high blood pressure, no of smoking will increase awareness in Speaking native language is associ- this subgroup. ated with increased risk of not knowing regular exercise, and worry/ Similar to the present study, the heart disease risk factors for two (ciga- anxiety/stress). Inter-Tribal Heart Project found that rette smoking and family history of women were more likely than men to heart disease) of the nine risk factors. know heart disease risk factors.10 Par-

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Fig 1. Overall awareness of heart disease risk factors: The Strong Heart Study

ticipants in the Inter-Tribal Heart Pro- all nine heart disease risk factors than Knowledge of risk factors may show ject were least likely to associate diabetes smokers. Nez Henderson et al found cultural variation, and in the American with heart disease risk, while the present smoking cessation in SHS participants Indian community knowledge can be study found family history of heart was associated with older age (65– influenced by native language, social disease to be the least known risk factor 74 years), daily cigarette consumption and ceremonial use of tobacco, educa- for heart disease.10 Of the nine risk of fewer than six cigarettes, fewer years tion, and dietary practices. Understand- factors, diabetes followed family history of smoking cigarettes, older age of ing risk factor awareness appears to be as a less familiar risk factor (Figure 1). smoking initiation ($17 years), being the key first step in reducing the rising In order to assist tribal leaders and from Arizona, and history of diabetes.26 tide of heart disease among American health planners to implement heart Improved and culturally appropriate Indians and Alaska Natives. disease reduction programs, additional smoking cessation and education ap- descriptive information on heart proaches can raise awareness in current disease risk factor awareness has been smokers and promote positive behavior ACKNOWLEDGMENTS published on SHS participants in the changes. As an alternative to standard The authors acknowledge the assistance and form of a community data book by the general population smoking cessation cooperation of the Ak-Chin Papago/Pima, National Heart, Lung, and Blood In- programs, the development of cessation Apache, Caddo, Cheyenne River Sioux, Comanche, Delaware, Fort Sill Apache, Gila stitute.5 curricula specifically for American Indi- River Pima/Maricopa, Kiowa, Oglala Sioux, Although overall knowledge of heart an and Alaska Natives, such as the Salt River Pima/Maricopa, Spirit Lake, and disease risk factors was high, more Second Wind program, have been Wichita American Indian communities, targeted education efforts are needed created. The Second Wind smoking without whose support this study would to reach lower awareness subgroups. We cessation program uses talking circles, not have been possible. The authors also identified five sociodemographic and American Indian/Alaska Native-specific thank the Indian Health Service hospitals lifestyle attributes associated with low- discussions on culture, to alleviate stress and clinics in each community. Special thanks to instructor Paul Siegel, MD, ered awareness of heart disease risk and talk about traditional/sacred use of 27 MPH and students of the Successful Scien- factors: living in Arizona and South/ tobacco. As of 2004, the American tific Writing course of the 39th Graduate North Dakota, male sex, lower educa- Legacy Foundation is funding 14 cessa- Summer Session in Epidemiology at the tional attainment, and smoking. Mid- tion, prevention, and education pro- University of Michigan School of Public dle-aged and elderly American Indian grams nationwide among organizations Health. This study was conducted by co- populations with these characteristics that serve American Indians and Alaska operative agreement grants (No. U01- would benefit most from heart disease Natives.28 The California Rural Indian HL41642, U01-HL41652, U01-HL41654) risk factor education. Health Board is an outstanding resource from the National Heart, Lung, and Blood Institute (NHLBI). This work was Smokers might be particularly re- and model for programs nationally in also supported by NHLBI through an sistant to current health education the development and implementation of Intramural Research Trainee Minority fel- efforts. We found that nonsmokers American Indian and Alaska Native- lowship. The views expressed in this paper had significantly more knowledge of specific tobacco programs.29 are those of the authors and do not

Ethnicity & Disease, Volume 16, Summer 2006 651 THE STRONG HEART STUDY - Schweigman et al necessarily reflect those of the Indian Health 11. Levin S, Welch VL, Bell RA, Casper ML. 22. Howard BV, Lee ET, Cowan LD, et al. Rising Service. Geographic variation in cardiovascular disease tide of cardiovascular disease in American risk factors among American Indians and Indians. The Strong Heart Study. Circulation. comparisons with the corresponding state 1999;99(18):2389–2395. REFERENCES populations. Ethn Health. 2002;7(1):57–67. 23. Reece DH. Historic ceremonial and medicinal 1. Indian Health Service. Regional Differences in 12. CDC. Prevalence of cigarette use among 14 use of tobacco among American Indians. Indian Health 1998–99. Rockville, Md: De- racial/ethnic populations–United States, Alaska Med. 1996;38(1):8. partment of Health and Human Services; 1999–2001. Morb Mortal Wkly Rep. 2004; 24. Schweigman KP. Tobacco in Portland Indians 2000. 53(3):49–52. Survey: The TIPI Survey. 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