Perceptions Related to Cardiovascular Disease Risk in Caucasian College Males

Abstract

Among younger adults, risk for cardiovascular disease (CVD) is higher among men than women. Young adult males in college engage in multiple behaviors that are associated with CVD risk. Although researchers have previously explored perceptions of factors related to hypertension in African American college males, surprisingly little is known about perceptions of CVD risk in Caucasian college males. A better understanding of these perceptions may be helpful in creating interventions to improve cardiovascular health in college men. Therefore, the purpose of this study was to explore Caucasian male college students’ perceptions of CVD risk. A qualitative descriptive study using semistructured, individual interviews was conducted using a sample of 10 undergraduate Caucasian males in college (mean age 20 years) free of CVD and not enrolled in a health-related major. Interviews were audio recorded, transcribed verbatim, and analyzed for themes using content analysis. The data reflected two primary themes regarding perceptions related to cardiovascular risk: barriers to implementing healthy lifestyle choices and impact of behaviors on CVD risk. Barriers to implementing healthy lifestyles included availability of unhealthy foods, time constraints, convenience, social influences, and ignoring long-term consequences of behaviors. Students primarily emphasized the importance of diet and physical activity in reducing CVD risk. Future research should focus on interventions to overcome college-specific barriers to engaging in healthy behaviors among men.

Approximately half of the 85.6 million adults affected with cardiovascular disease (CVD) in the United States are younger than 60 years of age (Mozaffarian et al., 2015), with the lifetime risk being greater among men than women (Lloyd-Jones et al., 2006) across most age groups (Wilkins et al., 2012). An important time to examine factors associated with CVD risk among young adult men is during the college years. Compared with college females, college males are at greater risk for CVD because of having lower high-density lipoprotein (HDL) cholesterol and higher low-density lipoprotein (LDL) cholesterol, blood pressure, fasting glucose, and body mass index (Morrell, Lofgren, Burke, & Reilly, 2012). All these risk factors can be modified through healthy lifestyle behaviors. However, many college students engage in behaviors associated with CVD development including cigarette smoking, alcohol abuse, physical inactivity, and low fruit and vegetable consumption (American College Health Association, 2009; Grace, 1997; Ha & Caine-Bish, 2009). Weight gain is also common among college students (Lloyd-Richardson, Bailey, Fava, & Wing, 2009; Racette, Deusinger, Strube, Highstein, & Deusinger, 2005; Wengreen & Moncur, 2009), with the frequency and magnitude of weight gain greater among men than women (Cluskey & Grobe, 2009; Racette, Deusinger, Strube, Highstein, & Deusinger, 2008). Men in college consume fast-food more frequently at lunch than females (Driskell, Meckna, & Scales, 2006), which may explain gender differences in weight gain. It is critical to have a greater understanding of factors associated with CVD risk among men in college because many modifiable CVD risk factors worsen during adolescence and young adulthood (Gordon-Larsen, Adair, Nelson, & Popkin, 2004; Gordon-Larsen, Nelson, & Popkin, 2004; Gordon-Larsen, The, & Adair, 2010; Harris, Gordon-Larsen, Chantala, & Udry, 2006).

Young adults may perceive they are at low risk for developing CVD, which may be a barrier to engaging in healthy behaviors. Although participants in the Coronary Artery Risk Development in Young Adults study generally lacked knowledge about CVD risk factors, changes in risk factors after 10 years of follow-up were similar in those with the most compared with the least knowledge (Lynch, Liu, Kiefe, & Greenland, 2006). Researchers have also reported that young adults, including those with an established cardiovascular risk factor, do not make improvements in health-risk behaviors when family members experience a heart attack or stroke (Kip, McCreath, Roseman, Hulley, & Schreiner, 2002). These data suggest that young adults may not make lifestyle changes to reduce future risk of CVD despite their knowledge and awareness of CVD risk factors.

Qualitative studies are needed to understand perceptions of CVD risk among young adult college males so that appropriate risk-reducing interventions can be implemented. Several qualitative studies have been conducted to examine factors related to healthy behaviors in college students (Boyd & Braun, 2007; Greaney et al., 2009; Luquis, Garcia, & Ashford, 2003), but little is known about perceptions of factors specific to CVD risk. Ludescher et al. (1993) previously explored male African American college students’ perceptions of stress, nutrition, and exercise as factors associated with hypertension and reported that lack of choice and financial limitations impacted satisfaction with ways of eating. Exploring perceptions specific to CVD risk in young adult Caucasian college males may provide additional insight into this largely unexplored area. Therefore, the purpose of this study was to explore Caucasian male college students’ perceptions of CVD risk.

Method

Design

A qualitative descriptive design was used to describe male college students’ perceptions of CVD risk. Qualitative descriptive studies produce findings that closely reflect the data as provided by participants and are less interpretative compared to other qualitative methods such as phenomenology (Sandelowski, 2000, 2010). Qualitative descriptive studies are useful for providing descriptions of experiences in a language that is comparable to the participants’ own language (Neergaard, Olesen, Andersen, & Sondergaard, 2009; Sandelowski, 2000).

Participants

Purposive and snowball sampling were used to recruit 10 participants in this study. A total of 10 participants were enrolled because data saturation was achieved by the 10th interview. Participants were recruited from a public, 4-year university in the southeastern United States with an enrollment of approximately 20,000 undergraduate students. Participants were freshmen (n = 3), sophomores (n = 5), and seniors (n = 2) living on (n = 6) and off-campus (n = 4). Inclusion criteria included the ability to speak English, Caucasian, male, ages 18 to 25 years, self-described as in good health, and a current undergraduate student. Exclusion criteria were being enrolled in a health-related major or having a cardiovascular-related medical diagnosis. Students enrolled in a health-related major or having a cardiovascular condition may have different perceptions regarding cardiovascular risk and may engage in health promoting behaviors due to their education or disease management.

Participants were initially recruited with the assistance from a graduate research assistant who had a close relationship with a key informant who was a student of the desired population. The key informant contacted acquaintances he thought might be interested and eligible to participate. Those who were interested in participating in the study were given the principal investigator’s ([PI], DAA) contact information and were instructed to follow up accordingly. Students who contacted the PI were given additional information regarding the study purpose and procedures and were assessed for eligibility. The PI and student then scheduled a date, time, and location to conduct the interview after determining eligibility criteria were met and the student confirmed his desire to participate.

Data Collection

Institutional review board approval was obtained prior to conducting the study. All participants provided signed informed consent prior to the interviews. Each participant was interviewed individually and completed a short demographic questionnaire that included questions on age, student status (i.e., freshman, sophomore, junior, senior), living arrangements, and major. The PI conducted all interviews using a semistructured interview guide (see the appendix). Examples of questions included “Tell me about what the risk for cardiovascular disease mean to you,” “Discuss your risks for future cardiovascular disease,” and “What influence does your health care provider have on your perceived risks for cardiovascular disease?”

The interviews were conducted in a quiet, private setting that was mutually agreed on between the participant and PI. Examples of interview settings included private study hall rooms across campus and dormitories. Each interview lasted approximately 30 to 45 minutes. Each participant received $10 for completing the interview. All interviews were audio recorded and later transcribed verbatim by the PI.

Data Analysis

Content analysis was used to analyze the data, which resulted in findings reflecting the verbal descriptions provided during the participant interviews (Sandelowski, 2000, 2011). Content analysis is a commonly used and flexible method of analyzing textual data (Hsieh & Shannon, 2005) that entails counting of the data to determine patterns (Sandelowski, 2000). Data analysis was ongoing from the start of the study. The PI independently transcribed and coded the data and regularly met with co-authors to discuss the emerging themes and corresponding quotations during the data analysis process.

The analysis process began by comparing the audio-recorded interviews to the transcriptions to correct any transcription errors and to assure accuracy. The data were managed, coded, and analyzed using Atlas Ti 5.0 (Berlin, Germany). After the data were coded, similar codes were combined in a data display to facilitate the emergence of categories and themes. A list of a priori codes was generated prior to analyzing the data. Examples included physical activity, stress, and smoking. Additional codes emerged during data analysis. Examples included habits, inconvenience, and time constraints. Data displays depicting the frequencies of the codes were created to guide the reduction of the coded data into broader categories. This process resulted in a description of perceived factors related to CVD risk as provided by the participants.

Rigor

Two strategies recommended by Creswell (2007) were used to enhance the rigor of the current study. First, credibility of findings was confirmed by performing member checks with three of the participants. The PI contacted these participants and provided a brief overview containing themes and subthemes from the data. The PI asked the participants whether the themes and subthemes accurately reflected their perceptions as provided during the interview; each participant confirmed the findings. Second, bracketing was done prior to initiating the study to clarify researcher bias by writing down assumptions, prejudices, and biases about perceptions that were expected from the students.

Results

Two themes emerged from the analysis: (a) barriers to implementing healthy lifestyle choices and (b) impact of behaviors on CVD risk. Several subthemes within each theme were apparent. The quotes in each section are examples of participants’ statements regarding those themes and subthemes.

Barriers to Implementing Healthy Lifestyle Choices

Availability of Unhealthy Foods

According to the participants, healthy food options were available on campus. However, these healthy options were overshadowed by availability of a greater number of unhealthy ones. College Male #9 stated:

I’ve gained some weight since coming to college. I think that there is a more of a lack of accessibility to those sorts of things [healthy foods]. Maybe not necessarily a lack, but an excess of the things that aren’t so good for you. Kind of harder to choose the healthier stuff with all the poor stuff.

Six participants also discussed the all-you-can eat buffet style dining on campus. These participants spoke about how this type of dining promoted unhealthy eating because they wanted to get the most food for their money. They also discussed how students overeat and choose unhealthy options in this setting. College Male #6 noted:

On Saturdays we’d get up after a long night and go and spend an hour there and just eat and eat and eat. You kind of. . . . My roommate and I would go throughout the day and almost fast . . . cause when you ate at Dining Area A . . . probably isn’t good . . . but we’d gorge ourselves. So it’s kind of . . . It’s there there’s so much to eat you can . . . so you just do it.

Time Constraints

Time constraints were considered a major barrier to living a healthy lifestyle. Participants discussed having various responsibilities while being a college student such as classes, course work, employment, and social commitments. Participants often felt it was difficult to engage in healthy behaviors while having to manage their other responsibilities. As College Male #9 noted:

For me personally, I’m involved with my church and that takes up some time . . . and I’m involved with the campus ministry which takes up some time. Obviously school work taking 19 hours each semester . . . homework and papers . . . and the social life . . . trying to balance all of that you have to cut some stuff out. . . . I probably made a poor choice to cut exercise out.

Convenience

Participants indicated that lack of convenience was a barrier to engaging in healthy behaviors. Participants discussed various challenges to using the recreational facility including distance to the facility and limited parking nearby. College Male #2 stated:

You wouldn’t think the [recreation] center is far away. Whenever you have homework and after you get done . . . you have to get ready and get your bag to take with you for lifting and stuff . . . and walk through [the parking lot] to get your car and drive to the [recreation] center and find a parking space somewhere and hope that the parking tower garage isn’t closed yet . . . then you have to walk all the way back to the [recreation] center then you go get your workout and come back . . . it’s like a 3-4 hour excursion. Then you have to always do that before it closes at midnight usually.

Participants’ diets were also influenced by convenience. Those who lived on campus indicated they would most often eat at the campus dining area closest to their dorm. For some participants, however, the most convenient dining area was perceived as having unhealthy food options. Although other campus dining facilities offered healthier food options, the convenience of dining close to their dorm was a stronger factor influencing the students’ dining location. As College Male #10 explained:

You live in Dorm A, Dining Area A is right there . . . so convenient . . . the easiest thing to do so why not do it . . . as opposed to walking to Dining Area B. South campus you have Dining Area C and . . . which is buffet and you can’t eat healthy there.

Participants living off-campus also described how convenience influenced their dietary habits, particularly the time required for meal preparation. When asked about the types of foods he prepared, College Male #5 stated:

Well . . . let’s see . . . usually macaroni and cheese and ramen noodles. They are easy to make and filling I guess. Frozen pizzas, hotdogs and hamburgers. . . . sandwiches. A lot of sandwiches and stuff like that.

College Male #6 stated:

I’d love to go have a healthy meal but it would cost me $10 for all the vegetables . . . cut them up would take an hour. I can heat this up and be done in 10 minutes.

Social Influences

Various social influences were perceived as barriers to engaging in behaviors associated with optimal cardiovascular health. For example, participants discussed social pressure for men to focus on “getting bigger” through strength training rather than emphasizing aerobic activity for cardiovascular health. College Male #7 stated:

You feel everyone else is expecting out of you . . . eat meat, exercise hard, and get big. No one is whispering much about, you got to make sure your heart is alright, you know?

Participants also discussed how peer influences promoted unhealthy behavior. College Male #9 described how his food intake was influenced by those with whom he dined:

Everyone was eating a lot . . . you really didn’t think there was anything wrong with it. Everyone around you goes up for three plates of food so why not you?

Ignoring Long-Term Consequences of Behaviors

A significant barrier to engaging in healthy lifestyle behaviors was choosing not to think about long-term behavioral consequences with respect to CVD. Participants felt that if a threat to health was not immediate, they would not address it. They also felt the risk of CVD did not feel immediate because similarly-aged peers did not experience these events. For example, College Male #5 stated:

I guess you don’t really hear about young men having heart attacks and going to the hospital. You just deal with older people . . . we don’t think about it. When you get older your co-workers and your parents and other people you know start having problems and you start to think about it.

Participants felt that health care providers should express a sense of urgency when encouraging CVD risk reducing behaviors. If a health care provider emphasized how current behaviors would lead to CVD in the future, participants would initially consider the recommendation, but ultimately not change. However, if the health care provider emphasized how the behavior could immediately contribute to CVD the recommendation would be more meaningful and the behavior change more likely to be sustained. College Male #2 remarked:

It’s one of those things that if a doctor tells you then he has to imply the immediate risks to me. You know he’d basically have to lie to me and say you have to do it now . . . it’s going to be a problem now . . . to get me to actually do anything . . . they would have to see the immediate risks before they will do anything . . . or else they’d say “well . . . I’ll fix it later.”

Impact of Behaviors on CVD Risk

Participants discussed the importance of behavioral factors in preventing CVD, particularly being physically active and eating healthy. They indicated these behaviors were vital to promote and maintain good cardiovascular health. However, they indicated they did not always engage in these healthy behaviors.

Diet and Physical Activity

Participants discussed their perceptions of how diet and physical activity were related to CVD risk and described their own behaviors to promote cardiovascular health. College Male #5 echoed:

Just try to stay away from fast food as much as possible. And making time for meals. Try to eat three meals . . . three healthy meals a day. Um . . . eat fruits and vegetables . . . stuff like that.

College Male #7 stated:

I like to get out on my bike . . . you know I feel like I accomplished something if I come home and I’m out of breath and sweating . . . I feel like I’ve done work and I feel like my body will thank me for that.

Although the participants suggested that being physically active was important for good cardiovascular health, they spoke about how their activity consisted mostly of lifting weights instead of aerobic exercises. However, they perceived aerobic activities as more important for heart health. Despite the beneficial perception of aerobic activity, most participants stated they neglected aerobic activities.

Lifestyles of Men Increase Risk

Participants perceived that the lifestyles of men including fast food consumption and neglecting aerobic activity increased the risk for CVD. Participants perceived that men are less likely to prepare their own meals, be less conscious of the foods they eat, and less likely to engage in aerobic activity. College Male #4 stated:

I think most girls will eat better than guys will. You know guys will get burgers and a pizza or something like that. Girls won’t exactly eat like that . . . they’ll eat smaller meals for the most part. . . . They’ll get the vegetable wrap or whatever and we’ll be like I’ll get this or whatever because it’s easier to get or tastes better. So I think men are the higher risk.

Overcoming Risk From Family History Through Healthy Behaviors

Participants perceived family history was an important factor related to their cardiovascular health. Participants felt if someone in their family had CVD, they would have a greater risk for a similar problem in the future. However, they also indicated family history was not the sole factor influencing cardiovascular health. According to participants, lifestyle choices would determine the extent to which family history would affect the development of CVD. As College Male #3 stated:

Some people are predetermined . . . more likely to have a certain disease or a certain condition. . . . I think I could also say that most people with work could overcome that partially at least . . . I mean most of the time.

Participants felt if their risk was greater due to a positive family history of CVD, they could overcome this risk by making healthier dietary choices and engaging in physical activity. Overall, these participants felt in control over whether or not they would develop CVD.

Discussion

Findings from this study provide evidence that despite recognizing the importance of healthy lifestyles in reducing CVD risk, young adult Caucasian college men perceive numerous barriers to engaging in these behaviors. The college years represent an important period to focus on CVD risk among men. Compared with college women, college men have lower HDL cholesterol and higher LDL cholesterol, blood pressure, fasting glucose, and body mass index (Morrell et al., 2012). Greater burden of these CVD risk factors in college men may be reflective of unhealthy behaviors that are also prevalent in this population. Many college students have diets low in fruits and vegetables (Racette et al., 2005; Strong, Parks, Anderson, Winett, & Davy, 2008), consume fast-food frequently (Driskell et al., 2006), and do not exercise regularly (Racette et al., 2008). To reduce CVD risk, the American College of Cardiology and American Heart Association recommend lifestyle changes such as consuming more fruits and vegetables, engaging in regular physical activity, and reducing saturated fat and sodium intake (Eckel et al., 2014). In order to effectively promote these healthy cardiovascular behaviors, it is first important to explore perceptions related to CVD risk among young adult college men to understand factors that may impede or facilitate behavior change in this population.

Participants in this study perceived several barriers to consuming healthy foods while being in college including a perceived abundance of less healthy foods on campus, time constraints, and convenience. These findings are consistent with other qualitative studies exploring perceptions related to health behaviors among college students (Greaney et al., 2009; Luquis et al., 2003; Nelson, Kocos, Lytle, & Perry, 2009). Despite reporting access to healthy foods on campus, participants in this study described difficulty choosing these options because they perceived less healthy items were more readily available. Buffet-style dining was also perceived as a barrier to healthy eating habits on campus. Participants felt overconsumption of food was associated with this type of environment, which is consistent with previous qualitative research (Nelson et al., 2009). Universities could promote healthier eating habits by reducing the amount of unhealthier food options and increasing the amount of tasty, healthier options that are available to students. Health care professionals should work with college males to identify and overcome perceived barriers to consuming a healthy diet to reduce CVD risk and should counsel college males about the short-term risk for weight gain due to overconsumption in buffet-style dining environments.

There is strong evidence that engaging in higher levels of physical activity is associated with lower risk for CVD (Li & Siegrist, 2012). Although many college students are sedentary (American College Health Association, 2009), physical activity was perceived as an important component of cardiovascular health among the participants in the current study. However, participants reported that time constraints and convenience influenced healthy behaviors such as engaging in physical activity, which is consistent with previous research (Nelson et al., 2009). Effective interventions to promote physical activity by overcoming these barriers are crucial to reducing CVD risk. Internet- or email-based programs that emphasize easy ways to incorporate physical activity may be options to encourage physical activity on college campuses. There is evidence that web-based programs are effective in increasing short-term physical activity (Grim, Hortz, & Petosa, 2011; Magoc, Tomaka, & Bridges-Arzaga, 2011), and email-based programs are effective in increasing moderate to vigorous physical activity in work settings (Sternfeld et al., 2009). Programs that were successful in the workplace could be adapted to help college males overcome perceived barriers impacting their ability to engage in physical activity. These programs may be most effective if administered by health care professionals because they are the most trusted source of health-related information among college students (American College Health Association, 2009).

College students’ perceptions of CVD risk may have important implications in promoting healthy behaviors in this population. As suggested in the present study, behavior change to reduce CVD risk may be more likely to occur if there is a perception of an immediate health threat. This finding is similar to Davies et al. (2000) who reported that men in college were aware of having health needs but stated they would not seek medical assistance unless in extreme pain. These views of health could be barriers to engaging in behaviors to reduce CVD risk because risk factors such as dyslipidemia, hypertension, and diabetes may be asymptomatic and therefore not perceived as a serious concern. This perspective is supported by Ludescher et al. (1993) who reported that male African American college students might forgo having their blood pressure or cholesterol checked due to the absence of signs and symptoms of these conditions. Many CVD risk factors may therefore remain unknown among college students unless detected by a health care provider or through a health-screening event. There is evidence, however, that many college students have an established CVD risk factor and could reduce their risk through lifestyle modification. In a sample of 207 college students, approximately 47% had low HDL cholesterol, 16% had hypertension, 14% had elevated triglycerides, and 7% had impaired glucose metabolism (Dalleck & Kjelland, 2012). It is therefore critical to develop effective strategies to promote healthy behaviors in this population to decrease physiological risk factors contributing to severe cardiovascular outcomes including myocardial infarction and stroke. Health care professionals should therefore consider emphasizing immediate health outcomes associated with health behaviors when working with this population.

Participants in the present study perceived that an immediate health risk must be present for behavior change to occur and that men’s lifestyles increase their risk for CVD. These findings may be interpreted in the context of gender theory, which poses that men’s health beliefs and behaviors are used to construct masculine identity (Courtenay, 2000). Masculinity has been considered an important social determinant of health that interacts with other factors to influence health outcomes (Evans, Frank, Oliffe, & Gregory, 2011). Conforming to masculine ideals has been associated with not receiving annual physical examinations and believing that a person should only admit to being sick if absolutely necessary (Mahalik, Lagan, & Morrison, 2006). Not seeking care unless there is an immediate threat to health may therefore be an expression of masculinity in this population. Young men in college may perceive that they should avoid seeking care for minor ailments as this would be viewed as a sign of weakness, but immediately concerning and severe health conditions may be perceived as threats to masculinity. Not engaging in cardiovascular-related health behaviors may also be an expression of masculinity among young adult college men. For example, participants in the present study discussed how men have pressure to increase muscle mass and that many ignore aerobic activity. The perceived impact of health conditions and behaviors in expressing masculinity may therefore serve an important role in developing effective interventions to reduce CVD risk in this population.

Limitations

This was one of the first qualitative studies to explore perceptions related to CVD risk in young adult college males. Data saturation was achieved through 10 interviews in this sample of Caucasian men, which provided an understanding of perceptions related to CVD risk in this population. Future research including students from diverse backgrounds may reveal additional perceptions regarding factors associated with CVD risk that are unique to other racial, ethnic, and cultural groups. Thus, findings from this study may not be transferrable to other populations. The sample also consisted primarily of freshmen and sophomores. College students who have had more time to adjust to college may have different perceptions about how the environment impacts CVD risk behaviors compared with those entering college. However, young adult college men in this study had similar perceptions associated with CVD risk regardless of their year in school. The living arrangements of the participants may have also influenced their perceptions related to CVD risk. Brunt and Rhee (2008) reported that students who live off-campus were more likely to be overweight or obese, consume alcohol, smoke cigarettes, and consume a lower variety of fruits and vegetables than those living on-campus. Given these behavioral differences, perceptions related to CVD risk might also be different between these two groups of students. Although these differences should be considered for future studies exploring perceptions of CVD risk in this population, students in the present study discussed similar barriers to engaging in healthy behaviors and had similar perceptions related to the importance of behaviors in reducing CVD risk despite their living arrangements.

Conclusions

This study provides evidence that young adult Caucasian college men have a basic understanding of behavioral risk factors associated with CVD and primarily view CVD risk with respect to lifestyle behaviors rather than the presence of risk factors such as hypertension, hyperlipidemia, and diabetes. Although participants in this study perceived that lifestyle behaviors play a critical role in modifying CVD risk, they perceived numerous barriers that limited their ability and desire to engage in healthy behaviors. Future research and health promotion efforts should address barriers to engaging in healthy behaviors to reduce CVD risk in this population. Given the emphasis placed on immediate consequences of unhealthy behaviors among participants in this study, focusing on immediate health consequences of behaviors associated with CVD may be an effective strategy for promoting behavior change in this population.