Evaluation of Honoring the Gift of Heart Health: The Strong Heart Study

Abstract

Due to the higher rates of cardiovascular disease (CVD), the “Honoring the Gift of Heart Health” CVD risk factor educational program was developed specifically for American Indian communities. However, the effectiveness of educational program materials may change overtime and updates may be required to influence community health behaviors. Therefore, the aim of this project was to work with American Indians to provide recommendations on updating the “Honoring the Gift of Heart Health” CVD risk factor curriculum. To achieve this aim, we used a qualitative research design and a narrative inquiry approach. We used snowball sampling to recruit American Indian community stakeholders from the Oklahoma communities that participate in the Strong Heart Study, a study of CVD among American Indians. Throughout 2022, we conducted 3 focus group discussions, with 12 total participants. Two researchers transcribed the focus group audio recordings and conducted a content analysis to identify themes and patterns. American Indian participants provided recommendations regarding educational material format, topics, and incorporating culture into learning. On average, participants spent the highest percentage of time discussing themes related to nutrition (46%), followed by educational material format, risk factors, special groups, and new recommendations. In conclusion, this project was the first step in working with American Indian communities to update an educational intervention to address the persistent public health issue of CVD.

Introduction

Cardiovascular disease (CVD) is the leading cause of death in the United States (US) and disproportionately affects American Indian (AI) communities. ¹ Over the past 5 decades, cardiovascular disease (CVD) prevalence has been rising in AI communities, which may be a result of limited access to widespread CVD prevention programs.^1,2 Results from the Strong Heart Study (SHS), the longest running and largest prospective cohort study of CVD conducted with AI communities, demonstrate that AI coronary heart disease (CHD) rates are higher than other populations in the US, and are more likely to be fatal. ³ In addition, SHS investigators have identified diabetes mellitus as a preeminent CHD risk factor, which is highly prevalent among AI.^4,5 Besides conventional clinical risk factors such as total cholesterol, LDL-cholesterol, and hypertension, ⁶ the SHS has reported that unique or emerging risk factors like albuminuria^6,7 and chronic inflammation^8,9 are prevalent and predictive of CVD among AI.^{6 -9} These unique results demonstrate the need for targeted interventions to reduce the CVD morbidity and mortality currently burdening AI communities. ¹

Culturally tailored CVD risk factor education is an integral component to intervention techniques for disease prevention, especially among AI communities most affected by CVD.^10,11 Due to the growing epidemic of CVD among AI, there is a need for updated prevention strategies, such as the Honoring the Gift of Heart Health (HGHH) cardiovascular education curriculum for AI populations. HGHH is unique because it incorporates a family-oriented approach for adopting heart health recommendations emphasizing lifestyle changes for people of all ages.^{12 -14} Although the HGHH program is a valuable resource to communities, it has not been revised since 2008. ¹⁵ The effectiveness of education program materials may have changed overtime and updates may be required to influence community health behaviors. Therefore, we worked with the AI in Oklahoma to evaluate and provide recommendations on updated the HGHH cardiovascular disease risk factor prevention curriculum.

Methods

Study Population

Since we were interested in a wide range of AI perspectives, we asked SHS field staff, who are members of the AI communities, and SHS cohort members to participate in the first focus group (n = 3). For the second focus group, we recruited community health representatives (n = 3). Since we were interested in both urban and rural perspectives, for the third focus group, we worked with a tribal liaison to recruit AI who live in urban areas of Oklahoma City but who are also members of the 7 Oklahoma communities that participate in the SHS (n = 6). The total number of participants for the 3 focus groups combined was 12.

Focus Group Process

Informal Welcome

We, the moderators, welcomed participants to the focus group session and introduced ourselves. We offered participants food and a space to share a meal in honor of AI communities’ long-standing traditions of sharing food and as a form of relationship-building. ¹⁶ This provided the opportunity for participants to introduce themselves and discuss their involvement with the SHS. Then, we presented an informal explanation of the HGHH educational program. ¹²

Focus Group Questions

We used a focus group guide to conduct the interviews. We gave participants a few minutes at the beginning of the interview to review the educational materials and get an overall impression of the presentation and informational content. We asked probing questions and prompted participants for more information throughout the interview. We grouped the focus group interview questions into 3 sections including 1. Educational Material Format, 2. Educational Topics, and 3. Learning into Practice and Culture in Learning. Examples of questions include: 1. “What changes would you make to the brochures to increase your interest in the topic?”, 2. “Do any of the topics seem confusing or unfamiliar?”, 3. “How likely would it be for you and other members of your community to change behaviors based on this educational material?” These questions along with others provided a basis for the conversational responses offered by the participants.

Closing

After discussion based on the focus group questions came to a natural conclusion, we thanked the participants for their time and participation. We asked the participants for any concluding thoughts about the materials.

Transcription and Qualitative Analysis

We collected primary data through 3 focus group sessions, which we recorded on an encrypted laptop with automatic audio-to-written transcription. We initially transcribed each focus group session for qualitative coding purposes, editing the automatic transcription along with review of the audio recording. During the second round of transcription, we corrected the transcripts. Finally, during the third round of transcription, we labeled speakers as moderator 1 to 3 or participant 1 to 6 to de-identify participants, as needed. To conduct qualitative content analysis of the focus group interviews, we used an inductive coding approach.^17,18 During the first round of transcript review, we developed codes based on themes and patterns that we identified inductively. During the second round of review, we coded the session using inductive codes. We used Excel software to create a code book, detailing code words for themes, patterns, and descriptions. We organized coded phrases and sentences according to code label words. ¹⁹

Results

The main themes that resulted from the discussion focused on nutrition, format of the materials, new recommendations, CVD risk factors (smoking, health conditions, and physical activity), and special groups including children/teens and elders (Figure 1). The moderated time for the 3 focus groups was 1.47, 1.67, and 1.37 h. On average, the participants spent the highest percentage of the discussion time on nutrition (46%), followed by educational material format, risk factors, special groups, and new recommendations (Figure 2). Specific recommendations from the 3 main questions are detailed below.

Figure 1.

Codes representing themes and patterns for focus group discussions on updating the “Honoring the Gift of Heart Health” curriculum of cardiovascular disease risk factor education in American Indians. Themes are in the colored boxes. Code words are in the gray boxes.

Figure 2.

Percent of discussion time by theme for focus group discussions on updating the “Honoring the Gift of Heart Health” curriculum of cardiovascular disease risk factor education in American Indians. n = 3 for the first focus group, n = 3 for the second focus group, and n = 6 for the third focus group, then the average of the 3 focus groups (n = 12).

Educational Material Format

Recommendations for HGHH educational material format and design include incorporating “real life” images and stories of AI community members (Table 1). In addition, including community members’ testimonial stories in the patient education booklet may also inspire people participating in the program. Stories of community members who were successful in making healthy changes and how it has affected their life may also be beneficial. Seeing and hearing from people with similar experiences, medically or culturally, may empower future participants to know that they are able to make healthy lifestyle changes too.

Table 1.

Key Recommendations for Updating the Format of Honoring the Gift of Heart Health Curriculum for Cardiovascular Disease Risk Factor Education Among American Indians.

Incorporate real life images and stories

• Seeing images of real people participating in health activities may help community members relate to the overall heart health program in a greater way than animated pictures.

• Including real community members’ testimonial stories may inspire people who are participating in the program.

Emphasize goal setting

• Goal setting activities should be kept with any program updates.

• Community members are asked to set small goals such as walking for 30 min 3 times a week. In the next education session, people are asked to share what they were able to accomplish and what problems they may have experienced trying to reach their goal.

• Goal setting activities allow community members to see that they can set attainable goals and complete those goals

In addition, the participants were excited about the title of the patient education booklet, “Your Choice for Change!”. Participants stated, “I like this book” and “I think that’s a good title, it definitely is a choice.” They also affirmed their belief that making healthy decisions is ultimately a personal choice that may be difficult. The title, “Your Choice for Change!” embodies a feeling of empowerment for community members by suggesting that they have the power to make their own healthy choices. With the positive perception of “Your Choice for Change!” and the potential difficulty of lifestyle changes, goal setting activities in the educator’s manual should be retained with any program updates. These goal setting activities allow community members to see that they can set attainable goals and complete those goals, while also planning for any barriers. They can use the skills learned through this process to continue to make heart-healthy choices.

Educational Topics

Based on the focus group discussions, the overall impression of the HGHH education program was positive, but they suggested that all materials need to be updated to reflect more recent health information and community values (Table 2). The HGHH curriculum emphasizes making healthy changes and choices as a family. Participants expressed that the family unit is an important part of community culture. With any updates to the educational materials, the aspect of family health should be retained and further emphasized. Incorporating new heart healthy changes may be challenging for an individual if other members of the household continue to practice unhealthy habits. In addition, promoting healthy change for the whole family will act as a protective factor of heart health for future generations. Healthy habits adopted by children at young ages can persist in adult years.

Table 2.

Recommendations and Examples Expressed by American Indians for the Incorporation of Culture in Learning for the “Honoring the Gift of Heart Health” Curriculum of Cardiovascular Disease Risk Factor Education.

Recommendation	Example
Family focused	Heart healthy meals for the whole family and physical activities that the entire family can participate in.
More focus on children and teens	Webpage, social media, or virtual learning may work better for this age group.
Updates regarding new forms of harmful exposures	Updated material should include information about vaping and overuse of prescription medications.
Culturally appropriate recipes	Identify heart healthy options and incorporate them into existing recipes. These may be different for individual communities.
Culturally appropriate forms of physical activity	Highlighting cultural dances as a way of promoting physical activity

Another recommendation for an updated heart health program was to create materials specifically for children and teens. Participants mentioned that the younger population may require different learning modes than adults for better program effectiveness. The creation of a sub-program for children and teens, within the overarching HGHH program, may be beneficial for the younger population.

Participants suggested that updated materials should include information about vaping and the effects of overuse of prescription medications. The use of e-cigarettes and vaping behaviors is a relatively new health concern. While the long-term and harmful effects of cigarette use are well documented, the long-term effects of vaping are still being discovered. Participants indicated that some community members do not know of the harmful effects vaping may have on their children. In a similar way that the materials outline plans to quit smoking, the materials can also include plans and information about available resources to quit vaping and the non-medically necessary use of prescription medications.

Learning into Practice/Culture in Learning

The participants also recommended making major alterations to the “Honoring Traditions with the Heart in Mind – Heart Healthy American Indian Recipes.” Participants stated that they were not familiar with the recipes currently included in the book. They would rather see familiar dishes that are altered to include heart-healthy ingredients, such as fresh vegetables. In addition, participants would appreciate lists of healthy alternative options. Therefore, alternatives for common ingredients laid out in a bulleted format would allow HGHH participating community members to easily identify heart healthy options and incorporate them into commonly used dishes. Also, because there is variability in traditional food dishes among different tribal nations, they recommended alternative recipes for many different meals. For example, one of the most common current food items in Oklahoma tribal communities is “frybread” and the accompanying “Indian taco.” Participants would like healthier alternatives to Indian tacos and options for different cooking methods such as an air fryer. They indicated that including food samples and examples in education sessions would be beneficial for people to visualize healthy options.

In addition, including more physical activities in the educator’s manual will encourage community members to engage in more exercise and learn new ways of engaging in physical activity. There is a session in the educator’s manual titled “Be More Physically Active.” One participant suggested highlighting cultural dances as a way of promoting physical activity. The participant indicated that people “have to stay in shape” if they are dancers. The educator’s manual does currently state traditional dancing as a type of activity but including more information about how traditional dances are healthy for the heart may help connect with the intended audience.

Discussion

We describe our community-based participatory approach to understanding AI community member’s beliefs and attitudes regarding updates to the cardiovascular disease educational curriculum- “Honoring the Gift of Heart Health.” Culturally tailored CVD risk factor education is an integral component to intervention techniques for disease prevention, especially among AI communities most affected by CVD.^10,11 In addition, these materials and techniques require frequent evaluation to remain relevant. This project was the first step in designing a more effective and relevant educational intervention to address cardiovascular morbidity and mortality among AIs.

During the previous development of the HGHH program, community members completed questionnaires after each learning session and suggested the use of specific cultural images and stories. ²⁰ This method for program development has appeared to work well, with independent investigators reporting improvement in heart attack symptom identification and general cardiovascular disease knowledge in the group receiving the HGHH curriculum compared to controls. ²¹ Other AI participating in the HGHH program also showed improvements in the identification of stroke symptoms, and CVD risk factor identification including hypertension, high LDL cholesterol, and trans-fat consumption.^{21 -23} For the update of materials, we used a similar method where we sought the opinions of AI in the communities where the updated program will be implemented. Based on previous methods and research the results of this study will inform the update of an effective CVD risk factor educational program that will be implemented with AI communities across the United States.

Regarding key recommendations and updates, central themes emerged on the overall cultural relevance of educational materials and their relevance within special groups. They suggest identifying heart healthy options and incorporating them into existing recipes. They recommend highlighting cultural dances as a way of promoting physical activity. In addition, they suggest that webpages, social media, or virtual learning may work better for children and teens, while an in-person interactive format may be better for elders. Since some of these factors may differ by community, such as diet, physical activity, and preferred mode of delivery, the updated program could allow individual community adaptations to make it more locally and culturally appropriate.

Although the results of this project provide valuable information about culturally relevant updates to an existing CVD risk factor educational program, there are some limitations. The beliefs expressed by the AI participating in this project are limited to 7 communities in southwest Oklahoma. To put this into context, there are 38 federally recognized tribes in Oklahoma, 574 federally recognized tribes nationally, and hundreds that are unrecognized.^16,24 Therefore, our results should not be considered transferable to all tribal communities across Oklahoma nor the US. In addition, we recruited participants from communities who have participated in the SHS, which is a long-standing epidemiologic study of CVD. ³ As a result, people residing in these communities may have different perspectives on research compared to other communities. Despite these potential limitations, this project is an example of a valuable approach for investigators in planning implementation programs designed to address CVD and other health issues with AI communities.

In conclusion, this work describes the first step in ensuring that the CVD risk factor educational program developed and implemented by the NHLBI is relevant and useful within AI communities. The HGHH program has worked well in the past to promote awareness of CVD risk factors. The design of any effective research study should include consultation of the communities they are designed to serve. Since CVD morbidity and mortality remain a persistent public health concern in AI communities, research on culturally tailored educational and interventional programs is essential in primary and secondary CVD prevention.