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Factors Related to Risk of Cardiovascular Disease Among Older Korean Chinese With Hypertension
Asian Nursing Research 5 (2011) 164e169
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Original Article
Factors Related to Risk of Cardiovascular Disease Among Older Korean Chinese With Hypertension Chun Yu Li, PhD, RN 1, Hae-Ra Han, PhD, RN 2, Jiyun Kim, PhD, RN 3, *, Miyong T. Kim, PhD, RN 4 1
School of Nursing, Yanbian University, Yanbian, China School of Nursing, Johns Hopkins University, Baltimore, USA 3 Department of Nursing, Kyungwon University, Seongnam, Korea 4 School of Nursing, Johns Hopkins University, Baltimore, USA 2
a r t i c l e i n f o
s u m m a r y
Article history: Received 14 February 2011 Received in revised form 24 August 2011 Accepted 29 August 2011
Purpose: The purpose of this study was to assess the prevalence of cardiovascular disease (CVD) risk factors among older Korean Chinese with hypertensiondone of the most underserved and understudied ethnic minority groups in China. In addition, factors underlying the risk of CVD were examined. Methods: A total of 334 participants were recruited at the Community Health Service Center in Yanji, China. Data regarding socioeconomic, health-related, psychosocial, and other CVD risk factors were collected between June and October 2009. In this cross-sectional study, factors related to the risk of CVD were assessed by multivariate logistic regression; the Framingham Risk Score was used to measure the risk of CVD. Results: The prevalence of dyslipidemia, diabetes, and current smoking were 75.4%, 6.6%, and 23.1% respectively. Participants who lived alone were twice as likely to have a high risk of CVD (10-year risk of CVD 15%; odds ratio [OR], 2.00; 95% confidence interval [CI], 1.13e3.54). Those with a higher education level and greater knowledge about hypertension were at 57% and 62% reduced risk for CVD (OR, 0.43; 95% CI, 0.21e0.92 and OR, 0.38; 95% CI, 0.15e0.95, respectively). Conclusion: Future intervention should include strategies to addressing social isolation and also focus on older Korean Chinese with low education. Knowledge enhancement program is warranted for the prevention of CVD in this population. Copyright Ó 2011, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.
Keywords: aged cardiovascular diseases hypertension minority health
Introduction The prevalence of cardiovascular disease (CVD) is increasing rapidly and has become a leading cause of mortality in China (Cao, DiGiacomo, Du, Ollerton, & Davidson, 2008; Gu et al., 2005; He et al., 2005; Wu et al., 2001). The increasing prevalence of hypertension and other CVD risk factors in China’s populations has been reported during the past few decades (Gu et al., 2002; Wu et al., 1995). This trend of increasing CVD and its risk factors in developing countries are receiving extensive global attention, as demonstrated by a recently released US Institute of Medicine report on the issue (Institute of Medicine, 2010).
* Correspondence to: Jiyun Kim, PhD, RN, Assistant Professor, Department of Nursing, Kyungwon University, San 65 Bokjeong-Dong, Sujeong-Gu, Seongnam, Gyeonggi, 461-701, Korea. E-mail address: [email protected] (J. Kim).
As clinicians, researchers, and policy planners of some developing countries such as China have begun to address this emerging health issue, the lessons learned from developed countries can offer valuable insights into prevention and management of CVD risk factors at population levels (Qin et al., 2009). Acknowledging and implementing an effective and systematic approach to prevent potential health disparities related to cardiovascular health fall into that category. In particular, a historical perspective of a pluralistic country such as the United States would be relevant to countries such as China where more than 50 ethnic minorities reside. Efforts to understand the cultural and contextual factors related to CVD risk factors of each ethnic minority community in the United States have been a fruitful strategy to reduce health disparities and deliver high quality, equitable care to increasingly diverse patient populations. The identification of the major independent risk factors for CVD such as age, gender, smoking, diabetes, cholesterol, and hypertension is very important in preventing CVD; using aggregated score of these risk factors helps predict of CVD death in many ethnic
1976-1317/$ e see front matter Copyright Ó 2011, Korean Society of Nursing Science. Published by Elsevier. All rights reserved. doi:10.1016/j.anr.2011.09.002
C.Y. Li et al. / Asian Nursing Research 5 (2011) 164e169
minorities as well as in white people (Hurley, Dickinson, Estacio, Steiner, & Havranek, 2010). Previous studies show that ethnic groups have differences in CVD risk (Chiu, Austin, Manuel, & Tu, 2010) and underserved patients has a low perception of risk and cardiovascular knowledge (Homko et al., 2008). Investigating the prevalence of CVD risk factors and factors related to aggregated score predicting CVD occurrence, especially knowledge relevant to CVD risk factors will help develop strategies for underserved population. Framingham Risk Score (FRS) is widely used as a mean to quantify the realistic risk of CVD (D’Agostino et al., 2008). Korean Chinese (KC) are the 13th largest ethnic minority among the 55 nationally acknowledged ones and reach a population of 2 million in 2005 (National Bureau of Statistics of China, 2006, Mar 16). A majority of KCddirect descendents of Koreans more than 2 centuries agodreside in the Yanbian Korean-Chinese Autonomous Prefecture, a northeastern part of China (Kim & Kim, 2005). The total population is 2.2 million, including about 0.8 million of Korean Chinese (Yanbian Tumen River Area China, n.d.). Overall, they still maintain their Korean language and traditional Korean dietary practices (D. S. Kim & J. M. Kim). While systematic health data on this group is scarce, a recent study found the prevalence of hypertension among the KC population was 45.9% among men and 31.3% among women (Wei, Sun, Xiong, & Fang, 2007). This is much higher than among the dominant Han Chinese population (37.7% in men; 28.6% in women) in the same region (Wei et al., 2007), their counterparts in Korea (24.9%) (Korea Centers for Disease Control and Prevention, 2007), and those in the United States (32%) (Kim, Kim, Juon, & Hill, 2000). In order to develop and implement an effective strategy for preventing CVD in older KC, it is critical that we have a more comprehensive understanding of a wide range of CVD risk factors and cultural/contextual factors salient to this population. Once significant CVD risk factors and their prevalence are identified among this underserved ethnic minority group in China, researchers and clinicians will be able to develop and implement effective intervention strategies, as has been the case for other ethnic minority groups in the United States (Kim et al., 2011; Kim, Han, Park, Lee, & Kim, 2006; Kim et al., 2000). Purpose The purpose of this study was to examine the prevalence of CVD risk factors among older KC with hypertension. CVD risk factors measured in the study included dyslipidemia, high-density lipoprotein (HDL) cholesterol, total cholesterol, diabetes, and smoking status. In addition, we examined a variety of socioeconomic and psychosocial factors that have been associated with increased risks for CVD. Methods Sample and setting Data were collected through a community assessment of KC in the Yanbian Korean-Chinese Autonomous Prefecture in Yanji City. Study inclusion criteria were (a) living in Yanji City, (b) age 60 years, and (c) systolic blood pressure (SBP) 140 mmHg and/or diastolic blood pressure (DBP) 90 mmHg, or being on antihypertensive medication. In order to determine sample size, we assumed that the prevalence of CVD among hypertensive individuals as 2.0% based on the previous study among Chinese population (Gu et al., 2008), because there is no statistical information of CVD occurrence among KC. We estimated our sample size to be 307 using PASS (Power Analysis and Sample Size; NCSS, Kaysville, Utah, USA) program with 90% confidence interval (CI) and a width equal to .03 when the sample proportion was .02. The total sample size
165
needed was 337 with an expected attrition rate of 10%. After obtaining institutional review board approval, we got a list of older KC with hypertension at the Yanji Community Health Center and asked the individuals to visit the center for data collection. Trained bilingual staff contacted 346 eligible individuals and final data collected from 334 individuals who gave consent to participate in this study between June 15 and October 30, 2009. Data were collected using multiple approaches including a structured questionnaire and clinical data including BP. Fasting blood samples were also drawn for measuring HDL cholesterol and total cholesterol among the eligible participants. Measurements We measured socioeconomic, health-related, and psychosocial factors known to relate to prevention and management of CVD. Socioeconomic factors included age, level of education, ability to afford medical fees, and living status. Education level was categorized into three groups: elementary school and under (years of education 6), middle school (years of education 7e9), and high school graduate and over (years of education 10). If participants felt that they could sufficiently afford their medical costs, we categorized this as “can comfortably afford treatment fees.” If participants lived alone because their partner had passed away or their children did not live with them, we defined this status as “living alone.” Health-related factors included health literacy, exercise, body mass index (BMI), duration of hypertension, health insurance, resource of care, and hypertension medication status. If participants felt that they needed someone to interpret Chinese language when they met a Chinese physician or other medical team, we categorized this as “Need interpreter.” When a participant answered “Yes” when asked, “Do you exercise for 3 or more days a week for weight control?” we categorized this as “Exercise for weight control.” BMI was categorized into three groups. BMI was measured according to a participant’s body weight (kg) and height (m); it is categorized as underweight and normal weight (BMI < 22.9 kg/m2), overweight (BMI 23.0e24.9 kg/m2), or obese (BMI 25.0 kg/m2) according to recommended standard for Asian population (World Health Organization Expert Consultation, 2004). If a participant had a particular doctor, physician’s assistant, or nurse with whom to consult or receive treatment, a regular resource of care was categorized as “having regular source.” If a participant was currently taking hypertension medication, this was categorized as “Taking BP medicine.” Psychosocial factors included hypertension knowledge, depression, and social support. Hypertension knowledge was measured using 26 items developed by the 1994 National Hypertension Education Program (National Heart, Lung, and Blood Institute, 1994) plus 14 items generated by the research team (Kim et al., 2007). Hypertension knowledge scores were determined by the number of correct responses to statements such as “You cannot prevent hypertension (yes/no question),” or “From the four answers in the answer sheet, what is not the main complication of hypertension? (Choose the right answer)” Total scores could range from 0 to 26, with higher scores representing higher levels of hypertension knowledge. This scale was used in previous studies of Korean Americans (Kim et al., 2007; Lee et al., 2010). In this study, the Cronbach’s alpha was .72 and lower 25th percentile was defined as a low knowledge level, mid-50th percentile as midknowledge level, and higher 75th percentile as high knowledge. For measuring depression, we used the Patient Health Questionnaire (PHQ)-9, a nine-item, self-report questionnaire in which participants were asked to rate how they felt during the previous 2 weeks. Each question was scored between 0 and 3 (where
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0 ¼ not at all, 1 ¼ several days, 2 ¼ more than half the days, and 3 ¼ nearly every day), with a resulting total range of 0e27 (Spitzer, Kroenke, & Williams, 1999) using the Korean version (Han, Jo, et al., 2008). The nine items reflect the Diagnostic and Statistical Manual of Mental Disorders (fourth edition; American Psychiatric Association, 2000) criteria for major depressive disorders. The validity and reliability of the PHQ-9 questionnaire have been demonstrated previously with Cronbach’s alpha .87 in this study and a cut-off score of 5 (5 is depressive) was used, as in a previous study conducted in Korean elderly (C. Han et al.). We used the Personal Resource Questionnaire (PRQ) 85-Part 2, a 25item, 7-point Likert-type questionnaire, to measure social support (Weinert, 1987). An example includes, “I belong to a group in which I feel important.’’ Higher scores indicate higher levels of perceived social support. The construct validity of the Korean version of the PRQ 85 has been tested with Korean Americans (Han, Kim, & Weinert, 2002) and Cronbach’s alpha was .87 in this study. Five and over mean score was defined as high social support. For measuring CVD risk factors, dyslipidemia, HDL cholesterol, total cholesterol, diabetes, and smoking status were selected. Dyslipidemia was defined as having one or more of the following: total cholesterol 5.2 mmol/L, triglycerides 1.7 mmol/L, HDL cholesterol < 1.0 mmol/L, or LDL cholesterol 3.4 mmol/L (Myers, Cooper, Winn, & Smith, 1989). Diabetes was defined as having a fasting plasma glucose level 7.0 mmol/L. We used the FRS for CVD to evaluate each patient’s actual risk of CVD, based on the algorithm developed by D’Agostino et al., 2008. FRS can be calculated with specific functions; risk factors included in the risk estimate were age, HDL cholesterol, total cholesterol, SBP, smoking, and diabetes (Framingham Heart Study, 2011). SBP was coded separately according to the participant’s treatment status. Scores were summed separately for men and women. The risk algorithm score, with points for each of the risk factors, was used to estimate the actual risk of CVD (National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, 2002). FRS provides a good ability to discriminate population at risk for CVD using easily measurable risk factors (Mendis, 2010). Analysis Differences in the risk factors used in the FRS according to gender were analyzed using the chi-square test and t test. Chisquare test was used to analyze the difference between dichotomous variables; level of education, affordability of medical fees, living status, health literacy, exercise, BMI, health insurance, resource of care, hypertension medication, categorized level of hypertension knowledge, depression, and categorized FRS. Age, duration of hypertension, and mean score of social support were analyzed with two-tailed t test. The main analysis of FRS was conducted using multiple logistic regression. The model was used to examine the factors related to the risk of CVD using FRS. We defined high and low actual risk of CVD as a 10-year risk of 15% and <15%, respectively, in reference to the previous study (Nanchahal, Morris, Sullivan, & Wilson, 2005). Because age, sex, and BP medication status were considered when calculating FRS, these variables were not analyzed in the logistic regression analysis. Results The characteristics of the sample are listed in Table 1. The mean age of participants was 75.0 years. Education level tended to be higher in men than in women (c2 ¼ 28.951, p < .001); women
Table 1 Sample Characteristics (N ¼ 334).a Factor
Total (N ¼ 334)
Male (n ¼ 96)
Female (n ¼ 238)
t/c2
Age, yr (SD)
75.0 (6.8) 75.7 (6.9)
75.2 (7.1)
0.666
Education Elementary school & under Middle school High school graduate & over
142 (42.5) 93 (27.8) 99 (29.6)
p .506
21 (21.9) 121 (50.8) 28.951 <.001 29 (30.2) 46 (47.9)
64 (26.9) 53 (22.3)
Can comfortably afford 187 (56.0) treatment fees Living alone 156 (46.7) Need interpreter 89 (26.6) Exercise for weight control 99 (29.6)
55 (57.3) 132 (55.5)
0.093
.761
36 (37.5) 120 (46.7) 4.588 30 (31.3) 59 (24.8) 1.461 41 (42.7) 58 (24.4) 11.031
.032 .227 .001
BMI 22.9 kg/m2 2324.9 kg/m2 25 kg/m2
148 (44.3) 92 (26.0) 19 (19.8)
52 (54.2) 25 (26.0) 19 (19.8)
96 (40.3) 67 (28.2) 75 (31.5)
6.403
.041
175 (52.4)
51 (53.1) 124 (52.1)
0.029
.865
Duration of hypertension, yr (SD) Having health insurance Having regular source of care Taking BP medicine
256 (76.6) 141 (42.2)
87 (90.6) 169 (71.0) 14.706 <.001 55 (57.3) 86 (36.1) 12.553 <.001
174 (52.1)
57 (59.4) 117 (49.2)
2.860
.091
Hypertension Knowledge Low Mid High
65 (19.5) 172 (51.5) 97 (29.0)
15 (15.6) 50 (21.0) 50 (52.1) 122 (51.3) 31 (32.3) 66 (27.7)
1.518
.468
123 (36.8)
25 (26.0)
6.735
.009
4.7 (0.7) 202 (60.5)
4.8 (0.7) 4.7 (0.7) 0.565 .573 87 (90.6) 115 (48.3) 51.223 <.001
Depression (PHQ score 5) Social support, M (SD) Higher FRS (15%)
98 (41.2)
Note. BMI ¼ body mass index; BP ¼ blood pressure; FRS ¼ Framingham Risk Score; PHQ ¼ Patient Health Questionnaire. a Except where stated otherwise, data are expressed in n (%).
tended to live alone than men (c2 ¼ 4.588, p ¼ .032). The proportion of overweight and obesity was higher in women than in men (c2 ¼ 6.403, p ¼ .041). Men tended to be more physically active than women (c2 ¼ 11.031, p ¼ .001), were more likely to have health insurance (c2 ¼ 14.706, p < .001) and a regular source of care (c2 ¼ 12.553, p < .001), and were more likely to have a higher FRS (15%) than women (c2 ¼ 51.223, p < .001). Characteristics of CVD risk factors according to the level of age and FRS by gender were presented in Table 2. The prevalence of dyslipidemia, diabetes, and current smoking were 75.4%, 6.6%, and 23.1% respectively. The prevalence of dyslipidemia, diabetes, and current smoking was higher in women than in men. The level of cholesterol is higher in high FRS group than in low FRS group among men and women. There was no significant difference in the prevalence of dyslipidemia and diabetes by the level of age in both men and women. Among women, mean value of SBP and current smoking was increased in the higher FRS group. Table 3 shows the odds ratios (OR) of high FRS (15% risk for 10year CVD) among older KC. Multivariate analysis of the factors related to the risk of CVD among KC revealed that the status of living alone was the factor significantly associated with the risk of CVD (OR, 2.00; 95% CI, 1.13e3.54). Specifically, old-age KC living alone were twice more likely to have higher risk of CVD than those living with a family member, whereas those with higher education level (OR, 0.43; 95% CI, 0.21e0.92) and more knowledge about hypertension were more likely to have a lower FRS for risk of CVD (OR 0.38, 95% CI 0.15e0.95). The risk of CVD was about 60% lower
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Table 2 Cardiovascular Disease Risk Factors According to Level of Age and FRS by Gender (N ¼ 334). Groups Total
Dyslipidemiaa n (%)
HDL cholesterol, mmol/L, M (SD)
Total Cholesterol, mmol/L, M (SD)
SBP, mmHg, M (SD)
Diabetesb n (%)
Current smoking n (%)
252 (75.4)
1.6 (0.5)
5.3 (2.2)
147.7 (17.5)
22 (6.6)
77 (23.1)
67 (69.8)
1.6 (0.6)
4.8 (1.5)
147.4 (17.5)
6 (6.3)
19 (19.8)
5 (55.6) 17 (73.9) 45 (70.3)
1.3 (0.2) 1.5 (0.3) 1.6 (0.7)
3.9 (1.2) 4.9 (0.9) 4.9 (1.6)
150.0 (17.8) 155.9 (18.3) 144.1 (16.4)
1 (11.1) 1 (4.3) 4 (6.3)
2 (22.2) 3 (13) 14 (21.9)
7 (63.6) 60 (70.6)
1.5 (0.3) 1.6 (0.6)
3.9 (1.0) 4.9 (1.5)
145.9 (18.8) 147.6 (17.5)
1 (9.1) 5 (5.9)
1 (9.1) 18 (21.2)
185 (77.7)
1.6 (0.5)
5.4 (2.4)
147.8 (17.5)
16 (6.7)
58 (24.4)
18 (78.3) 68 (81.0) 99 (75.6)
1.6 (0.3) 1.6 (0.4) 1.6 (0.6)
5.1 (1.1) 5.4 (2.0) 5.5 (2.8)
146.1 (12.2) 146.8 (15.7) 148.8 (19.3)
1 (4.3) 6 (7.1) 9 (6.9)
6 (26.1) 10 (11.9) 42 (32.1)
53 (71.6) 132 (80.5)
1.6 (0.4) 1.6 (0.6)
4.9 (0.8) 5.7 (2.8)
137.2 (12.1) 152.6 (17.4)
2 (2.7) 14 (8.5)
5 (6.8) 53 (32.3)
Men overall Age 6064 6574 >74 FRS Low High Women overall Age 60e64 6574 >74 FRS Low High
Note. FRS ¼ Framingham Risk Score; HDL ¼ high-density lipoprotein; PHQ ¼ Patient Health Questionnaire; SBP ¼ systolic blood pressure. Dyslipidemia: total cholesterol 5.2 mmol/L, HDL cholesterol < 1.0 mmol/L, serum triglycerides 1.7 mmol/L, and/or low-density lipoprotein cholesterol 3.4 mmol/L; b Fasting plasma glucose 7.0 mmol/L. a
among those highly educated and those knowledgeable about hypertension than among their counterparts. Discussion To our knowledge, this is the first study to examine overall CVD risk among older KC with hypertension. Even though direct comparison is difficult because of the differences in sample characteristics, the prevalence of dyslipidemia (75.4% vs. 53.6%) and diabetes (6.6% vs. 5.2%) were higher in older KC than in Han Chinese
Table 3 Factors Related to Risk of Cardiovascular Disease (N ¼ 334).a Factor
Odds ratio
95% CI
p
Education Elementary school & under Middle school High school graduate & over
0.44 0.43
(0.22e0.89) (0.21e0.92)
.043 .023 .028
Can comfortably afford treatment fees Living alone Need interpreter Exercise for weight control
1.63 2.00 1.25 0.81
(0.93e2.85) (1.13e3.54) (0.67e2.32) (0.45e1.47)
.089 .017 .479 .490
BMI <22.9 kg/m2 2324.9 kg/m2 25 kg/m2
0.68 0.66
(0.36e1.27) (0.35e1.24)
.330 .223 .193
Duration of hypertension (10 yr) Having health insurance Having regular source of care
0.88 1.48 1.35
(0.52e1.48) (0.70e3.17) (0.78e2.34)
.618 .308 .289
Hypertension knowledge Low Mid High
0.47 0.38
(0.20e1.13) (0.15e0.95)
.117 .091 .038
Depression (PHQ score 5) High social support Intercept
1.33 1.23 4.36
(0.76e2.35) (0.70e2.17)
.322 .470 .021
Notes. BMI ¼ body mass index; CI ¼ confidence interval; PHQ ¼ Patient Health Questionnaire. Risk estimates based on age, high-density lipoprotein cholesterol, total cholesterol, systolic blood pressure, smoking and diabetes. a
among the same age group, although the prevalence of smoking in older KC was lower than that among Chinese (23.1% vs. 11.0%) (Gu et al., 2005; Ouyang et al., 2010). In addition, the prevalence of dyslipidemia (75.4% vs. 60.3%) in KC was higher than in United States adults aged 65 and over (Mcdonald, Hertz, Unger, & Lustik, 2009). Traditionally, Koreans prefer a high carbohydrate diet (Lee, Kim, & Daly, 2008; Lee, Lee, Kim, & Han, 2009); this may be the reason for the higher prevalence of dyslipidemia and diabetes (Backes et al., 2008; Kim, Kim, Choi, & Huh, 2008; Kirk et al., 2008). To manage the heightened prevalence of cholesterol and diabetes, an educational program and culturally tailored dietary recommendations for reducing the excess carbohydrate diet are warranted. This study revealed that older KC who live alone are at a particularly higher risk of CVD. The social support including other resources did not have an effect on preventing CVD disease among older KC with hypertension. Social support from family seems to be very important in preventing CVD. Caregiving from family members can help prevent ill health (Turagabeci, Nakamura, Kizuki, & Takano, 2007). The support of family members can ensure that such people receive a nutritious diet, perform exercise, and adhere to their regular BP medication regimen (Lewis, Askie, Randleman, & Shelton-Dunston, 2010). Living with a family member is also associated with significantly decreased long-term mortality following acute myocardial infarction (Schmaltz et al., 2007). In the Korean culture, filial piety is the central value among family members despite social changes (Sung, 1990). Chronically ill seniors depend on family caregivers, even among immigrant Koreans (Han, Choi, et al., 2008; Han, Jo, et al., 2008). The basis of filial piety lies in the responsibility of children for their family and it is a general custom for old-aged parents and adult children to live together. However, in the Yanbian Korean Societyd especially after the 1992 establishment of diplomatic relations between South Korea and Chinadmany young KC women and men have gone in search of a new job in South Korea and families have dispersed (Kim & Kim, 2005). Therefore, an appropriate intervention strategy, such as a formal educational program developed from the community-based participatory research for older KC, is necessary. Moreover, intervention need to include navigating and guiding for adoption of healthy lifestyle and telephone counseling
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after education program may be effective in this population if this intervention consist of emotional support, culturally tailored diet program, exercise, weight control, and regular hypertension medication. Our analysis resulted in additional variables that were associated with increased risk for CVD: low education and low hypertension knowledge. Older KC with a low level of education had a higher risk of CVD than those with a higher level of education. This reflects the result of a previous study showing the relationship between education and overall cardiovascular scores (Gupta, Kaul, Agrawal, Guptha, & Gupta, 2010). A low level of education has been related to the rate of death from CVD (Minh, Byass, & Wall, 2003) and self-reported chronic conditions (Van Minh et al., 2008). Future intervention programs for promoting health and managing CVD risk factors should focus on disadvantaged groups, especially older KC with low education. Similarly, our findings have significant clinical implications, because they provide empirical evidence that knowledge about hypertensiondincluding information regarding complications such as CVDdis an important predictor of risk of CVD among the older KC with hypertension. The positive relationship between hypertension knowledge and adherence to BP medication has been documented in Korean Americans with hypertension (Kim et al., 2007). Previous studies revealed that the level of knowledge of CVD in underserved population such as African American in rural area was very low (Hamner, 2008). On the other hand, knowledge about hypertension, one of CVD risk factors, was found to be related to FRS in this study. A future educational strategy should include promoting hypertension knowledge among hypertensive older KC in order to prevent CVD as well as to manage hypertension. The study results need to be interpreted with the following considerations in mind. First, our sample included a group of older KC who were present at a community health center in Yanji City at the time of the study. Generalizability of the study findings is limited to those with similar characteristics that are relevant to this study. Second, the knowledge used in this study had no cutoff point and the category was divided into percentiles in this population because the participants were not particularly knowledgeable about BP issues, with no one scoring higher than 20 out of a possible 26 points. However, a relationship between knowledge about high BP and risk of CVD was found, which supports the concept that educating patients regarding BP and hypertension will not only help control their BP, but it will also help prevent CVD. This issue should be investigated further in future research, including validating hypertension knowledge questionnaire, and testing relationship with hypertension control. Third, data collection, such as about exercise and ability to afford medical fees, was achieved via a self-report method, which may have incurred measurement errors. Using objective measures of exercise, observing the type of physical activity and duration time, and data related to income level (e.g., payment of tax or personal expenses) will be helpful in future research in this population. Nevertheless, our study findings provide important insights into the prevention of CVD in a poorly studied, elderly, ethnic minority group with hypertension in China. Forth, although the FRS used in this study is well established and widely adopted to assess absolute risk of heart disease (National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III), 2002), it overestimates the risk of heart disease for Chinese population (Liu, Hong, D’Agostino, Wu, Wang, Sun, et al., 2004). For populations for which CVD risk factors and event data such as mortality are available, Framingham functions can be recalibrated and this improves estimation of CVD prediction (Liu et al., 2004). However, FRS itself can make a substantial contribution to prevention of CVD and a very cost-
effective tool for ethnic minorities with limited epidemiologic data, in disregard of imperfect predictability. Conclusions We found that the prevalence of dyslipidemia and diabetes were higher among older KC than the general Chinese population. The results highlight potential health disparities in CVD risk in China. Especially, older KC who live alone and those with low levels of education and hypertension knowledge were at a particularly high risk for CVD. The study results suggest a pressing need for recognizing social isolation as a significant CVD risk factor among older KC and develop culturally appropriate strategies to address the issue, particularly among the disadvantaged group of elders. Knowledge enhancement appears to be a potentially fruitful strategy for promoting cardiovascular health in the KC population. Conflict of interest There are no conflicts of interest. Acknowledgments This study was financially supported by Jilin Provincial Science and Technology Department in China and partially supported by Mercy Corporation. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Backes, A. C., Abbasi, F., Lamendola, C., McLaughlin, T. L., Reaven, G., & Palaniappan, L. P. (2008). Clinical experience with a relatively low carbohydrate, calorie-restricted diet improves insulin sensitivity and associated metabolic abnormalities in overweight, insulin resistant south Asian Indian women. Asia Pacific Journal of Clinical Nutrition, 17, 669e671. Cao, Y., DiGiacomo, M., Du, H. Y., Ollerton, E., & Davidson, P. (2008). Cardiovascular disease in Chinese women: an emerging high-risk population and implications for nursing practice. The Journal of Cardiovascular Nursing, 23, 386e394. Chiu, M., Austin, P. C., Manuel, D. G., & Tu, J. V. (2010). Comparison of cardiovascular risk profiles among ethnic groups using population health surveys between 1996 and 2007. Canadian Medical Association Journal, 182(8), 1e10. D’Agostino, R. B., Sr., Vasan, R. S., Pencina, M. J., Wolf, P. A., Cobain, M., Massaro, J. M., et al. (2008). General cardiovascular risk profile for use in primary care: the Framingham heart study. Circulation, 117, 743e753. Framingham Heart Study. (2011). General cardiovascular disease (10-year-risk). Retrieved March 24, 2010, from http://www.framinghamheartstudy.org/risk/ gencardio.html Gu, D., Gupta, A., Muntner, P., Hu, S., Duan, X., Chen, J., et al. (2005). Prevalence of cardiovascular disease risk factor clustering among the adult population of china: results from the international collaborative study of cardiovascular disease in Asia (InterAsia). Circulation, 112, 658e665. Gu, D., Kelly, T. N., Wu, X., Chen, J., Duan, X., Huang, J. F., et al. (2008). Blood pressure and risk of cardiovascular disease in Chinese men and women. American Journal of Hypertension, 21, 265e272. Gu, D., Reynolds, K., Wu, X., Chen, J., Duan, X., Muntner, P., et al. (2002). Prevalence, awareness, treatment, and control of hypertension in china. Hypertension, 40, 920e927. Gupta, R., Kaul, V., Agrawal, A., Guptha, S., & Gupta, V. P. (2010). Cardiovascular risk according to educational status in India. Preventive Medicine, 51, 408e411. Hamner, J. (2008). Knowledge and risk of cardiovascular disease in rural Alabama women. Journal of the American Academy of Nurse Practitioners, 20, 333e338. Han, C., Jo, S. A., Kwak, J. H., Pae, C. U., Steffens, D., Jo, I., et al. (2008). Validation of the patient health questionnaire-9 Korean version in the elderly population: the Ansan Geriatric study. Comprehensive psychiatry, 49, 218e523. Han, H. R., Choi, Y. J., Kim, M. T., Lee, J. E., & Kim, K. B. (2008). Experiences and challenges of informal caregiving for Korean immigrants. Journal of Advanced Nursing, 63, 517e526. Han, H. R., Kim, M. T., & Weinert, C. (2002). The psychometric evaluation of Korean translation of the personal resource questionnaire 85-part 2. Nursing Research, 51, 309e316. He, J., Gu, D., Wu, X., Reynolds, K., Duan, X., Yao, C., et al. (2005). Major causes of death among men and women in china. The New England Journal of Medicine, 353, 1124e1134. Homko, C. J., Santamore, W. P., Zamora, L., Shirk, G., Gaughan, J., Cross, R., et al. (2008). Cardiovascular disease knowledge and risk perception among
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Original Article
Factors Related to Risk of Cardiovascular Disease Among Older Korean Chinese With Hypertension Chun Yu Li, PhD, RN 1, Hae-Ra Han, PhD, RN 2, Jiyun Kim, PhD, RN 3, *, Miyong T. Kim, PhD, RN 4 1
School of Nursing, Yanbian University, Yanbian, China School of Nursing, Johns Hopkins University, Baltimore, USA 3 Department of Nursing, Kyungwon University, Seongnam, Korea 4 School of Nursing, Johns Hopkins University, Baltimore, USA 2
a r t i c l e i n f o
s u m m a r y
Article history: Received 14 February 2011 Received in revised form 24 August 2011 Accepted 29 August 2011
Purpose: The purpose of this study was to assess the prevalence of cardiovascular disease (CVD) risk factors among older Korean Chinese with hypertensiondone of the most underserved and understudied ethnic minority groups in China. In addition, factors underlying the risk of CVD were examined. Methods: A total of 334 participants were recruited at the Community Health Service Center in Yanji, China. Data regarding socioeconomic, health-related, psychosocial, and other CVD risk factors were collected between June and October 2009. In this cross-sectional study, factors related to the risk of CVD were assessed by multivariate logistic regression; the Framingham Risk Score was used to measure the risk of CVD. Results: The prevalence of dyslipidemia, diabetes, and current smoking were 75.4%, 6.6%, and 23.1% respectively. Participants who lived alone were twice as likely to have a high risk of CVD (10-year risk of CVD 15%; odds ratio [OR], 2.00; 95% confidence interval [CI], 1.13e3.54). Those with a higher education level and greater knowledge about hypertension were at 57% and 62% reduced risk for CVD (OR, 0.43; 95% CI, 0.21e0.92 and OR, 0.38; 95% CI, 0.15e0.95, respectively). Conclusion: Future intervention should include strategies to addressing social isolation and also focus on older Korean Chinese with low education. Knowledge enhancement program is warranted for the prevention of CVD in this population. Copyright Ó 2011, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.
Keywords: aged cardiovascular diseases hypertension minority health
Introduction The prevalence of cardiovascular disease (CVD) is increasing rapidly and has become a leading cause of mortality in China (Cao, DiGiacomo, Du, Ollerton, & Davidson, 2008; Gu et al., 2005; He et al., 2005; Wu et al., 2001). The increasing prevalence of hypertension and other CVD risk factors in China’s populations has been reported during the past few decades (Gu et al., 2002; Wu et al., 1995). This trend of increasing CVD and its risk factors in developing countries are receiving extensive global attention, as demonstrated by a recently released US Institute of Medicine report on the issue (Institute of Medicine, 2010).
* Correspondence to: Jiyun Kim, PhD, RN, Assistant Professor, Department of Nursing, Kyungwon University, San 65 Bokjeong-Dong, Sujeong-Gu, Seongnam, Gyeonggi, 461-701, Korea. E-mail address: [email protected] (J. Kim).
As clinicians, researchers, and policy planners of some developing countries such as China have begun to address this emerging health issue, the lessons learned from developed countries can offer valuable insights into prevention and management of CVD risk factors at population levels (Qin et al., 2009). Acknowledging and implementing an effective and systematic approach to prevent potential health disparities related to cardiovascular health fall into that category. In particular, a historical perspective of a pluralistic country such as the United States would be relevant to countries such as China where more than 50 ethnic minorities reside. Efforts to understand the cultural and contextual factors related to CVD risk factors of each ethnic minority community in the United States have been a fruitful strategy to reduce health disparities and deliver high quality, equitable care to increasingly diverse patient populations. The identification of the major independent risk factors for CVD such as age, gender, smoking, diabetes, cholesterol, and hypertension is very important in preventing CVD; using aggregated score of these risk factors helps predict of CVD death in many ethnic
1976-1317/$ e see front matter Copyright Ó 2011, Korean Society of Nursing Science. Published by Elsevier. All rights reserved. doi:10.1016/j.anr.2011.09.002
C.Y. Li et al. / Asian Nursing Research 5 (2011) 164e169
minorities as well as in white people (Hurley, Dickinson, Estacio, Steiner, & Havranek, 2010). Previous studies show that ethnic groups have differences in CVD risk (Chiu, Austin, Manuel, & Tu, 2010) and underserved patients has a low perception of risk and cardiovascular knowledge (Homko et al., 2008). Investigating the prevalence of CVD risk factors and factors related to aggregated score predicting CVD occurrence, especially knowledge relevant to CVD risk factors will help develop strategies for underserved population. Framingham Risk Score (FRS) is widely used as a mean to quantify the realistic risk of CVD (D’Agostino et al., 2008). Korean Chinese (KC) are the 13th largest ethnic minority among the 55 nationally acknowledged ones and reach a population of 2 million in 2005 (National Bureau of Statistics of China, 2006, Mar 16). A majority of KCddirect descendents of Koreans more than 2 centuries agodreside in the Yanbian Korean-Chinese Autonomous Prefecture, a northeastern part of China (Kim & Kim, 2005). The total population is 2.2 million, including about 0.8 million of Korean Chinese (Yanbian Tumen River Area China, n.d.). Overall, they still maintain their Korean language and traditional Korean dietary practices (D. S. Kim & J. M. Kim). While systematic health data on this group is scarce, a recent study found the prevalence of hypertension among the KC population was 45.9% among men and 31.3% among women (Wei, Sun, Xiong, & Fang, 2007). This is much higher than among the dominant Han Chinese population (37.7% in men; 28.6% in women) in the same region (Wei et al., 2007), their counterparts in Korea (24.9%) (Korea Centers for Disease Control and Prevention, 2007), and those in the United States (32%) (Kim, Kim, Juon, & Hill, 2000). In order to develop and implement an effective strategy for preventing CVD in older KC, it is critical that we have a more comprehensive understanding of a wide range of CVD risk factors and cultural/contextual factors salient to this population. Once significant CVD risk factors and their prevalence are identified among this underserved ethnic minority group in China, researchers and clinicians will be able to develop and implement effective intervention strategies, as has been the case for other ethnic minority groups in the United States (Kim et al., 2011; Kim, Han, Park, Lee, & Kim, 2006; Kim et al., 2000). Purpose The purpose of this study was to examine the prevalence of CVD risk factors among older KC with hypertension. CVD risk factors measured in the study included dyslipidemia, high-density lipoprotein (HDL) cholesterol, total cholesterol, diabetes, and smoking status. In addition, we examined a variety of socioeconomic and psychosocial factors that have been associated with increased risks for CVD. Methods Sample and setting Data were collected through a community assessment of KC in the Yanbian Korean-Chinese Autonomous Prefecture in Yanji City. Study inclusion criteria were (a) living in Yanji City, (b) age 60 years, and (c) systolic blood pressure (SBP) 140 mmHg and/or diastolic blood pressure (DBP) 90 mmHg, or being on antihypertensive medication. In order to determine sample size, we assumed that the prevalence of CVD among hypertensive individuals as 2.0% based on the previous study among Chinese population (Gu et al., 2008), because there is no statistical information of CVD occurrence among KC. We estimated our sample size to be 307 using PASS (Power Analysis and Sample Size; NCSS, Kaysville, Utah, USA) program with 90% confidence interval (CI) and a width equal to .03 when the sample proportion was .02. The total sample size
165
needed was 337 with an expected attrition rate of 10%. After obtaining institutional review board approval, we got a list of older KC with hypertension at the Yanji Community Health Center and asked the individuals to visit the center for data collection. Trained bilingual staff contacted 346 eligible individuals and final data collected from 334 individuals who gave consent to participate in this study between June 15 and October 30, 2009. Data were collected using multiple approaches including a structured questionnaire and clinical data including BP. Fasting blood samples were also drawn for measuring HDL cholesterol and total cholesterol among the eligible participants. Measurements We measured socioeconomic, health-related, and psychosocial factors known to relate to prevention and management of CVD. Socioeconomic factors included age, level of education, ability to afford medical fees, and living status. Education level was categorized into three groups: elementary school and under (years of education 6), middle school (years of education 7e9), and high school graduate and over (years of education 10). If participants felt that they could sufficiently afford their medical costs, we categorized this as “can comfortably afford treatment fees.” If participants lived alone because their partner had passed away or their children did not live with them, we defined this status as “living alone.” Health-related factors included health literacy, exercise, body mass index (BMI), duration of hypertension, health insurance, resource of care, and hypertension medication status. If participants felt that they needed someone to interpret Chinese language when they met a Chinese physician or other medical team, we categorized this as “Need interpreter.” When a participant answered “Yes” when asked, “Do you exercise for 3 or more days a week for weight control?” we categorized this as “Exercise for weight control.” BMI was categorized into three groups. BMI was measured according to a participant’s body weight (kg) and height (m); it is categorized as underweight and normal weight (BMI < 22.9 kg/m2), overweight (BMI 23.0e24.9 kg/m2), or obese (BMI 25.0 kg/m2) according to recommended standard for Asian population (World Health Organization Expert Consultation, 2004). If a participant had a particular doctor, physician’s assistant, or nurse with whom to consult or receive treatment, a regular resource of care was categorized as “having regular source.” If a participant was currently taking hypertension medication, this was categorized as “Taking BP medicine.” Psychosocial factors included hypertension knowledge, depression, and social support. Hypertension knowledge was measured using 26 items developed by the 1994 National Hypertension Education Program (National Heart, Lung, and Blood Institute, 1994) plus 14 items generated by the research team (Kim et al., 2007). Hypertension knowledge scores were determined by the number of correct responses to statements such as “You cannot prevent hypertension (yes/no question),” or “From the four answers in the answer sheet, what is not the main complication of hypertension? (Choose the right answer)” Total scores could range from 0 to 26, with higher scores representing higher levels of hypertension knowledge. This scale was used in previous studies of Korean Americans (Kim et al., 2007; Lee et al., 2010). In this study, the Cronbach’s alpha was .72 and lower 25th percentile was defined as a low knowledge level, mid-50th percentile as midknowledge level, and higher 75th percentile as high knowledge. For measuring depression, we used the Patient Health Questionnaire (PHQ)-9, a nine-item, self-report questionnaire in which participants were asked to rate how they felt during the previous 2 weeks. Each question was scored between 0 and 3 (where
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C.Y. Li et al. / Asian Nursing Research 5 (2011) 164e169
0 ¼ not at all, 1 ¼ several days, 2 ¼ more than half the days, and 3 ¼ nearly every day), with a resulting total range of 0e27 (Spitzer, Kroenke, & Williams, 1999) using the Korean version (Han, Jo, et al., 2008). The nine items reflect the Diagnostic and Statistical Manual of Mental Disorders (fourth edition; American Psychiatric Association, 2000) criteria for major depressive disorders. The validity and reliability of the PHQ-9 questionnaire have been demonstrated previously with Cronbach’s alpha .87 in this study and a cut-off score of 5 (5 is depressive) was used, as in a previous study conducted in Korean elderly (C. Han et al.). We used the Personal Resource Questionnaire (PRQ) 85-Part 2, a 25item, 7-point Likert-type questionnaire, to measure social support (Weinert, 1987). An example includes, “I belong to a group in which I feel important.’’ Higher scores indicate higher levels of perceived social support. The construct validity of the Korean version of the PRQ 85 has been tested with Korean Americans (Han, Kim, & Weinert, 2002) and Cronbach’s alpha was .87 in this study. Five and over mean score was defined as high social support. For measuring CVD risk factors, dyslipidemia, HDL cholesterol, total cholesterol, diabetes, and smoking status were selected. Dyslipidemia was defined as having one or more of the following: total cholesterol 5.2 mmol/L, triglycerides 1.7 mmol/L, HDL cholesterol < 1.0 mmol/L, or LDL cholesterol 3.4 mmol/L (Myers, Cooper, Winn, & Smith, 1989). Diabetes was defined as having a fasting plasma glucose level 7.0 mmol/L. We used the FRS for CVD to evaluate each patient’s actual risk of CVD, based on the algorithm developed by D’Agostino et al., 2008. FRS can be calculated with specific functions; risk factors included in the risk estimate were age, HDL cholesterol, total cholesterol, SBP, smoking, and diabetes (Framingham Heart Study, 2011). SBP was coded separately according to the participant’s treatment status. Scores were summed separately for men and women. The risk algorithm score, with points for each of the risk factors, was used to estimate the actual risk of CVD (National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, 2002). FRS provides a good ability to discriminate population at risk for CVD using easily measurable risk factors (Mendis, 2010). Analysis Differences in the risk factors used in the FRS according to gender were analyzed using the chi-square test and t test. Chisquare test was used to analyze the difference between dichotomous variables; level of education, affordability of medical fees, living status, health literacy, exercise, BMI, health insurance, resource of care, hypertension medication, categorized level of hypertension knowledge, depression, and categorized FRS. Age, duration of hypertension, and mean score of social support were analyzed with two-tailed t test. The main analysis of FRS was conducted using multiple logistic regression. The model was used to examine the factors related to the risk of CVD using FRS. We defined high and low actual risk of CVD as a 10-year risk of 15% and <15%, respectively, in reference to the previous study (Nanchahal, Morris, Sullivan, & Wilson, 2005). Because age, sex, and BP medication status were considered when calculating FRS, these variables were not analyzed in the logistic regression analysis. Results The characteristics of the sample are listed in Table 1. The mean age of participants was 75.0 years. Education level tended to be higher in men than in women (c2 ¼ 28.951, p < .001); women
Table 1 Sample Characteristics (N ¼ 334).a Factor
Total (N ¼ 334)
Male (n ¼ 96)
Female (n ¼ 238)
t/c2
Age, yr (SD)
75.0 (6.8) 75.7 (6.9)
75.2 (7.1)
0.666
Education Elementary school & under Middle school High school graduate & over
142 (42.5) 93 (27.8) 99 (29.6)
p .506
21 (21.9) 121 (50.8) 28.951 <.001 29 (30.2) 46 (47.9)
64 (26.9) 53 (22.3)
Can comfortably afford 187 (56.0) treatment fees Living alone 156 (46.7) Need interpreter 89 (26.6) Exercise for weight control 99 (29.6)
55 (57.3) 132 (55.5)
0.093
.761
36 (37.5) 120 (46.7) 4.588 30 (31.3) 59 (24.8) 1.461 41 (42.7) 58 (24.4) 11.031
.032 .227 .001
BMI 22.9 kg/m2 2324.9 kg/m2 25 kg/m2
148 (44.3) 92 (26.0) 19 (19.8)
52 (54.2) 25 (26.0) 19 (19.8)
96 (40.3) 67 (28.2) 75 (31.5)
6.403
.041
175 (52.4)
51 (53.1) 124 (52.1)
0.029
.865
Duration of hypertension, yr (SD) Having health insurance Having regular source of care Taking BP medicine
256 (76.6) 141 (42.2)
87 (90.6) 169 (71.0) 14.706 <.001 55 (57.3) 86 (36.1) 12.553 <.001
174 (52.1)
57 (59.4) 117 (49.2)
2.860
.091
Hypertension Knowledge Low Mid High
65 (19.5) 172 (51.5) 97 (29.0)
15 (15.6) 50 (21.0) 50 (52.1) 122 (51.3) 31 (32.3) 66 (27.7)
1.518
.468
123 (36.8)
25 (26.0)
6.735
.009
4.7 (0.7) 202 (60.5)
4.8 (0.7) 4.7 (0.7) 0.565 .573 87 (90.6) 115 (48.3) 51.223 <.001
Depression (PHQ score 5) Social support, M (SD) Higher FRS (15%)
98 (41.2)
Note. BMI ¼ body mass index; BP ¼ blood pressure; FRS ¼ Framingham Risk Score; PHQ ¼ Patient Health Questionnaire. a Except where stated otherwise, data are expressed in n (%).
tended to live alone than men (c2 ¼ 4.588, p ¼ .032). The proportion of overweight and obesity was higher in women than in men (c2 ¼ 6.403, p ¼ .041). Men tended to be more physically active than women (c2 ¼ 11.031, p ¼ .001), were more likely to have health insurance (c2 ¼ 14.706, p < .001) and a regular source of care (c2 ¼ 12.553, p < .001), and were more likely to have a higher FRS (15%) than women (c2 ¼ 51.223, p < .001). Characteristics of CVD risk factors according to the level of age and FRS by gender were presented in Table 2. The prevalence of dyslipidemia, diabetes, and current smoking were 75.4%, 6.6%, and 23.1% respectively. The prevalence of dyslipidemia, diabetes, and current smoking was higher in women than in men. The level of cholesterol is higher in high FRS group than in low FRS group among men and women. There was no significant difference in the prevalence of dyslipidemia and diabetes by the level of age in both men and women. Among women, mean value of SBP and current smoking was increased in the higher FRS group. Table 3 shows the odds ratios (OR) of high FRS (15% risk for 10year CVD) among older KC. Multivariate analysis of the factors related to the risk of CVD among KC revealed that the status of living alone was the factor significantly associated with the risk of CVD (OR, 2.00; 95% CI, 1.13e3.54). Specifically, old-age KC living alone were twice more likely to have higher risk of CVD than those living with a family member, whereas those with higher education level (OR, 0.43; 95% CI, 0.21e0.92) and more knowledge about hypertension were more likely to have a lower FRS for risk of CVD (OR 0.38, 95% CI 0.15e0.95). The risk of CVD was about 60% lower
C.Y. Li et al. / Asian Nursing Research 5 (2011) 164e169
167
Table 2 Cardiovascular Disease Risk Factors According to Level of Age and FRS by Gender (N ¼ 334). Groups Total
Dyslipidemiaa n (%)
HDL cholesterol, mmol/L, M (SD)
Total Cholesterol, mmol/L, M (SD)
SBP, mmHg, M (SD)
Diabetesb n (%)
Current smoking n (%)
252 (75.4)
1.6 (0.5)
5.3 (2.2)
147.7 (17.5)
22 (6.6)
77 (23.1)
67 (69.8)
1.6 (0.6)
4.8 (1.5)
147.4 (17.5)
6 (6.3)
19 (19.8)
5 (55.6) 17 (73.9) 45 (70.3)
1.3 (0.2) 1.5 (0.3) 1.6 (0.7)
3.9 (1.2) 4.9 (0.9) 4.9 (1.6)
150.0 (17.8) 155.9 (18.3) 144.1 (16.4)
1 (11.1) 1 (4.3) 4 (6.3)
2 (22.2) 3 (13) 14 (21.9)
7 (63.6) 60 (70.6)
1.5 (0.3) 1.6 (0.6)
3.9 (1.0) 4.9 (1.5)
145.9 (18.8) 147.6 (17.5)
1 (9.1) 5 (5.9)
1 (9.1) 18 (21.2)
185 (77.7)
1.6 (0.5)
5.4 (2.4)
147.8 (17.5)
16 (6.7)
58 (24.4)
18 (78.3) 68 (81.0) 99 (75.6)
1.6 (0.3) 1.6 (0.4) 1.6 (0.6)
5.1 (1.1) 5.4 (2.0) 5.5 (2.8)
146.1 (12.2) 146.8 (15.7) 148.8 (19.3)
1 (4.3) 6 (7.1) 9 (6.9)
6 (26.1) 10 (11.9) 42 (32.1)
53 (71.6) 132 (80.5)
1.6 (0.4) 1.6 (0.6)
4.9 (0.8) 5.7 (2.8)
137.2 (12.1) 152.6 (17.4)
2 (2.7) 14 (8.5)
5 (6.8) 53 (32.3)
Men overall Age 6064 6574 >74 FRS Low High Women overall Age 60e64 6574 >74 FRS Low High
Note. FRS ¼ Framingham Risk Score; HDL ¼ high-density lipoprotein; PHQ ¼ Patient Health Questionnaire; SBP ¼ systolic blood pressure. Dyslipidemia: total cholesterol 5.2 mmol/L, HDL cholesterol < 1.0 mmol/L, serum triglycerides 1.7 mmol/L, and/or low-density lipoprotein cholesterol 3.4 mmol/L; b Fasting plasma glucose 7.0 mmol/L. a
among those highly educated and those knowledgeable about hypertension than among their counterparts. Discussion To our knowledge, this is the first study to examine overall CVD risk among older KC with hypertension. Even though direct comparison is difficult because of the differences in sample characteristics, the prevalence of dyslipidemia (75.4% vs. 53.6%) and diabetes (6.6% vs. 5.2%) were higher in older KC than in Han Chinese
Table 3 Factors Related to Risk of Cardiovascular Disease (N ¼ 334).a Factor
Odds ratio
95% CI
p
Education Elementary school & under Middle school High school graduate & over
0.44 0.43
(0.22e0.89) (0.21e0.92)
.043 .023 .028
Can comfortably afford treatment fees Living alone Need interpreter Exercise for weight control
1.63 2.00 1.25 0.81
(0.93e2.85) (1.13e3.54) (0.67e2.32) (0.45e1.47)
.089 .017 .479 .490
BMI <22.9 kg/m2 2324.9 kg/m2 25 kg/m2
0.68 0.66
(0.36e1.27) (0.35e1.24)
.330 .223 .193
Duration of hypertension (10 yr) Having health insurance Having regular source of care
0.88 1.48 1.35
(0.52e1.48) (0.70e3.17) (0.78e2.34)
.618 .308 .289
Hypertension knowledge Low Mid High
0.47 0.38
(0.20e1.13) (0.15e0.95)
.117 .091 .038
Depression (PHQ score 5) High social support Intercept
1.33 1.23 4.36
(0.76e2.35) (0.70e2.17)
.322 .470 .021
Notes. BMI ¼ body mass index; CI ¼ confidence interval; PHQ ¼ Patient Health Questionnaire. Risk estimates based on age, high-density lipoprotein cholesterol, total cholesterol, systolic blood pressure, smoking and diabetes. a
among the same age group, although the prevalence of smoking in older KC was lower than that among Chinese (23.1% vs. 11.0%) (Gu et al., 2005; Ouyang et al., 2010). In addition, the prevalence of dyslipidemia (75.4% vs. 60.3%) in KC was higher than in United States adults aged 65 and over (Mcdonald, Hertz, Unger, & Lustik, 2009). Traditionally, Koreans prefer a high carbohydrate diet (Lee, Kim, & Daly, 2008; Lee, Lee, Kim, & Han, 2009); this may be the reason for the higher prevalence of dyslipidemia and diabetes (Backes et al., 2008; Kim, Kim, Choi, & Huh, 2008; Kirk et al., 2008). To manage the heightened prevalence of cholesterol and diabetes, an educational program and culturally tailored dietary recommendations for reducing the excess carbohydrate diet are warranted. This study revealed that older KC who live alone are at a particularly higher risk of CVD. The social support including other resources did not have an effect on preventing CVD disease among older KC with hypertension. Social support from family seems to be very important in preventing CVD. Caregiving from family members can help prevent ill health (Turagabeci, Nakamura, Kizuki, & Takano, 2007). The support of family members can ensure that such people receive a nutritious diet, perform exercise, and adhere to their regular BP medication regimen (Lewis, Askie, Randleman, & Shelton-Dunston, 2010). Living with a family member is also associated with significantly decreased long-term mortality following acute myocardial infarction (Schmaltz et al., 2007). In the Korean culture, filial piety is the central value among family members despite social changes (Sung, 1990). Chronically ill seniors depend on family caregivers, even among immigrant Koreans (Han, Choi, et al., 2008; Han, Jo, et al., 2008). The basis of filial piety lies in the responsibility of children for their family and it is a general custom for old-aged parents and adult children to live together. However, in the Yanbian Korean Societyd especially after the 1992 establishment of diplomatic relations between South Korea and Chinadmany young KC women and men have gone in search of a new job in South Korea and families have dispersed (Kim & Kim, 2005). Therefore, an appropriate intervention strategy, such as a formal educational program developed from the community-based participatory research for older KC, is necessary. Moreover, intervention need to include navigating and guiding for adoption of healthy lifestyle and telephone counseling
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after education program may be effective in this population if this intervention consist of emotional support, culturally tailored diet program, exercise, weight control, and regular hypertension medication. Our analysis resulted in additional variables that were associated with increased risk for CVD: low education and low hypertension knowledge. Older KC with a low level of education had a higher risk of CVD than those with a higher level of education. This reflects the result of a previous study showing the relationship between education and overall cardiovascular scores (Gupta, Kaul, Agrawal, Guptha, & Gupta, 2010). A low level of education has been related to the rate of death from CVD (Minh, Byass, & Wall, 2003) and self-reported chronic conditions (Van Minh et al., 2008). Future intervention programs for promoting health and managing CVD risk factors should focus on disadvantaged groups, especially older KC with low education. Similarly, our findings have significant clinical implications, because they provide empirical evidence that knowledge about hypertensiondincluding information regarding complications such as CVDdis an important predictor of risk of CVD among the older KC with hypertension. The positive relationship between hypertension knowledge and adherence to BP medication has been documented in Korean Americans with hypertension (Kim et al., 2007). Previous studies revealed that the level of knowledge of CVD in underserved population such as African American in rural area was very low (Hamner, 2008). On the other hand, knowledge about hypertension, one of CVD risk factors, was found to be related to FRS in this study. A future educational strategy should include promoting hypertension knowledge among hypertensive older KC in order to prevent CVD as well as to manage hypertension. The study results need to be interpreted with the following considerations in mind. First, our sample included a group of older KC who were present at a community health center in Yanji City at the time of the study. Generalizability of the study findings is limited to those with similar characteristics that are relevant to this study. Second, the knowledge used in this study had no cutoff point and the category was divided into percentiles in this population because the participants were not particularly knowledgeable about BP issues, with no one scoring higher than 20 out of a possible 26 points. However, a relationship between knowledge about high BP and risk of CVD was found, which supports the concept that educating patients regarding BP and hypertension will not only help control their BP, but it will also help prevent CVD. This issue should be investigated further in future research, including validating hypertension knowledge questionnaire, and testing relationship with hypertension control. Third, data collection, such as about exercise and ability to afford medical fees, was achieved via a self-report method, which may have incurred measurement errors. Using objective measures of exercise, observing the type of physical activity and duration time, and data related to income level (e.g., payment of tax or personal expenses) will be helpful in future research in this population. Nevertheless, our study findings provide important insights into the prevention of CVD in a poorly studied, elderly, ethnic minority group with hypertension in China. Forth, although the FRS used in this study is well established and widely adopted to assess absolute risk of heart disease (National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III), 2002), it overestimates the risk of heart disease for Chinese population (Liu, Hong, D’Agostino, Wu, Wang, Sun, et al., 2004). For populations for which CVD risk factors and event data such as mortality are available, Framingham functions can be recalibrated and this improves estimation of CVD prediction (Liu et al., 2004). However, FRS itself can make a substantial contribution to prevention of CVD and a very cost-
effective tool for ethnic minorities with limited epidemiologic data, in disregard of imperfect predictability. Conclusions We found that the prevalence of dyslipidemia and diabetes were higher among older KC than the general Chinese population. The results highlight potential health disparities in CVD risk in China. Especially, older KC who live alone and those with low levels of education and hypertension knowledge were at a particularly high risk for CVD. The study results suggest a pressing need for recognizing social isolation as a significant CVD risk factor among older KC and develop culturally appropriate strategies to address the issue, particularly among the disadvantaged group of elders. Knowledge enhancement appears to be a potentially fruitful strategy for promoting cardiovascular health in the KC population. Conflict of interest There are no conflicts of interest. Acknowledgments This study was financially supported by Jilin Provincial Science and Technology Department in China and partially supported by Mercy Corporation. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Backes, A. C., Abbasi, F., Lamendola, C., McLaughlin, T. L., Reaven, G., & Palaniappan, L. P. (2008). Clinical experience with a relatively low carbohydrate, calorie-restricted diet improves insulin sensitivity and associated metabolic abnormalities in overweight, insulin resistant south Asian Indian women. Asia Pacific Journal of Clinical Nutrition, 17, 669e671. Cao, Y., DiGiacomo, M., Du, H. Y., Ollerton, E., & Davidson, P. (2008). Cardiovascular disease in Chinese women: an emerging high-risk population and implications for nursing practice. The Journal of Cardiovascular Nursing, 23, 386e394. Chiu, M., Austin, P. C., Manuel, D. G., & Tu, J. V. (2010). Comparison of cardiovascular risk profiles among ethnic groups using population health surveys between 1996 and 2007. Canadian Medical Association Journal, 182(8), 1e10. D’Agostino, R. B., Sr., Vasan, R. S., Pencina, M. J., Wolf, P. A., Cobain, M., Massaro, J. M., et al. (2008). General cardiovascular risk profile for use in primary care: the Framingham heart study. Circulation, 117, 743e753. Framingham Heart Study. (2011). General cardiovascular disease (10-year-risk). Retrieved March 24, 2010, from http://www.framinghamheartstudy.org/risk/ gencardio.html Gu, D., Gupta, A., Muntner, P., Hu, S., Duan, X., Chen, J., et al. (2005). Prevalence of cardiovascular disease risk factor clustering among the adult population of china: results from the international collaborative study of cardiovascular disease in Asia (InterAsia). Circulation, 112, 658e665. Gu, D., Kelly, T. N., Wu, X., Chen, J., Duan, X., Huang, J. F., et al. (2008). Blood pressure and risk of cardiovascular disease in Chinese men and women. American Journal of Hypertension, 21, 265e272. Gu, D., Reynolds, K., Wu, X., Chen, J., Duan, X., Muntner, P., et al. (2002). Prevalence, awareness, treatment, and control of hypertension in china. Hypertension, 40, 920e927. Gupta, R., Kaul, V., Agrawal, A., Guptha, S., & Gupta, V. P. (2010). Cardiovascular risk according to educational status in India. Preventive Medicine, 51, 408e411. Hamner, J. (2008). Knowledge and risk of cardiovascular disease in rural Alabama women. Journal of the American Academy of Nurse Practitioners, 20, 333e338. Han, C., Jo, S. A., Kwak, J. H., Pae, C. U., Steffens, D., Jo, I., et al. (2008). Validation of the patient health questionnaire-9 Korean version in the elderly population: the Ansan Geriatric study. Comprehensive psychiatry, 49, 218e523. Han, H. R., Choi, Y. J., Kim, M. T., Lee, J. E., & Kim, K. B. (2008). Experiences and challenges of informal caregiving for Korean immigrants. Journal of Advanced Nursing, 63, 517e526. Han, H. R., Kim, M. T., & Weinert, C. (2002). The psychometric evaluation of Korean translation of the personal resource questionnaire 85-part 2. Nursing Research, 51, 309e316. He, J., Gu, D., Wu, X., Reynolds, K., Duan, X., Yao, C., et al. (2005). Major causes of death among men and women in china. The New England Journal of Medicine, 353, 1124e1134. Homko, C. J., Santamore, W. P., Zamora, L., Shirk, G., Gaughan, J., Cross, R., et al. (2008). Cardiovascular disease knowledge and risk perception among
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