Applying Epidemiology to Program Design: Controlling Heart Disease and Stroke (ChronicDisease) in African Americans

Chronic Health Issue and Population Identification

This program will focus on heart disease and stroke, two of the primary cardiovascular
chronic conditions identified by the CDC’s National Center for Chronic Disease Prevention and
Health Promotion among the African American population. “Heart disease” is a category of heart
conditions, including coronary artery disease (CAD), heart failure, heart valve disease, and
arrhythmia. CAD is the commonest type of heart disease in the US. On the other hand, stroke
occurs when blood supply to the brain is cut abruptly due to a blood vessel rupture or blockage.
In either case, part of the brain dies or becomes damaged, leading to long-term brain injury,
disability, or death of the patient.
Approximately 877,500 US citizens annually die from stroke, heart disease, and other
cardiovascular diseases. This translates to nearly $216 billion in healthcare costs and $147 in lost
productivity on employment due to premature deaths annually. According to the Centers for
Disease Control and Prevention (2021), heart disease and stroke are the 1 st and 5 th leading causes
of mortality in the country. Despite being the overall leading cause of mortalities in the US
population, evidence suggests that cardiovascular diseases (heart disease and stroke) are
disproportionately distributed in the US ethnic groups, affecting minority communities like
African Americans more than Whites. The rates of stroke and heart disease remain 40 percent
and 20 percent higher in the Black population than in Whites (Mensah, 2018).
The Geographic and Important Characteristics of the Population
i. Geographic Characteristics

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African American or Black American is a racial group comprising Americans with total
or partial ancestry from any black ethnic group from Africa. Generally, the term “African
American” signifies descendants or offspring of enslaved Africans from the US. In the 2020 US
census, the African American or Black alone population was estimated to be 41.1 million,
accounting for 12.4 percent of the total US population. This represents a 5.6 percent growth from
38.9 million in 2010. In comparison, at least 204.3 million people identified as White alone,
representing 61.6 percent of the entire US population (Jones et al., 2021). This disparity explains
why the African American race is often identified as a minority group in America.
Since slavery, the population of Blacks has been concentrated in the southern states and
sparsely distributed in the West. In the 2000 US census, the South (at 20%) recorded the highest
population of the African American population, followed by the Northeast (12%), the Midwest
(11%), and the West (6%). More than a million people reported as African American in all the
ten southern states – Mississippi, Alabama, South Carolina, Virginia, Louisiana, Maryland,
North Carolina, Georgia, Florida, and Texas. The state with the highest number of people
reporting as African American was New York (3,014,385). New York City (2.3 million) and
Chicago (1.1 million) were the two top cities with a population of Blacks above one million.
Houston, Philadelphia, and Detroit each recorded a population of between 500,000 and 1 million
Blacks (US Census Bureau, n.d.).
ii. Social, Religious, Cultural, and Economic Characteristics
The African American group has distinct health behaviors and social, religious, cultural,
and economic characteristics. African Americans have traditionally revered children, marriage,
and romantic partnerships. Socially, most African Americans believe in strong family ties and
long-lasting marriages or unions. This means that single-parenting and cohabiting are considered

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distasteful and off-limits among Black communities. However, structural and institutional
barriers often hinder them from realizing these values, especially for low-income earners.
African Americans also believe in integrity, honesty, and treating others with compassion –
values that prevail in most modern Black families. These values stem from the Christian roots
most Black families have been brought up in – a religious following dating back to the slavery
days. According to the Pew Research Center, nearly 83 percent of African Americans identify as
Christians, and most depend on prayer when making major decisions (Mohamed et al., 2021).
Economically, African Americans have a long history of being classified as poor and
low-income earners – aspects attributed to institutional and structural biases. For example, in
2019, the proportion of African Americans in poverty was 1.8 times higher than the general
population. African Americans accounted for nearly 13.2 percent of the overall US population
but 23.8 percent of the poverty population (Creamer, 2020). This inequality is also reflected in
average income earnings. The median household income of an African American family is
roughly $41,000 as of 2020, compared to $70,000 for a white family. Historically, racial
inequities have been reflected not in labor earnings alone but also in benefits (promotions,
bonuses, allowances, and career growth) received from employers voluntarily.
Evidence has linked the poor economic status of the Black community to existing
inequities in the distribution of critical resources like educational opportunities, disadvantaging
African American families across their lifespan. Essentially, lacking a college education has been
one of the reasons Blacks have been unable to secure high-paying jobs. In 2016, statistics show
that only 14% of African American adults had attained a bachelor’s degree compared to 23.7%
of the white adult population. About 30.8% had attained some college degree (an associate

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degree and above), compared to 47.1% of the white population (Nichols & Schak, 2017). These
factors exacerbate the high unemployment, low income, and poverty rates among Black adults.
iii. Health Behavioral Characteristics
Besides socioeconomic factors, certain health behavioral aspects predispose Blacks to
stroke and heart diseases more than any other ethnic community in the US. Some of the leading
risk factors are obesity and overweight, hypertension, cholesterol levels, cigarette smoking, and
participation in physical exercise. In 2018, African Americans were 1.3 times more likely to be
overweight and obese than whites. Between 2013 and 2016, Black women were 2.3 times more
likely to be obese and overweight than their white compatriots. This is because African
Americans are 20% less likely to participate in active physical activity than whites. Black men
are also more likely to smoke cigarettes (17.6%) than white men (16.7%). All these factors
account for the high proportions of obesity (76.1% vs. 69.8%) and hypertension (57.1% vs.
43.6%) among African Americans than whites. According to the HHS Office of Minority Health
(n.d.), because Blacks have a high risk of being overweight and obese, they are more likely to
suffer from hypertension, high-fat levels, LDL cholesterol, and diabetes – all risk variables for
stroke and heart disease.
New evidence also links cultural food practices of the African American population to
overweight and obesity – key foundational variables responsible for developing stroke and heart
diseases. For example, a study by (Sumlin & Brown, 2017) shows that most Blacks focus on a
meal’s taste, a preference deeply rooted in the community’s culture of flavoring foods. Most
Blacks consider non-healthier flavored foods as tasting better than non-flavored but healthier
foods. Therefore, a majority would opt for deep-fried foods or highly-flavored delicacies instead
of baked or boiled cuisines. Additionally, most Blacks tend to consume large portions of foods to

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show love and appreciation to those tasked with preparing their meals. The two eating practices
(preferring tastier and flavored foods and consuming large chunks) predispose African
Americans to multiple chronic conditions, including obesity and diabetes, and ultimately heart
disease and stroke.

The Disease Patterns in the Selected Population

Approximately 877,500 people die from stroke, heart disease, and other cardiovascular
diseases annually in the US. However, evidence suggests that African Americans are at the
greatest risk compared to whites and other ethnic groups of being diagnosed and dying from
heart diseases (especially cardiovascular disease), stroke, and other cardiovascular conditions.
For example, Blacks were 30% more likely to succumb to heart disease in 2018 than non-
Hispanic whites. The age-adjusted proportion of non-Hispanic Black people aged 18 years and
above diagnosed with cardiovascular disease (CAD) in 2018 was 5.4%, compared to 5.8% non-
Hispanic whites. The 2018 age-adjusted heart disease mortality rate per 100,000 was 270.6 and
168.6 for non-Hispanic Black men and women, respectively, compared to 213.1 and 130 for non-
Hispanic White men and women.

A Health Outcome to Improve

The health outcome I wish to improve is African American population’s heart disease
mortality rate. The heart disease mortality rate is the ratio of deaths/mortalities of a population in
a specific area within a specified period, usually estimated as the total deaths per one hundred
thousand people annually. I desire to significantly lower mortality rates from heart disease in the
Black community by improving access to heart disease and stroke resources and empowering
African Americans to take control of their health. This would fundamentally create health equity
in the country.

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Current Evidence that Supports the Importance of Improving the Health Outcome
Recent evidence shows that mortality rates from heart disease are alarmingly higher in
the African American ethnic group than in the white population and slightly higher than other
US minority groups like the Hispanic community. In 2018, the age-adjusted heart disease
mortality rates per 100,000 people for African American men and women were 270.6 and 168.6,
respectively. In comparison, the age-adjusted heart disease mortality rates per 100,000 people for
white men and women were 213.1 and 130.7, respectively (HHS Office of Minority Health,
n.d.). In 2015, heart disease accounted for the highest mortality rates across all ethnic groups,
including White (23.7%), Black (23.5%), Asian American/Pacific Islander (21.4%), Hispanic
(20.3%), and American Indian/Alaska Native (18%) (CDC, 2022).

The Type of Data to Collect and how to Obtain and Analyze It
For this proposal, I would predominantly collect and analyze secondary data from leading
government databases and websites like the CDC, the US Census Bureau, and the HHS Office of
Minority Health. Besides being readily and easily accessible, secondary data and statistics from
these websites are reliable and authentic. CDC is unquestionably a trustworthy resource, being
the country’s health protection institution or agency. The organization conducts integral
scientific research and provides health statistics and information that shields the county against
health threats, including chronic conditions. Secondary data from these resources is also
comprehensive because it covers multiple epidemiological and demographic aspects, including
sex, race, gender, age, and geographical locations.
I will use the following steps in collecting and analyzing the relevant data from these
databases. The first step is to open the relevant website and database links for data collection.
The second step is to retrieve appropriate data linked to heart disease, stroke, and other

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cardiovascular diseases, including their risk factors. I would use both descriptive and inferential
statistical methods in analyzing the data. Descriptive methods include measures of central
tendency (mean, mode, and median), measures of dispersion (variance, standard deviation, and
range), and measures of frequency (frequency, percent, and count). I might also use pictorial or
graphical presentations, including histograms, pie charts, and bar graphs. Inferential statistical
methods include t-tests and analysis of variance (ANOVA).

Short-and Long-Term SMART Objectives for the Program

Short-Term Objectives
i. To lower heart disease and stroke mortality rates among Blacks by 20 percent within
the next twelve months
ii. To lower heart disease and stroke prevalence rates among Blacks by 20 percent
within the next twelve months

Long-Term Objectives
i. To improve healthy dietary intake (fruits and vegetables) by 30 percent among
African Americans within the next 2-3 years
ii. To enhance physical exercise engagement by 20 percent among Blacks within the
next 2-3 years

Key Stakeholders

The key stakeholders involved in program planning are project managers, public health
workers, and other clinicians, including nurses. These individuals will form the core of the
project planning and implementation team. Other stakeholders to consider are heart disease and
stroke hospitals and clinics, heart disease and stroke patients, policymakers (lawmakers), and
related healthcare departments and agencies, including the HHS and the CDC’s Division for

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Heart Disease and Stroke Prevention, the CDC’s National Center for Chronic Disease Prevention
and Health Promotion, and the American Heart Association.
Program Planning Model and How to Plan, Implement, and Evaluate the Program
The program will use the PRECEDE-PROCEED model to plan, implement, and evaluate
the proposed heart disease and stroke intervention outcomes. The PRECEDE acronym stands for
predisposing, reinforcing, and enabling constructs in educational diagnosis and evaluation. At the
same time, the PROCEED acronym represents the policy, regulatory, and organizational
constructs in educational and environmental development (Curley, 2020). Since heart disease
and stroke are chronic lifestyle diseases, the PRECEDE-PROCEED model is best suited because
it focuses on health promotion and prevention rather than treatment.
I will use the first four steps of the PRECEDE and the last four steps of the PROCEED
phase in planning, implementing, and evaluating the program interventions. I will use the
following eight steps of the PRECEDE-PROCEED model: (1) social diagnosis, (2) behavioral,
epidemiological, & environmental diagnosis, (3) ecological & educational diagnosis, (4) policy
& administrative diagnosis, (5) implementation, (6) process evaluation, (7) impact evaluation,
and (8) outcome evaluation (Curley, 2020).

Relevant Cultural and Ethical Considerations

Major cultural considerations include the eating habits and the food preferences and
tastes of the African American community. Evidence suggests that most African Americans
prefer eating large portions of foods to show appreciation to people involved in preparing meals.
They also prefer flavored foods (Sumlin & Brown, 2017). Ethical considerations include respect
for human choices and the right to choose freely without interference. African Americans have
the right to select their preferred interventions, including food choices, and make independent

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lifestyle decisions. Before the experiment, it is also important that the informed consent of the
participants is obtained. Participants are also entitled to know the benefit and risks of their
participation, while the program leaders must guarantee participant information and data
confidentiality.

How to Fund the Program

There are multiple ways to fund the program. The first way is by seeking financial help
directly from the US Department of Health and Human Services, the CDC, the American Heart
Association, or other leading federal government agencies. The second way is by applying for
funding from private NGOs like the Bill & Melinda Gates Foundation.

Marketing Strategies

Marketing the program requires a multidimensional approach, leveraging traditional
marketing and promotional strategies and contemporary digital techniques. Traditional methods
include making advertisements on TV, radio, and newspapers; erecting billboards; and printing
flyers and posters targeting the specific target population. Digital methods include printing
promotional content on social media sites (Facebook, YouTube, Twitter) and corporate websites.
Emails, telephones, and word of mouth can also assist market the program.

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References

CDC. (2022). Heart disease facts. https://www.cdc.gov/heartdisease/facts.htm
Centers for Disease Control and Prevention. (2021). National Center for Chronic Disease
Prevention and Health Promotion (NCCDPHP): Home.
https://www.cdc.gov/chronicdisease/index.htm
Creamer, J. (2020, Sep 15). Inequities persist despite decline in poverty for all major races and
Hispanic origin groups. US Census Bureau.
https://www.census.gov/library/stories/2020/09/poverty-rates-for-blacks-and-hispanics-
reached-historic-lows-in-2019.html
Curley, A. L. C. (Ed.). (2020). Population-based nursing: Concepts and competencies for
advanced practice (3 rd ed.). Springer.
HHS Office of Minority Health. (n.d.). Heart disease and African Americans.
https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=19
Jones, N., Marks, R., Ramirez, R., & Rios-Vargas, M. (2021). The 2020 census illuminates the
racial and ethnic composition of the country. US Census Bureau.
https://www.census.gov/library/stories/2021/08/improved-race-ethnicity-measures-
reveal-united-states-population-much-more-multiracial.html
Mensah, G. A. (2018). Cardiovascular diseases in African Americans: Fostering community
partnerships to stem the tide. American Journal of Kidney Diseases, 72(1), 37-42. doi:
10.1053/j.ajkd.2018.06.026

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Mohamed, B., Cox, K., Diamant, J., & Gecewicz, C. (2021, Feb 16). Faith among Black
Americans. Pew Research Center.
https://www.pewresearch.org/religion/2021/02/16/faith-among-black-americans/
Nichols, A. H., & Schak, J. O. (2017). Degree attainment for black adults: National and state
trends. The Education Trust. https://edtrust.org/wp-content/uploads/2014/09/Black-
Degree-Attainment_FINAL.pdf
Sumlin, L. L., & Brown, S. A. (2017). Culture and food practices of African American women
with type 2 diabetes. Diabetes Education, 43(6), 565-575. doi:
10.1177/0145721717730646
US Census Bureau. (n.d.). Majority of African Americans live in 10 states; New York City and
Chicago are cities with largest Black population.
https://www.census.gov/newsroom/releases/archives/census_2000/cb01cn176.html