BIOPSYCHOSOCIAL-SPIRITUAL FACTORS IMPACTING AFRICAN AMERICAN

PATIENTS’ CARDIAC REHABILITATION REFERRAL AND PARTICIPATION

by

Aubry Nelson Koehler

March 2015

Director of Dissertation: Jennifer L. Hodgson, Ph.D.

Department of Child Development and Family Relations

African Americans carry a heavier burden of cardiovascular risk factors and have higher

rates of death from coronary heart disease than any other racial/ethnic group in the United States,

yet they are also less likely to be referred to, participate in, or benefit from Cardiac

Rehabilitation (CR). In order to investigate the demographic and biopsychosocial-spiritual

factors impacting African American patients’ referral to and participation in CR, three research

articles were completed: (a) a systematic review of the literature regarding this topic; (b) a

descriptive phenomenological study designed to explore the lived experience of seven African

American patients recovering from cardiac events and/or surgeries; and (c) a policy brief

synthesizing the findings from a systematic review of the literature and a mixed methods study to

offer policy-, programmatic-, and individual-level recommendations to best support African

American patients’ recovery from cardiac events and/or experiences. The systematic review

demonstrated a paucity of studies on the demographic and biopsychosocial-spiritual factors

impacting African American patients’ CR referral and attendance. The studies that were

identified demonstrated that, among African American patients, there was a lower likelihood for

CR referral, a higher likelihood of enrolling in CR with more cardiovascular risk factors, and a

lower likelihood of CR participation and completion due to factors related to low socioeconomic
status. The phenomenological study resulted in six emergent themes relevant to the lived

experience of seven African Americans (4 men and 3 women) who had experienced a cardiac

event and/or surgery: (a) Participants valued medical providers’ involvement during treatment

and recovery; (b) Social support and participants’ need for it changed post-event/surgery; (c)

Participants’ pre- and post-event/surgery experiences affected health outcomes; (d) Participants’

sense of agency affected their life perspectives and health behaviors; (e) Participants experienced

inconsistent referral to and utilization of CR; and (f) Participants’ investment in faith was

intensified or maintained. The policy brief emphasized the role of patients’ education and

income levels in their likelihood to attend CR. Recommendations for improving cardiac

outcomes for African American patients in the rural Southeast included systematizing orders for

CR on discharge paperwork, assessing and accounting for patients’ levels of social support and

spiritual resources, and coaching medical providers to reinforce treatment recommendations in a

way that is understandable to patients and opens up discussion regarding potential

biopsychosocial-spiritual barriers to implementing these recommendations.

BIOPSYCHOSOCIAL-SPIRITUAL FACTORS IMPACTING AFRICAN AMERICAN

PATIENTS’ CARDIAC REHABILITATION REFERRAL AND PARTICIPATION

A Dissertation

Presented to the Faculty of the Department of Child Development and Family Relations

East Carolina University

In Partial Fulfillment of the Requirements for the Degree

Doctor of Philosophy in Medical Family Therapy

by

Aubry Nelson Koehler

 © 2015

Aubry Nelson Koehler

 BIOPSYCHOSOCIAL-SPIRITUAL FACTORS IMPACTING AFRICAN AMERICAN

PATIENTS’ CARDIAC REHABILITATION REFERRAL AND PARTICIPATION

by

Aubry Nelson Koehler

APPROVED BY:

DIRECTOR OF
DISSERTATION: _______________________________________________________________
Jennifer L. Hodgson, Ph.D.

COMMITTEE MEMBER: ________________________________________________________

Bernice A. Dodor, Ph.D.

COMMITTEE MEMBER: ________________________________________________________

Sharon M. Knight, Ph.D.

COMMITTEE MEMBER: _______________________________________________________

Damon L. Rappleyea, Ph.D.

CHAIR OF THE DEPARTMENT OF CHILD

DEVELOPMENT AND FAMILY RELATIONS:______________________________________
Sharon M. Ballard, Ph.D.

DEAN OF THE
GRADUATE SCHOOL __________________________________________________________
Paul J. Gemperline, Ph.D.
 DEDICATION
This dissertation could not have been completed without the following godsends: a team

of incredibly hardworking, generous people and the participants who agreed to be a part of this

study. I would also like to dedicate this work to my mother, who nurtured my dreams and

walked with me towards them, and to Sean who is my greatest dream come true.
 ACKNOWLEDGEMENTS

I am convinced I am the luckiest doctoral student in the world. I have been blessed with

the most incredible support system, people who have believed in and advocated for me fiercely.

I could have never done enough to deserve this, but I have somehow received it anyway, and

miracles do not need explanation. Thank you to Dr. Jennifer Hodgson, my chair, advisor, and

mentor. You have grown me into a professional and a researcher that I would not be without

your mentorship. You have walked me through all the ups and downs of research, provided me

with access to research assistance, and always shown care and concern for my personal

wellbeing. Thank you for demonstrating the utmost intellectual discernment and professionalism,

while simultaneously leading with your heart.

Many thanks to Drs. Damon Rappleyea and Bernice Dodor. You two have helped me

tremendously in navigating the hinterlands of quantitative research, from study development to

operationalization and analysis. I took you on quite a tour of pie-in-the-sky analysis ideas.

Thank you for helping to ground me, while still preserving the core values and objectives of my

study. An additional thanks to Dr. Rappleyea for donating research assistant hours to my cause.

I want to thank the final member of my committee, Dr. Sharon Knight, for helping me to

remember my anthropological self. Before I became a medical family therapist, I dreamed of

being an anthropologist, riding a moped down dusty roads and gathering qualitative data in far

away places. Our conversations unveiled for me that Greenville was my India. Take away the

moped and add pavement to the streets, I could chase stories with the same fervor and curiosity.

And, in gathering the stories of others, I would be weaving a story of my own. Thank you for

helping me to see the beauty in this ever-changing tapestry of shared experience.

 To my program director, Dr. Angela Lamson, thank you for being the gatekeeper to this

incredible program. You saw the hard worker and the dreamer in me four years ago. Thank you

for believing this through the times I lost sight of it myself. Also, to Dr. Lisa Tyndall, you have

offered me big-picture guidance and mentorship over the past two-and-a-half years. I deeply

admire you professionally and personally. I thank you for our countless conversations and for

the moments you have caught me when I was faltering and scared. To me, you exemplify

courage in living authentically and lovingly. Thank you.

Beyond my faculty, I want to thank the team of individuals who supported me with my

data collection. I am still in awe that I had access to this kind of assistance for my research, and

even more so that this team was made up of some of the most devoted and skillful people I could

have imagined for the job. To Patricia Huerta, who co-parented this study with me during the

first months of recruitment, you cared for this “baby” like it was your own. You have no idea

what this meant to me, especially after I relocated for my internship in New Hampshire. To

Michelle Tracy, thank you for making follow-up calls, collecting and entering participation data,

and for your enthusiasm for this study. You are a tireless and devoted researcher. Stacey

Greenway, thank you so much for supporting Michelle’s involvement in this study, for all your

correspondence in helping me to clarify terminology and variables, and for becoming a recruiter

yourself when push came to shove. Morgan Lancaster, you have been invaluable both as a

recruiter and a triangulated researcher. You kept up with my impossible timeline and you did so

competently and cheerfully! Finally, Sarah Maton, thank you for your work as second reviewer

to my systematic review. I could not have done it without each of you.

Also involved in this study were the administrators, nurses, and staff of the East Carolina

Heart Institute who tolerated our presence during eight months of recruitment. I am so grateful
for your assistance. To the patients who spoke to us during their hospital stays, and to those who

ultimately decided to participate in the study, thank you for your very valuable and

understandably limited time and energy. You are this study.

My supervisors and co-workers at Concord Hospital/Family Medicine Residency

Program have been a great support to me in the final months of this study and throughout the

writing process. Thank you, Dr. Bill Gunn and Joni Haley, for your investment in me as an

intern, student, and human being. I appreciate the many conversations I had with each of you

about building a life and a career while also completing a doctorate.

To my family and friends, you sustained me. I want to thank my mother, Teri Nelson, for

getting me through the most overwhelming and homesick months of my life with nightly phone

calls and visits to North Carolina. And thank you to my father, John Klondike Koehler, for your

reassurance and reminders about the long-view when the short-view was all I could see. Thank

you also to my mother and my aunt, Tilly Rothwell, for lovingly proofing my final manuscript!

Next, to my program friends: when I was far from home, you provided me with a great sense of

belonging. You enlivened me with joy and humor and love. Thank you, thank you, thank you.

Of course, I have saved you, Sean Hildebrandt, for last. Had this program not brought

me to Greenville, we might never have met. Conducting a dissertation about hearts, it seems

only fitting that I would meet the man of my heart here. Thank you, Sean, for existing, for

showing me all the love and support I could ever ask for, and for creating with me a shared

future that extends forever beyond this dissertation.

 TABLE OF CONTENTS
DEDICATION .............................................................................................................................. iv

ACKNOWLEDGEMENTS ........................................................................................................... v

LIST OF TABLES ....................................................................................................................... xv

LIST OF FIGURES .................................................................................................................... xvi

PREFACE .................................................................................................................................. xvii

References ........................................................................................................................ xx

CHAPTER 1: INTRODUCTION .................................................................................................. 1

Cardiovascular Health Disparities for African Americans ................................................ 3

Cardiac Rehabilitation Referral and Participation ............................................................. 4

BPSS Factors Impacting Cardiovascular Health Behaviors for African Americans ......... 5

Biological Factors .................................................................................................. 6

Psychological Factors ............................................................................................ 7

Social Factors ......................................................................................................... 8

Spiritual Factors ..................................................................................................... 9

Culturally-Sensitive Interventions for African American Patients .................................. 10

Purpose and Design.......................................................................................................... 13

Summary .......................................................................................................................... 14

References ........................................................................................................................ 16

CHAPTER 2: DEMOGRAPHIC AND BIOPSYCHOSOCIAL-SPIRITUAL FACTORS

IMPACTING AFRICAN AMERICAN PATIENTS’ CR REFERRAL AND PARTICIPATION:

A SYSTEMATIC REVIEW ........................................................................................................ 27

Background Literature ..................................................................................................... 28

Disparities in Cardiovascular Health/Health Behaviors for African Americans . 28

 Biological factors ..................................................................................... 28

Psychological factors ............................................................................... 29

Social factors ............................................................................................ 29

Spiritual factors ........................................................................................ 30

Objectives ........................................................................................................................ 31

Method ............................................................................................................................. 31

Results .............................................................................................................................. 32

Demographic Factors: Rehabilitation Referral and Participation ........................ 32

Biological Factors: Referral and Participation ..................................................... 35

Psychological Factors: Referral and Participation ............................................... 35

Social Factors: Referral and Participation ........................................................... 36

Discussion ........................................................................................................................ 38

Implications for Future Research and Practice .................................................... 39

Limitations ........................................................................................................... 40

Conclusion ....................................................................................................................... 41

References ........................................................................................................................ 42

CHAPTER 3: METHODOLOGY ............................................................................................... 72

Mixed Methods Research ................................................................................................ 73

Study Design .................................................................................................................... 75

Setting .................................................................................................................. 77

Participants ........................................................................................................... 77

Measures .............................................................................................................. 80

Independent Variables ......................................................................................... 80

 Demographic information ........................................................................ 81

Type of cardiac event/surgery .................................................................. 81

Follow-up appointment with a cardiologist or cardiac surgeon............... 81

Anxiety and depression ............................................................................ 81

Social support........................................................................................... 82

Helpless inevitability ............................................................................... 83

Dependent Variable Measures ............................................................................. 84

Data Collection and Procedures ....................................................................................... 84

Recruitment, Enrollment, and Consent ................................................................ 84

Data Collection .................................................................................................... 86

Phase 1: Surveys (Time 1 [T1] and Time 2 [T2]) .................................... 87

Electronic Health Record and paper records ........................................... 89

Phase 2: In-depth, Open-ended, Semi-structured Interviews................... 90

Data Analysis ....................................................................................................... 91

Phase 1 ..................................................................................................... 91

Phase 2 ..................................................................................................... 92

Verification Processes .......................................................................................... 94

Statements of Bias............................................................................................................ 96

Lead Researcher ................................................................................................... 96

Triangulated Researcher ...................................................................................... 97

Ethical Considerations ..................................................................................................... 98

Summary ........................................................................................................................ 100

References ...................................................................................................................... 101

CHAPTER 4: AFRICAN AMERICAN PATIENTS’ LIVED EXPERIENCE THROUGH

CARDIAC EVENT/SURGERY AND RECOVERY ............................................................... 106

Method ........................................................................................................................... 108

Participants ......................................................................................................... 109

Data Collection and Procedures ......................................................................... 111

Enrollment and consent.......................................................................... 111

Data collection ....................................................................................... 111

Data Analysis ..................................................................................................... 112

Verification processes ............................................................................ 113

Findings.......................................................................................................................... 115

Participants Valued Medical Providers’ Involvement during Treatment and

Recovery ............................................................................................................ 116

Medical providers’ interventions impacted cardiac outcomes............... 116

Medical providers offered guidance on healthy lifestyle changes ......... 118

Participants perceived support (functional and emotional) offered by

medical providers ................................................................................... 119

Participants appreciated medical providers ........................................... 120

Participants needed additional support from medical providers ............ 121

Social Support and Participants’ Need for It Changed Post-Event/Surgery ...... 122

Social support was increased during recovery process .......................... 122

Sense of social isolation or limited support during recovery ................. 123

Challenges with social interactions and type of social support ............. 125
Participants’ Pre- & Post-Event/Surgery Experiences Affected Health Outcomes

............................................................................................................................ 127

Participants had pre-event/surgery health problems .............................. 127

Participants experienced post-event/surgery health improvements ....... 128

Post-event/surgery limitations called for lifestyle adjustments ............. 129

Some interventions ineffective or inaccessible post-event/surgery ....... 130

Sense of Agency Affected Life Perspectives & Health Behaviors .................... 132

Unpredictability of health challenges and outcomes affected distress level

................................................................................................................ 132

Participants had different levels of proactivity about health and recovery

process.................................................................................................... 133

Cardiac events/surgeries led to lifestyle changes ................................... 134

Passing on new knowledge was a part of participants’ recovery

process.................................................................................................... 136

Participants Experienced Inconsistent Referral to and Utilization of Cardiac

Rehabilitation ..................................................................................................... 137

Participants experienced health-related successes with CR................... 137

Participants experienced barriers to CR participation ........................... 138

Participants’ Investment in Faith was Intensified or Maintained ...................... 140

Involvement in faith and faith communities .......................................... 140

Faith was a source of strength and gratitude for participants ................ 141

Exhaustive Description ...................................................................................... 142

Statement of Identification ................................................................................. 145

 Discussion ...................................................................................................................... 145

Limitations ......................................................................................................... 149

Conclusion ..................................................................................................................... 150

References ...................................................................................................................... 151

CHAPTER 5: PROMOTING ACCESS TO CARDIAC REHABILITATION FOR AFRICAN

AMERICAN PATIENTS: A POLICY BRIEF.......................................................................... 162

Method ........................................................................................................................... 164

Results ............................................................................................................................ 166

Systematic Review Findings .............................................................................. 166

Quantitative Findings ......................................................................................... 167

Qualitative Findings ........................................................................................... 169

Invisible Findings: Reflections on Data Collection ........................................... 171

Implications and Recommendations .............................................................................. 173

Conclusion ..................................................................................................................... 178

References ...................................................................................................................... 179

APPENDIX A: IRB APPROVAL ............................................................................................. 196

APPENDIX B: PERMISSION TO USE MEASURES ............................................................. 198

APPENDIX C: RECRUITMENT/TELEPHONE SCRIPTS .................................................... 201

APPENDIX D: INFORMED CONSENT ................................................................................ 206

APPENDIX E: SURVEYS ........................................................................................................ 220

APPENDIX F: BEHAVIORAL HEALTH RESOURCES ....................................................... 232

APPENDIX G: INTERVIEW GUIDE ..................................................................................... 236

APPENDIX H: REFLEXIVE JOURNAL SELECTED ENTRIES .......................................... 239

APPENDIX I: STATEMENTS OF BIAS ................................................................................. 241

References ...................................................................................................................... 243

 LIST OF TABLES
CHAPTER TWO
Table 1. Article Search Summary ................................................................................................ 50

Table 2. Subject Heading Equivalencies by Database ................................................................. 67

Table 3. Study Quality Criteria. ................................................................................................... 68

Table 4. Article Summaries ......................................................................................................... 69

CHAPTER FOUR

Table 1. Participant Demographics ............................................................................................ 158

Table 2. Emergent Themes and Thematic Clusters ................................................................... 159

Table 3. Selected Examples of Narratives and Emergent Theme Formation ............................ 160

CHAPTER FIVE
Table 1. Summary of Search Terms and Equivalencies by Database ........................................ 189

Table 2. Article Summaries ....................................................................................................... 190

Table 3. Survey Participants’ Demographic Information .......................................................... 192

Table 4. Survey Participants’ Income, Education, and Cardiac Rehabilitation Attendance ...... 193

Table 5. Emergent Themes, Definitions, and Selected Quotations ........................................... 194

 LIST OF FIGURES
CHAPTER TWO
Figure 1. BPSS Factors Negatively Impacting Cardiovascular Health and Cardiovascular Health

Behaviors among African Americans .......................................................................................... 49

Figure 2. Flow Chart of Included Articles for Review ................................................................ 71

CHAPTER FIVE
Figure 1. Education and CR Attendance Participant Descriptives ............................................ 187

Figure 2. Income and CR Attendance Participant Descriptives ................................................ 188

 PREFACE

When I moved to Greenville, North Carolina in July 2012, I thought I knew what this

place would hold for me. I had planned to study pediatric and adolescent genetic and chronic

illness, a topic close to my heart. I had also planned to complete my degree and return to New

England, the “homeland,” as soon as possible. Eastern North Carolina has confronted my plans

and preconceived notions on many levels. When I first drove through the neighborhoods of

Greenville, and began working in rural community health care, I realized how many people here

were struggling with access to basic needs. In conversations with my mentor, Dr. Jennifer

Hodgson, and my peers, I also realized how frequently access to resources was divided down

racial/ethnic lines. Access to healthcare resources appeared to be no exception.

As I approached my dissertation topic in the fall of 2012, national factors were also at

play. Just a few months prior to beginning the first year of my doctoral studies, the Patient

Protection and Affordable Care Act (PPACA) had been upheld by the U.S. Supreme Court (CNN,

2012). Dr. Hodgson and I had a series of conversations about PPACA’s Readmission Reduction

Program, which would leverage payment penalties against hospitals with high 30-day

readmission ratios for myocardial infarction, heart failure, and pneumonia (Centers for Medicare

& Medicaid Services, 2013). Two out of three of these targeted conditions were cardiovascular,

so we wondered about what kind of primary, secondary, and tertiary resources would decrease

rehospitalization for cardiac patients.

When I learned about Cardiac Rehabilitation (CR), I found an anchor point: a secondary

treatment and prevention program that had been shown to offer dramatic benefits to cardiac

patients. Whether patients were being referred to and were participating in this program seemed

to be another story. Some of my preliminary reading pointed to a disparity that alarmed me.
Rates of cardiovascular disease were higher among African Americans than Non-Hispanic

Whites, but rates of referral to and participation in CR were lower for this population. That

African Americans were more vulnerable to disease but less able to access appropriate treatment

struck me as profoundly unjust. I wanted to better understand this injustice, and I wanted to

address it. This is the topic I would labor with for the next two-and-a-half years.

Over the course of the next year, I completed a systematic review (Chapter 2) of the

existing literature on biopsychosocial-spiritual factors impacting African Americans’ referral to

and participation in CR. This review demonstrated the paucity of research on this topic. I

determined that a mixed methods study would allow me to: (a) investigate whether or not the

factors deemed relevant to CR referral and participation in the general population were also

relevant to African Americans, and (b) explore the factors that members of this population

recovering from cardiac events and/or surgeries deemed relevant to their process of recovery.

As seems to often be the case, my study hit major methodological hurdles. And, as is

also often the case, I learned just as much from these hurdles as I did from the data I was actually

able to gather. My inability to recruit the number of African American participants I needed to

do a comparative racial analysis has given me a great deal to ponder (see Chapter 5). However,

due to this limitation in recruitment, my committee and I made the decision to revise the scope of

my second article (Chapter 4) to reflect only the qualitative portion of my initially-mixed

methods study.

One thing that has been constant in this process has been change. There has been an

ongoing adaptation of myself and this study, throughout, and hopefully a positive evolution of

both. I began my doctorate with a heart for one topic and developed a heart for another. I came

to Greenville with the expectation that I could live here for two years and leave unchanged and,
luckily, I was wrong. Somewhere in the midst of this journey, I realized the ludicrousness of my

preconceived notions and expectations. I realized the impossibility of staying the same. I had to

let this place change me and change my heart. It has.

There is a poetic sense to this study, a conceptualization that has inspired me when

numbers alone did not. I wanted to learn how “broken hearts” could be healed, not only through

adherence to biological and physiological treatments but also through channeling social support,

relieving psychological/emotional suffering, and connecting resources with need. If

cardiovascular disease is a state of broken heartedness, interventions that are culturally

competent and socially just are a form of love that can contribute towards that healing. Support

from others, relief of suffering, access to resources—what are these other than love? This

research is an offering and an act of love from my heart to the hearts of others.

It is my hope that readers will also let this work change them. This is an opportunity to

be drawn into a very particular issue that may shed light on issues more pervasive. May we use

what we learn to both heal and be healed.

 References

Cable News Network. (2012, Jun 28). “Timeline of the health care law.” CNN Politics.

Retrieved from http://www.cnn.com/2012/06/28/politics/supreme-court-health-timeline/

Centers for Medicare & Medicaid Services. (2013). Readmissions Reduction Program. U.S.

Centers for Medicare & Medicaid Services. Retrieved from

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html
 CHAPTER ONE: INTRODUCTION

Cardiac Rehabilitation (CR) is a secondary prevention and treatment program that has

been demonstrated to improve health outcomes for patients with cardiovascular disease (CVD)

(Brown, Clark, Dalal, Welch, & Taylor, 2011; Heran et al., 2011). Unfortunately, CR referral

and participation rates have remained low (Ayala, Xie, McGruder, & Valderrama, 2008; Suaya

et al., 2007), especially for racial/ethnic minorities (Beswick et al., 2004; Evenson, Johnson, &

Aytur, 2006; Suaya et al., 2007). African Americans, in particular, have a 20% higher age-

adjusted death rate from coronary heart disease than Non-Hispanic Whites (CDC, 2013), and

they are less likely than Non-Hispanic Whites to be referred to (Allen, Scott, Stewart, & Young,

2004; Gregory, LaVeist, & Simpson, 2006), participate in (Cannistra, O’Malley, & Balady,

1995; Evenson et al., 2006), or benefit from CR (Cannistra et al., 1995; Sanderson, Mirza, Fry,

Allison, & Bittner, 2007).

Researchers studying referral rates for cardiovascular procedures and rehabilitation

programs have found a relationship between race/ethnicity and the type of procedures/programs

recommended for or received by patients (Gregory et al., 2006; Hannan et al., 1999; Ibrahim et

al., 2003; Peterson et al., 1997; Schneider et al., 2001; van Ryn, Burgess, Malat, & Griffin, 2006).

For example, African Americans are less likely to be recommended for (Ibrahim et al., 2003) and

receive revascularization procedures (Hannan et al., 1999; Peterson et al., 1997; Schneider et al.,

2001). Researchers have also demonstrated that cardiac patients who do not receive these

procedures are, in turn, less likely to be referred for CR (Suaya et al., 2007). In relation to this

indicator, other researchers have shown that being scheduled for a follow-up appointment with a

cardiologist or cardiac surgeon is positively associated with a CR referral (Barber, Stommel,

Kroll, Holmes-Rovner, & McIntosh, 2001).

 On the level of CR participation among African Americans, researchers have identified a

number of factors associated with poorer cardiovascular health and/or decreased likelihood of

adopting heart healthy behaviors (e.g., recommended diet and exercise changes). These factors

include depressive symptoms (Dickson, McCarthy, Howe, Schipper, & Katz, 2013; Dickson,

McCarthy, & Katz, 2013), lower socioeconomic status (SES) (Blustein, Valentine, Mead, &

Regenstein, 2008), and lower levels of social support (Grewen, Anderson, Girdler, & Light,

2003; Liu & Newschaffer, 2011; Tkatch et al., 2011). Some researchers have also argued that

religious fatalism is a commonly held spiritual belief in the African American community, which

can reinforce a passive approach to self-care (Dickson, McCarthy, Howe, et al., 2013; Johnson,

Elbert-Avila, & Tulsky, 2005; Polzer & Miles, 2007) and fatalistic beliefs about cardiovascular

risk factors and health (Dickson, McCarthy, Howe, et al., 2013).

While the aforementioned studies point to a handful of demographic, biological,

psychological, social, and spiritual factors impacting cardiovascular health and health behaviors,

none have looked at how these factors impact CR referral and participation for/among African

American patients with CVD. Researchers have advocated for studies that measure the impact

of larger system factors (e.g., protocol for referral, insurance coverage) on CR participation

(Cortés & Arthur, 2006), as well as factors specific to racial/ethnic minorities in the development

of interventions for patients with CVD (Cortés & Arthur, 2006; Davis, Vinci, Okwuosa, Chase,

& Huang, 2007; Schneiderman et al., 2004). In accordance with these recommendations, this

dissertation research aims to expand and enhance this area of the literature using a systemic

Biopsychosocial-Spiritual (BPSS) theoretical approach (Engel, 1977, 1980; Wright, Watson, &

Bell, 1996) and a mixed methods design, incorporating both quantitative and qualitative methods

of data collection and analysis (Creswell, 2009).

 This chapter introduces the background knowledge related to African Americans patients’

CR referral and participation. The extant literature on cardiovascular health and cardiovascular

health behaviors for African Americans is presented using a BPSS approach. This chapter also

includes a discussion of culturally-sensitive interventions for African Americans, the theoretical

perspective and purpose of this research, and a brief description of the chapters contained in this

dissertation proposal.

Cardiovascular Health Disparities for African Americans

From prevention and intervention to mortality rates, African Americans have experienced

significant cardiovascular health disparities. In 2009, African Americans had a higher age-

adjusted death rate from coronary heart disease than Non-Hispanic Whites (141.3 per 100,000

population for African Americans compared with 117.7 per 100,000 population for Non-

Hispanic Whites) (CDC, 2013). As a population, African Americans also had a higher rate of

hypertension (41.3% among African Americans compared to 28.6% among Non-Hispanic

Whites during 2007–2010), but were less likely to have their hypertension controlled (42.5% of

African Americans compared with 52.6% of Non-Hispanic Whites) (CDC, 2013).

Although these disparities are well documented, research on the development of

interventions to address them is limited. Researchers have identified a need for interventions

tailored to racial/ethnic minority patients with CVD and have made a call for studies that

measure factors specific to these groups to assist in intervention development (Cortés & Arthur,

2006; Davis et al., 2007; Sanderson et al., 2007; Schneiderman et al., 2004). CR is an

intervention for patients with CVD that has been validated for the general population but on

which there has been little research regarding adaptation specifically for racial/ethnic minorities.

3
 Cardiac Rehabilitation Referral and Participation

Outpatient CR is an American College of Cardiology/American Heart Association

recommended program designed to treat multiple cardiovascular conditions and/or assist in the

recovery from cardiac events/surgeries (i.e., myocardial infarction [MI], coronary artery bypass

grafting [CABG], stable angina, heart valve repair/replacement, percutaneous transluminal

coronary angioplasty [PCTA] or coronary stenting, heart/heart-lung transplant, congestive heart

failure [CHF], coronary artery disease, diabetes, and/or peripheral artery disease [American

Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), 2014]). Cardiac

Rehabilitation consists of three phases, all or some of which a patient with CVD may participate

in depending on his or her disease presentation and/or availability of programs: (a) Phase I—

acute, inpatient treatment (one to 14 days), (b) Phase II—medically supervised outpatient

treatment lasting three to six months, and (c) Phase III—minimally supervised or unsupervised

maintenance (Jafri, 2004).

Although Phase I and III are also viable components of CR, Phase II CR is the phase

generally emphasized in CR treatment and discussed in the literature. Phase II CR consists of

the following: (a) physician-prescribed exercise training; (b) cardiac risk factor modification,

including education, counseling, and behavioral intervention; (c) psychosocial assessment; (d)

outcomes assessment; and (e) individualized treatment plan (AACVPR, 2014). For the purpose

of this dissertation research, Phase II CR will also be the focus of discussion and “Cardiac

Rehabilitation” and “CR” will be used to refer to this particular phase of treatment.

Cardiac Rehabilitation has been shown to reduce mortality rates related to CVD and other

conditions (Heran et al., 2011), improve depression and anxiety symptoms in patients with CVD

(Whalley et al., 2011), and lower rates of rehospitalization (Heran et al., 2011). However, only

4
about one third of eligible patients are referred to or participate in CR (Ayala et al., 2008; Cortés

& Arthur, 2006; Suaya et al., 2007). Referral and participation rates are even lower for

racial/ethnic minorities (Beswick et al., 2004; Suaya et al., 2007), including African Americans

(Evenson et al., 2006; Gregory et al., 2006). Non-Hispanic Whites are twice as likely to receive a

referral for CR than African American patients (Gregory et al. 2006), and are a third more likely

to participate than other racial/ethnic minority groups (Suaya et al., 2007).

Considering the cardiovascular health disparities experienced by African Americans

(CDC, 2013; U.S. Department of Health and Human Services–Office of Minority Health, 2012),

these rates of referral and participation are particularly disturbing. One might hypothesize CR is

not being made available and/or utilized by a population that is in dire need of it, and/or lack of

referral to and participation in CR and other cardiovascular interventions is contributing to or

compounding these disparities.

BPSS Factors Impacting Cardiovascular Health Behaviors for African Americans

The Biopsychosocial-Spiritual (BPSS) approach is a theoretical framework developed by

Engel (1977, 1980) and adapted by Wright and colleagues (1996) to promote a holistic

conceptualization of illness and health. According to Engel (1980), a patient’s experience is the

result of the intersection of biological, psychological, and social factors operating on multiple

levels of the system (i.e., societal-national level, cultural-subcultural level, community and

family levels, and the individual level). Wright and colleagues (1996) highlighted spirituality

giving way to the Biopsychosocial-Spiritual approach.

This dissertation research draws upon the BPSS approach as a foundational theoretical

perspective. The BPSS approach is particularly germane to the current research as it allows for a

holistic conceptualization of health, illness, and health behaviors by taking into account not only

5
biological factors (e.g., cardiovascular health diagnoses and disparities), but also psychological

factors (e.g., depression, self-efficacy), social factors (e.g., social support, SES), and spiritual

factors (e.g., religious/spiritual beliefs and community). The extant literature demonstrates the

importance of each of these factors (biological, psychological, social, and spiritual) on African

Americans’ cardiovascular health behaviors.

In addition to being the theoretical foundation for this dissertation research, the BPSS

approach is used in the following section as a means of categorizing the different factors

impacting cardiovascular health behaviors for African Americans. Because the research on

African Americans patients’ health behaviors specific to CR is limited (Koehler, Hodgson,

Dodor, Knight, & Rappleyea, 2014), this section looks at African American patients’

cardiovascular health behaviors more broadly.

Biological Factors

In addition to experiencing disparities in terms of cardiovascular health outcomes (CDC,

2013; U.S. Department of Health and Human Services–National Institutes of Health [DHHS–

NIH], 2012), African Americans also experience disparities in medically-indicated care (Hannan

et al., 1999; Ibrahim et al., 2003; Peterson et al., 1997; Schneider et al., 2001; van Ryn et al,

2006). When compared with Non-Hispanic Whites, African Americans were significantly less

likely to receive CABG (Hannan et al., 1999; Peterson et al., 1997) or PCTA (Peterson et al.,

1997; Schneider et al., 2001). Even when potentially confounding variables were controlled (e.g.,

age, disease status, or health risk factors), the ethnic/racial disparity in procedural

recommendations and receipt by African American patients with CVD persisted (Hannan et al.,

1999; Ibrahim et al., 2003; Peterson et al., 1997). It also appears that this disparity is the result

of “underuse” of medically indicated procedures in African Americans rather than “overuse” in

6
Non-Hispanic Whites (Schneider et al., 2001). Further, because patients who received these

procedures are also more likely to be referred to CR (Suaya et al., 2007), it is possible that

racial/ethnic disparities at the level of surgical intervention, in turn, impact CR referral and

participation.

Even when African American patients are referred to and participate in CR, Sanderson

and colleagues (2007) have identified a “benefit gap” (p. 985) in that African American patients:

(a) began CR with more cardiovascular risk factors than Non-White Hispanics and (b) ended CR

with less improvement. Sanderson and colleagues (2007) recommended the development of

population-specific interventions to address this gap. In addition to biological factors,

psychological factors also have bearing on African American cardiovascular health behaviors,

and specifically, implications for CR participation.

Psychological Factors

In the general population, depression and/or low mood have been associated with lower

rates of CR participation (Casey, Hughes, Waechter, Josephson, & Rosneck, 2008; Malach &

Imperato, 2004; Swardfager et al., 2011; Taylor, Wilson, & Sharp, 2011). Although the

relationship between depression and CR participation within the African American population

has not been studied, related research has demonstrated a negative association between levels of

depression and heart healthy self-care practices among African American patients with CHF

(Dickson, McCarthy, Howe, et al., 2013; Dickson, McCarthy, & Katz, 2013).

In contrast, high levels of self-efficacy in African American patients with CHF have been

shown to be positively correlated with self-care (Warren-Findlow, Seymour, & Brunner Huber,

2012). Depression, self-care, and self-efficacy may all have implications for participation in CR,

as an intervention promoting health behavior change, but unfortunately there have been no

7
studies investigating this particular relationship. The next section looks at social factors

impacting cardiovascular health behaviors in African Americans.

Social Factors

In addition to biological and psychological factors, a number of social factors have

implications for African Americans’ cardiovascular health behaviors. Racism, a societal-

national factor experienced on the community, family, and individual levels, has been shown to

increase cardiovascular risk factors for African Americans (Din-Dzietham, Nembhard, Collins,

& Davis, 2004; Lewis, Aiello, Leurgans, Kelly, & Barnes, 2010). Physicians’ treatment

recommendations have also been shown to be guided by assumptions regarding patients’ level of

education and exercise preferences, and these assumption-guided recommendations have further

compounded racial/ethnic disparities experienced by patients (van Ryn et al., 2006).

Culturally-specific health beliefs held by some African Americans may also influence

self-care behaviors related to cardiovascular health (Dickson, McCarthy, Howe, et al., 2013;

Ford, Kim, & Dancy, 2009; Warren-Findlow & Issel, 2010). For example, in three studies,

cardiovascular risk factors or diseases were accepted as normative and/or unavoidable (Dickson,

McCarthy, Howe, et al., 2013; Ford et al., 2009; Warren-Findlow & Issel, 2010). In their study

of patients with CHF, Dickson, McCarthy, Howe, and colleagues (2013) noticed that this belief,

along with the belief that stress increased CHF symptoms, was correlated with a more passive

approach to self-care (e.g., “stay in bed,” “relax…let it pass,” p. 115). Although these

researchers did not comment directly on CR, one can imagine how this sort of approach would

be largely incompatible with CR participation and the activities it requires and promotes.

Researchers have also demonstrated the importance of patient-provider communication

(Collins, Clark, Petersen, & Kressin, 2002; Lutfiyya, Cumba, McCullough, Barlow, & Lipsky,

8
2008; Shaw, Armin, Torres, Orzech, & Vivian, 2012) and social support from friends and family

in promoting cardiovascular self-care in African American patients (Grewen et al., 2003; Liu &

Newschaffer, 2011; Tkatch et al., 2011). With regard to patient-provider communication,

Collins and colleagues (2002) found African American patients cited rapport-building and

establishing trust in the provider as very important, especially before consenting to a procedure.

With regard to social support, researchers uncovered a positive relationship between higher

levels of support and improved cardiovascular health and cardiovascular health behaviors

(Grewen et al., 2003; Liu & Newschaffer, 2011; Tkatch et al., 2011).

Finally, there appears to be a negative correlation between SES among African

Americans and access to resources for self-care/cardiovascular health behaviors (Blustein et al.,

2008; Wexler et al., 2008). For example, Wexler argued that limited resources may influence

exercise behaviors more than differences in attitudes or beliefs about exercising. It may follow

that individuals without access to resources for self-care will also be less likely to have resources

to participate in CR and its recommended activities.

Spiritual Factors

Last but not least, spirituality has been shown to have a culturally-specific presentation

among African Americans (Newlin, Knafl, & Melkus, 2002) and to be particularly important for

many African Americans in the provision of medical and behavioral health care (Carter, 2002;

Johnson et al., 2005). Unfortunately, the literature regarding the impact of spiritual factors on

African American patients’ cardiovascular health behaviors is ambiguous. On the one hand,

spirituality has been cited as an emotional coping strategy for managing the stress of

cardiovascular health problems (Dickson, McCarthy, Howe, et al., 2013; Johnson et al., 2005;

Warren-Findlow & Issel, 2010). On the other hand, religious fatalism (i.e., a belief that a higher

9
power has control over the events and outcomes of an individual’s life) may promote a passive

approach to self-care (Dickson, McCarthy, Howe, et al., 2013; Polzer & Miles, 2007). This, in

turn, may be problematic for participation in CR.

Some researchers working on cardiovascular studies and interventions for African

Americans have successfully drawn upon the community spiritual resources, for example, by

involving local churches in the study or intervention (Kalenderian et al., 2009; Peterson & Cheng,

2011; Plescia, Herrick, & Chavis, 2008; Yanek, Becker, Moy, Gittelsohn, & Koffman, 2001).

However, in a study that compared attendance to a church-based and clinic-based exercise

program for women, age was found to be the independent predictor of attendance rather than

location (women ages 50-70 were more likely to attend) (Dornelas, Stepnowski, Fischer, &

Thompson, 2007). Researchers have also cautioned those developing interventions from making

the assumption that all African Americans are religious (Rucker-Whitaker et al., 2006).

The preceding section has reviewed various biological, psychological, social, and

spiritual factors impacting African Americans’ cardiovascular health behaviors. The following

section continues the discussion started here regarding the development and implementation of

culturally-sensitive interventions for African American patients.

Culturally-Sensitive Interventions for African American Patients

The historical traumas African Americans have suffered at the hands of the White

majority have been both countless and egregious. From a century of enslavement to legacies of

exploitation by the medical and scientific research communities (e.g., Marion Sims’

experimental fistula operations on female slaves, the Tuskegee Syphilis study on lower SES

African American males) (Washington, 2006), there is little wonder why African Americans may

be cautious about involving themselves in current research studies and medical interventions.

10
While understandable, this reticence also presents a barrier to developing and improving

interventions for African Americans; without recruiting and retaining members of this population,

researchers are hard pressed to validate culturally-appropriate interventions and best practices

which may ultimately serve to improve health outcomes and lower mortality rates.

Over the past two decades, the NIH has set forth guidelines for research requiring the

recruitment of women and minorities in clinical research (DHHS–NIH, 2001). These guidelines

have given researchers incentive to recruit minorities; however, they do not necessarily offer

solutions to problems of recruitment and retention. Further, simply including minorities in

studies does not necessarily support the development of interventions or best practices for these

populations. Schneiderman and colleagues’ (2004) post hoc analysis of the Enhancing Recovery

in Coronary Heart Disease Clinical Trial (ENRICHD) found significant treatment effects for

White men receiving the intervention, but not for White women or minority men or women.

These researchers argued it is essential that studies not only recruit and retain minority

populations, but also “consider carefully the sociodemographic attributes of the population in

designing the behavioral interventions” (Schneiderman et al., 2004, p. 481).

Researchers who have successfully recruited and retained minority participants have done

so with careful attention to the needs and concerns of the population (Rucker-Whitaker et al.,

2006; Sisk et al., 2008). Successful strategies for implementing a culturally-sensitive approach

included, but were not limited to, using lay and/or race-concordant recruiters and study

facilitators (Rucker-Whitaker et al., 2006; Sisk et al., 2008), having a flexible scheduling

protocol, providing assistance with transportation, and encouraging participants to bring a

support person with them (Sisk et al., 2008). Additionally, a series of focus groups with African

American patients with CHF enrolled in the Heart Failure Adherence and Retention Trial

11
(HART) also identified that the social support provided by co-participants in the study was an

important factor in promoting retention (Rucker-Whitaker et al., 2006).

Beyond issues of recruitment and retention, researchers have also turned their attention to

the development of culturally-sensitive and effective interventions and best practices. The use of

peer coaching alongside office-based clinical counseling in heart healthy behavioral changes has

been shown to assist African American participants in reducing cardiovascular risks such as

hypertension (Turner et al., 2012), while the use of community health advisors to provide health-

based and social support has been recommended for African American patients with CHF

(Durant et al., 2013). Some researchers have argued for incorporating spirituality/religion into

interventions for African Americans (Kalenderian et al., 2009; Peterson & Cheng, 2011; Plescia

et al., 2008; Yanek et al, 2001), while Rucker-Whitaker and colleagues (2006) have cautioned

against researchers making a blanket assumption that all African Americans are religious. As a

counterbalance to this caution, Rucker-Whitaker and colleagues (2006) also recommended that

researchers do not avoid topics of religion/spirituality when developing and implementing

interventions for African Americans as these may be potential storehouses of strength and

resources for participants.

It is also worth noting that individuals who do not participate in studies or interventions

may have found alternative ways to access the resources that the interventions were designed to

provide. For example, a UK-based study of CR participation found that many individuals who

did not participate in a CR program engaged in rehabilitative activities at home, such as exercise

and lifestyle modification (Jones, Jolly, Raftery, Lip, & Greenfield, 2007). Unfortunately, Jones

and colleagues’ (2007) study sample was predominately comprised of White British individuals

and, therefore, cannot be generalized to racial/ethnic minorities. Studies investigating the at-

12
home or in-community rehabilitative activities of African American patients with CVD would be

very instrumental in better understanding how to design relevant studies and interventions that

build on existing individual and community strengths. This dissertation research is a step

towards identifying population-specific factors for consideration in the development of CR

referral protocol and programming for African Americans patients.

Purpose and Design

This dissertation research is a mixed methods concurrent transformative design (Creswell,

2009) developed to answer the following research question: “What demographic and

biopsychosocial-spiritual factors impact CR referral and participation for/among adult African

American patients with CVD?” The study will incorporate self-report surveys from African

American and Non-Hispanic White patients with CVD (quantitative portion) and semi-structured

phenomenological interviews with African American patients recovering from cardiac events

and/or surgeries (qualitative portion). The qualitative portion of this study aligns with Husserl’s

(1970) descriptive phenomenological approach and draws upon Colaizzi’s (1978)

phenomenological analysis method.

Although the research question referenced above will guide the study as a whole, the

research question for the qualitative portion of this study is: “What is the lived experience of

African American patients recovering from cardiac events and/or surgeries?” While the

quantitative portion of this study sought to identify larger system (e.g., referral practices, health

care policies) and individual-level factors impacting both CR referral and participation

for/among this population, the qualitative portion invited participants to identify their

experiences with larger system and individual-level factors impacting their CR participation.

13
 Summary

This chapter has introduced background knowledge and gaps in the literature on African

Americans patients’ CR referral and participation. Through the lens of the BPSS approach

(Engel 1977, 1980; Wright et al., 1996), cardiovascular health, health behaviors, and barriers

impacting CR participation for African Americans will be studied to aid in the development and

implementation of culturally-sensitive interventions for African American patients with CVD.

The following chapters will include content relative to building the rationale, explaining the

methodology, reporting the results, and recommending advancements in research, clinical care,

healthcare policy, and for the field of Medical Family Therapy as related to this dissertation’s

focus.

The second chapter is a systematic review of the literature on demographic and BPSS

factors impacting African American patients’ CR referral and participation. The research

question guiding this review was: “What demographic and biopsychosocial-spiritual factors

impact CR referral and participation for/among adult African American patients with CVD?”

This review was conducted by the lead researcher and yielded seven studies that fit the inclusion

criteria. These seven studies demonstrated that African Americans patients have a lower

likelihood for CR referral, a higher likelihood of enrolling in CR with more cardiovascular risk

factors, and a lower likelihood of CR participation and completion due to factors related to low

SES (e.g., lack of insurance, work conflicts, lower level of education) when compared with Non-

Hispanic Whites. Among these studies, social and biological factors were investigated most

frequently, psychological factors were investigated to a very limited degree, and spiritual factors

were not investigated at all. Both the results from the seven studies and the low number of

14
articles that fit inclusion criteria reinforced the need for future studies that investigate the BPSS

factors unique to African Americans patients’ CR referral and participation.

The third chapter details the methodology of this mixed methods dissertation research,

consisting of a self-report survey given at two time points to patients with CVD (quantitative

portion) and semi-structured phenomenological interviews with a subset of this patient sample—

African Americans who experienced a cardiac event and were referred to CR but did not

participate (qualitative portion). The research question guiding this dissertation as a whole was:

“What demographic and biopsychosocial-spiritual factors impact CR referral and participation

for/among adult African American patients with CVD?” The research question guiding the

qualitative portion of this study was: “What is the lived experience of African American patients

recovering from cardiac events and/or surgeries?” This study was designed in alignment with

Husserl’s (1970) descriptive phenomenological approach and interview transcripts were

analyzed using Colaizzi’s (1978) phenomenological analysis method.

Chapter four reports the qualitative results of this study. This represents a departure from

the initially proposed methodology (mixed methods). Due to limitations in recruitment, the

sample size collected for the quantitative portion was not large enough to power the proposed

analyses. Therefore, the lead researcher and dissertation committee made the decision to revise

the scope of chapter four to reflect the qualitative results only. Chapter five is a discussion of

this study’s implications and recommendations for future interventions. It is in this final chapter

that the preliminary quantitative results of this study are also presented.

15
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26
 CHAPTER TWO: DEMOGRAPHIC AND BIOPSYCHOSOCIAL-SPIRITUAL FACTORS

IMPACTING AFRICAN AMERICAN PATIENTS’ CR REFERRAL AND PARTICIPATION:

A SYSTEMATIC REVIEW

Cardiac Rehabilitation (CR) is an American College of Cardiology/American Heart

Association Class I treatment for multiple cardiovascular conditions and procedures (American

Association of Cardiovascular and Pulmonary Rehabilitation, 2014). As a secondary prevention

and treatment program, CR has been shown to offer participants significant physical and

psychological health benefits, including reduced mortality related to cardiovascular and other

health conditions, lower rates of hospitalization (Heran et al., 2011), and improved depression

and anxiety symptoms (Whalley et al., 2011). Despite these results, CR referral and participation

rates are generally low, with approximately one third of eligible patients referred or participating

(Ayala, Xie, McGruder, & Valderrama, 2008; Cortés & Arthur, 2006; Suaya et al., 2007).

Cardiac Rehabilitation referral and participation rates are especially low for African

American patients with cardiovascular disease (CVD) (Allen, Scott, Stewart, & Young, 2004;

Evenson, Johnson, and Aytur, 2004; Gregory, LaVeist, and Simpson, 2006). Unfortunately, this

disparity exists even though African Americans have higher cardiovascular risk factors and

higher rates of mortality from coronary artery disease than Non-Hispanic Whites (Centers for

Disease Control and Prevention [CDC], 2013). Presently, there is a gap in the literature

regarding barriers and facilitators of CR referral and participation for racial/ethnic minorities

Beswick et al., 2004; Cortés & Arthur, 2006; Taylor, Wilson, & Sharpe, 2011).

In order to address this racial/ethnic disparity in care, it is essential to understand the

multi-level systemic factors associated with African Americans patients’ CR referral and

participation and to allow this understanding to inform future interventions. This systematic
review of the literature aims to identify extant knowledge and gaps in the literature regarding the

demographic and biopsychosocial-spiritual factors impacting CR referral and participation for

African American patients with CVD.

Background Literature
Disparities in Cardiovascular Health/Health Behaviors for African Americans

The Biopsychosocial-Spiritual (BPSS) approach offers a model for conceptualizing the

intersection of multiple factors in health-related experiences and outcomes (Engel, 1977, 1980;

Wright, Watson, & Bell, 1996). Although a number of researchers have investigated

demographic, biological, psychological, and social factors impacting CR referral and

participation in the general population, there is a paucity of research on the factors impacting CR

referral and participation for African American patients. The following sections present the

available BPSS literature on African American cardiovascular disparities and population-specific

factors impacting cardiovascular health behaviors (see Figure 1).

Biological factors. Researchers have demonstrated that African American patients with

CVD are significantly less likely than Non-Hispanic White patients to receive coronary artery

bypass grafting (CABG) (Hannan et al., 1999; Peterson et al., 1997) or percutaneous

transluminal coronary angioplasty (PCTA) (Peterson et al., 1997, Schneider et al., 2001).

Because patients who received these procedures were also more likely to be referred to CR

(Suaya et al., 2007), it is possible that racial disparities at the level of surgical intervention

impacted CR referral and participation. Sanderson, Mirza, Fry, Allison, and Bittner (2007) have

also observed that African American patients who participated in CR began their programs with

more cardiovascular risk factors than Non-Hispanic White patients and ended CR with fewer

improvements (e.g., BMI level, waist circumference).

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 Psychological factors. Within the African American population with congestive heart

failure (CHF), depressive symptoms have been shown to be negatively associated with

engagement in cardiovascular self-care practices (Dickson, McCarthy, Howe, Schipper, and Katz,

2013; Dickson, McCarthy, & Katz, 2013). Dickson, McCarthy, and Katz (2013) found a high

incidence (40%) of depressive symptoms among African American patients with CHF. They

also documented an association between such symptoms and poorer self-care (Dickson,

McCarthy, & Katz, 2013). In contrast to the detrimental effect of depression on self-care,

Warren-Findlow, Seymour, and Brunner Huber (2012) demonstrated a correlation between

personal self-efficacy and hypertension self-care in African American adults with hypertension.

Social factors. Racism is a harmful social factor impacting cardiovascular health for

African Americans (Din-Dzietham, Nembhard, Collins, & Davis, 2004; Lewis, Aiello, Leurgans,

Kelly, & Barnes, 2010; van Ryn, Burgess, Malat, and Griffin, 2006; Wyatt et al., 2003). A study

by van Ryn and colleagues (2006) demonstrated that “physicians’ perceptions of patients’

education and physical activity preferences were significant predictors of their recommendations,”

(p. 351) and that these physician behaviors further compounded racial/ethnic disparities

experienced by patients at the individual level. Collins, Clark, Petersen, and Kressin (2002) also

found that African American patients generally emphasized the importance of rapport-building

and establishing trust in providers, especially before consenting to procedures.

Certain beliefs and practices may be held by African American communities and, in turn,

impact cardiovascular health behaviors. Some researchers have argued that there is a tendency

among members of these communities to normalize CVD or risk factors such as hypertension as

natural or unavoidable (Ford, Kim, & Dancy, 2009; Warren-Findlow & Issel, 2010). Dickson,

McCarthy, Howe, and colleagues (2013), in their study of African American patients with CHF,

29
reported that a fatalistic perspective about risk factors combined with the belief that stress caused

CHF symptoms promoted a “passive approach (e.g. ‘stay in bed,’ ‘relax…let it pass’)” (p. 115).

Some researchers have cautioned against confounding cultural differences with socioeconomic

status (SES) differences, as beliefs and practices around self-care may ultimately reflect access to

health information and resources (Blustein, Valentine, Mead, & Regenstein, 2008; Wexler et al.,

2008).

At the community and family level, researchers studying the impact of social support on

cardiovascular health among African Americans have identified a positive association between

social support and improved cardiovascular health and healthy behaviors (Grewen, Anderson,

Girdler, & Light, 2003; Liu & Newschaffer, 2011; Tkatch et al., 2011). In terms of

cardiovascular health behaviors, Tkatch and colleagues (2011) reported that African American

CR participants with larger social support networks had more health support and demonstrated

healthier behaviors and higher coping self-efficacy than those who did not have such networks.

Spiritual Factors. Beyond these psychosocial factors, researchers have also

demonstrated the importance of spirituality in health-related coping and decision-making for

many African Americans (Dickson, McCarthy, Howe, et al., 2013; Johnson, Elbert-Avila, &

Tulsky, 2005; Warren-Findlow & Issel, 2010). African American patients with CHF have been

shown to draw upon both intrinsic spirituality (e.g., praying) and extrinsic spirituality (e.g.

affiliation with a religious community) in their self-care behaviors (Dickson, McCarthy, Howe,

et al., 2013). Conversely, some researchers argue spirituality may also be a risk factor by

resulting in more passive, and thereby less effective, approaches to self-care (Dickson, McCarthy,

Howe, et al., 2013; Polzer & Miles, 2007).

30
 This systematic review sought to identify population-specific BPSS factors impacting CR

referral and participation for African American patients. The following sections present the

objectives, methods, and findings of this systematic review.

Objectives

The aim of this study was to: (a) complete a systematic review of the peer-reviewed

literature related to demographic and BPSS factors impacting CR referral and participation for

African American patients with CVD; (b) identify BPSS factors acting as facilitators of and

barriers to CR referral and participation for this population; (c) identify gaps in the literature; and

(d) make recommendations for future research studies and interventions to address

cardiovascular health disparities for this population. The research question guiding this

systematic review was: “What demographic and biopsychosocial-spiritual factors impact CR

referral and participation for adult African American patients with CVD?”

Method

This review utilized Cooper's (2010) seven-step protocol for research synthesis. The lead

researcher formulated the aforementioned research question and, using a combination of subject

headings and keywords, searched the literature utilizing Medline via PubMed, PsycINFO via

EBSCO, and CINAHL via EBSCO (see Table 1 for article search summary and Table 2 for

subject heading equivalences across databases). The search strategy yielded 1,751 articles once

duplicates were removed. Review of titles and abstracts left 40 articles for full text review. From

these 40 articles, seven fit the inclusion criteria. A review of the reference lists of the final seven

articles yielded no further applicable studies. A second reviewer performed the searches

conducted in the initial review (see Figure 2 for flow chart summary of the search and review

process). The quality of the seven articles was assessed using Hall, Ferreira, Maher, Latimer,

31
and Ferreira’s (2010) seven criteria for evaluating observational studies, adapted from criteria

developed by Sanderson, Tatt, & Higgins (2007) and von Elm and colleagues (2007) (see Table 3

for criteria and summary of article quality). The results of analysis and integration of study

outcomes are summarized in Table 4.

Results

The seven articles selected for this review explored the relationship between African

American race/ethnicity and CR referral and participation. The results have been divided into

four categories in keeping with the BPSS approach, with the addition of a section on

demographic factors (i.e., sex/gender, race/ethnicity): (a) demographic factors; (b) biological

factors; (c) psychological factors; and (d) social factors. No studies reported on spiritual factors,

and some studies fell into more than one of the four categories.

Demographic Factors: Rehabilitation Referral and Participation

Three studies investigated the impact of race/ethnicity as a demographic factor on CR

referral (Allen et al., 2004; Bittner, Sanderson, Breland, & Green, 1999; Gregory et al., 2006).

Allen and colleagues (2004) recruited 253 women (108 African American and 145 White) who

had experienced a cardiovascular event or procedure (i.e., myocardial infarction [MI],

percutaneous coronary intervention [PCI], and CABG) and surveyed them within a month of

discharge and again six months later. Allen and colleagues (2004) found significant racial

disparities in referrals to CR, with African American women approximately half as likely (55%)

to be referred when compared with White women.

Gregory and colleagues (2006) also investigated factors impacting CR referral in a

sample of 1,933 patients (863 African American and 1070 White) who had experienced a

cardiovascular event or procedure in the past year or had a diagnosis of recurrent CHF. Gregory

32
and colleagues (2006) interviewed participants within a year of discharge and found that White

patients were two times more likely to receive a referral than African American patients. This

finding remained statistically significant even after other variables (e.g., age, education, SES,

insurance status) were held constant (Gregory et al., 2006).

In contrast to the above two studies, Bittner and colleagues (1999) did not find race to be

a significant predictor of CR referral. The researchers reviewed CR enrollment screening logs of

1,329 patients (422 African American and 890 White) who were discharged from the hospital

with a primary diagnosis of MI or angina or who had received CABG (Bittner et al., 1999).

Although a higher percentage of White patients (9.5%) received a referral than those who were

African American (7.4%), Bittner and colleagues (1999) reported that this difference was not

statistically significant. Instead, two different demographic factors—in-county residence and

younger age—were predictive of CR referral.

Five research teams investigated the impact of demographic factors on CR participation

(Allen et al., 2004; Cannistra, O’Malley, & Balady, 1995; Evenson et al., 2006; Rankin, 2002;

Young, Waller, & Kahana, 1991). Allen and colleagues (2004) found that enrollment (after

receiving a referral) was proportionately lower among African American women than White

women (9% compared to 19%, respectively). Evenson and colleagues (2006) also reported that,

according to program directors’ estimates of their patient populations in 2004, only 9% of CR

participants were African American compared to 90% of program participants who were White

Non-Hispanic. Similarly, Rankin’s (2002) study of 76 female patients who had experienced a MI

(81% White and 19% African American), reported that only 13 participants were enrolled at

some point in CR during their yearlong study and that “all cardiac rehabilitation participants

were white” (p. 405).

33
 Young and colleagues (1991) also reported racial/ethnic disparities in CR participation.

Their study included 246 participants (77 African American and 167 White), all of whom were

patients who had experienced an MI. Young and colleagues (1991) found that, when compared

with White MI patients, African American MI patients were less likely to be enrolled in CR,

recommended for a catheterization, assigned a cardiologist, or to have received patient education

on smoking or exercise.

In contrast with the four studies demonstrating racial/ethnic disparities negatively

impacting African American patients’ CR participation rates, Cannistra and colleagues’ (1995)

investigation found no statistically significant racial/ethnic disparity in CR completion. This

study included 82 participants (35 African American and 47 White) who had had a

cardiovascular event or procedure and were enrolled in a CR program. The researchers reported

that the percentage of African American women who completed the program was lower than that

of White women (51% and 64%, respectively), but this finding was not statistically significant

(Cannistra et al., 1995).

Another salient demographic factor cited by Evenson and colleagues (2006) was

sex/gender. Evenson and colleagues’ (2006) study was based on survey responses from CR

program directors in North Carolina. Program directors were surveyed at two intervals (1999

and 2004) using a study-specific survey. Results from data collected in 2004 demonstrated a

male majority among participants (65%). Data collected by these researchers did not measure

CR referral and participation across sex/gender and race/ethnicity (Evenson et al., 2006).

The main limitation of these studies was the extent to which they addressed relationships

between racial/ethnic disparities and reasons for CR referral and participation. For example,

Evenson and colleagues (2006) did not explore the associations between race/ethnicity and other

34
BPSS factors impacting non-participation or drop-out. Similarly, Rankin (2002) investigated

psychosocial and physical outcomes of MI recovery for female patients, but did not comment on

how these factors impacted referral and participation for African American patients.

Biological Factors: Referral and Participation

Only two studies reported on biological factors impacting CR referral and/or participation

(Bittner et al., 1999; Cannistra et al., 1995). In their study on referral rates, Bittner and

colleagues (1999) found that a discharge diagnosis of MI or hypercholesterolemia was positively

associated with CR referral. The researchers did not investigate the interaction between these

biological factors and race/ethnicity (Bittner et al., 1999).

Cannistra and colleagues (1995) explored the impact of biological factors on CR

participation and reported on the interaction of these factors with participants’ race/ethnicity.

The researchers collected data on baseline risk factors (e.g., smoking, hypertension, diabetes, and

body weight) at program entry and completion. Findings revealed that, compared with White

women, African American women generally began the program with more cardiovascular risk

factors and ended the program having experienced fewer benefits in terms of weight loss.

However, CR was shown to benefit both African American women and White women in terms

of improved functional capacity. Regardless of race, women identified medical illness as the

most frequently cited cause of CR non-completion (Cannistra et al., 1995).

Psychological Factors: Referral and Participation

Only one study investigated the impact of psychological factors on CR referral and

participation. Allen and colleagues’ (2004) study of White and African American female

patients with CVD measured depression as a variable. According to these researchers, there was

no statistically significant difference in rates of depression across races/ethnicities and no

35
interaction observed among the variables of depression, race/ethnicity, and CR referral or

enrollment (Allen et al., 2004). In contrast, Rankin (2002) reported that, compared with White

female patients with CVD, African American female patients with CVD had higher levels of

mood disturbance. Rankin (2002) did not address how this may have contributed to the observed

racial/ethnic disparity in CR participation.

Social Factors: Referral and Participation

Six studies investigated the impact of social factors on CR referral and participation

(Allen et al., 2004; Bittner et al., 1999; Cannistra et al., 1995; Evenson et al., 2006; Gregory et

al., 2006; Young et al., 1991). Therefore, social factors was the second largest category of

studies after demographic factors.

Allen and colleagues (2004) reported that study participants’ income was a predictor of

CR referral and enrollment, but statistical analyses on the interaction between income and race

were insignificant. In contrast, Gregory and colleagues (2006) demonstrated that African

American patients were more likely than those who were White to have Medicaid (17.9%

compared to 4.1%, respectively) or be uninsured (4.4% compared to 2.8% respectively). The

researchers also found that patients with private insurance had higher odds of CR referral than

patients with either Medicare or Medicaid (Gregory et al., 2006). Bittner and colleagues (1999)

observed a positive association between insurance coverage and CR referral but did not comment

on the interaction of this predictor with race/ethnicity.

Evenson and colleagues (2006) found that 72% of program directors cited policy issues

(e.g., “cost, financial, insurance,” p. 372) as the primary barrier to CR participation, whereas

work conflicts were cited as the primary reason for enrolled participants dropping out of CR.

Nearly a quarter of program directors surveyed also cited transportation as a barrier to

36
participation (Evenson et al., 2006). Like Bittner and colleagues (1991), Evenson and colleagues

(2006) did not comment on the interaction of these variables with race/ethnicity.

In contrast with the above studies, Cannistra and colleagues (1995) investigated the

interaction between social factors, race/ethnicity, and CR referral and participation. According

to these researchers, 23% of African American women compared to 6% of White women

reported withdrawing from CR due to work conflicts, and 12% of African American participants

compared to 6% of White participants reported withdrawing due to personal reasons (Cannistra

et al., 1995). It is not clear if “personal reasons” referred to lack of social support or other

factors. Cannistra and colleagues (1995) hypothesized that withdrawal from CR due to work

conflicts or personal reasons, “may also reflect the apparent lower socioeconomic status of black

women in the program” (p. 892).

Young and colleagues’ (1991) study on CR participation specifically investigated the

interactions between and among the variables of race/ethnicity, CR participation, and SES as

defined by educational level. When both race/ethnicity and SES were included in analysis,

Young and colleagues (1991) found that African American participants who were designated low

SES ranked lowest in both health status and enrollment in CR. SES alone, however, did not

account for disparities, as race/ethnicity still emerged as a predictive factor of enrollment (Young

et al., 1991). For example, African American participants designated as high SES and White

participants designated as low SES were on par in terms of likelihood of CR enrollment. Young

and colleagues (1991) argued for the consideration of race/ethnicity and SES as confounding

variables in cardiovascular health outcomes.

37
 Discussion

The seven studies examined in this systematic review provided useful but limited insights

into the demographic and BPSS factors impacting CR referral and participation for African

American patients with CVD. Within this population, researchers have observed a lower

likelihood for CR referral, a higher likelihood of enrolling in CR with more cardiovascular risk

factors, and a lower likelihood of CR participation and completion due to factors related to low

SES (e.g., lack of insurance, work conflicts, lower level of education) when compared with Non-

Hispanic White patients. This review revealed the limited extent to which research

investigations have explored interactions between BPSS factors, race/ethnicity, and CR referral

and participation. For example, only three of the seven studies included in this review

investigated the impact of the interaction between race/ethnicity and another BPSS factor on CR

referral and participation rates (Allen et al., 2004; Cannistra et al., 1995; Young et al., 1991).

Among the seven studies included in the review, researchers provided little information about

psychological factors and no information on spiritual factors related to CR referral or

participation for this population.

Lack of uniformity across studies made comparison and synthesis of study results

difficult. For example, the research studies varied significantly in sample size, participant

population (e.g., patients versus CR program directors), type of variables investigated, and

method of measuring variables (e.g., patient self-report, provider/program director report, or

chart review). Studies also varied somewhat in terms of quality (Table 3). The greatest

variability was seen in the collection of follow-up data. Only four of the seven studies reviewed

had a greater than 85% follow-up rate, limiting the degree to which inferences could be made

about participants over time. Data collected at multiple time points post-cardiovascular event

38
would be especially useful for the measurement of CR participation, and specifically, completion.

Finally, variability was also seen in use of multivariate analysis with adjustment for confounding

variables and the reporting of outcome data at follow-up. Adjustment for confounds is especially

important if, for example, CR referral and participation were influenced by a variable such as

SES.

Considering the level of variability across methodologies in this systematic review of the

literature, generalizations regarding factors impacting CR referral and participation for African

American patients are not warranted. Rather, given the paucity of research on this topic, this

discussion offers implications for future research and practice.

Implications for Future Research and Practice

While researchers have begun to investigate BPSS factors impacting CR referral and

participation for African American patients with CVD, these findings are not comprehensive.

Specifically, little research has been conducted on the impact of psychological and spiritual

factors on CR participation for this population. Studies that investigate psychological factors are

important considering the negative association between psychological factors, such as depression,

and cardiovascular self-care (Dickson, McCarthy, Howe, et al., 2013; Dickson, McCarthy, &

Katz, 2013). Similarly, studies that investigate spiritual factors are needed considering the

relationship between spiritual factors, coping, and cardiovascular self-care for African American

patients with CVD (Dickson, McCarthy, Howe, et al, 2013; Johnson et al., 2005; Polzer & Miles,

2007; Warren-Findlow & Issel, 2010;).

Studies on CR referral and participation for this population have included limited analysis

on the interaction between race/ethnicity and other BPSS factors. Therefore, studies that employ

path analysis or multiple regression to investigate the moderating relationships between

39
demographic or BPSS factors and CR referral and participation rates are strongly indicated.

Such analyses would allow for a more nuanced understanding of interactions between variables

and would also help to account for potentially confounding variables such as SES. Also, studies

that are able to retain participants for follow-up would enable the collection of data across

multiple time points, which would be useful for the investigation of CR completion.

Another gap in the research are qualitative studies that amplify the voices of African

American patients with CVD. At this point, the voices of African American patients are

virtually absent from the research. Although many of the studies in this review include data

from patient self-report, the methodologies used did not allow participants to expound upon their

individual experiences of rehabilitation. Qualitative methodologies that employ focus groups,

observation, and/or individual interviews would enable researchers to identify issues impacting

CR referral and participation that may not have been investigated in previous studies.

Research that supports the development of culturally-sensitive interventions for African

American patients with CVD is needed. Although surveying individuals on their perspectives

and experiences is a start, additional investigation of how this population defines its own needs

and interests will increase the likelihood that future interventions will address those needs and

interests. A mixed methods approach would offer researchers an opportunity to measure

previously identified factors related to CR referral and participation and could potentially

identify contextual issues that may not have been investigated.

Limitations

This systematic review has two important limitations. First, although the researcher

employed many combinations of search terms to increase the likelihood of capturing every

relevant article, a risk exists that relevant articles were missed or overlooked. The enlistment of

40
a second reviewer to check the work and the inclusion and exclusion decisions of the lead

researcher reduced but did not eliminate the risk. Second, searches for this review were

restricted to published articles in peer-reviewed journals that were written in English. Relevant

articles that were currently in the process of being catalogued within research databases or were

catalogued in non-peer reviewed or non-English language journals would not have been accessed

for this review.

Conclusion

Currently, there is a paucity of research on the BPSS factors impacting CR referral and

participation for African American patients with CVD. When compared with their Non-

Hispanic White counterparts, African Americans suffer from poorer cardiovascular outcomes

(CDC, 2013), yet this population is less likely to receive referrals or participate in CR. Not only

does this represent a disparity, it also suggests an injustice in that a population most in need of an

intervention has been shown to be less likely to receive it. A need exists for research that

contributes to a BPSS understanding of African American patients’ cardiovascular health

disparities and participation in cardiovascular health behaviors. Findings from this research, in

turn, will help to correct this disparity and assist in the development of effective and population-

specific interventions to promote CR referral and participation for African American patients

with CVD.

41
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48
Figure 1. BPSS Factors Negatively Impacting Cardiovascular Health and Cardiovascular Health

Behaviors among African Americans. Key of abbreviations: CR = Cardiac Rehabilitation; CVD

= Cardiovascular disease; SES = Socioeconomic status.

1
Hannan et al. (1999); Peterson et al. (1997); Schneider et al. (2001).
2
Sanderson, Mirza, et al. (2007).
3
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8
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49
Table 1

Article Search Summaries

Medline via PubMed PsycINFO via EBSCO CINAHL via EBSCO

Cardiovascular Diseases AND Cardiovascular Disorders AND Cardiovascular Diseases AND
Rehabilitation AND African Rehabilitation AND Blacks Rehabilitation AND Blacks
Americans Found: 1 Found: 65
Found: 94 Yield: 0 Yield: 2
Yield: 0
Cardiovascular Diseases AND Cardiovascular Disorders AND Cardiovascular Diseases AND
Rehabilitation AND “African Rehabilitation AND “African Rehabilitation AND “African
Americans” Americans” Americans”
Found: 115 Found: 0 Found: 44
Yield: 0 Yield: 0 Yield: 2
“Cardiovascular Disorders”
AND "Rehabilitation" AND
“African Americans”
Found: 0
Yield: 0
Cardiovascular Diseases AND Cardiovascular Disorders AND Cardiovascular Diseases AND
Rehabilitation AND “Blacks” Rehabilitation AND “Blacks” Rehabilitation AND “Blacks”
Found: 142 Found: 1 Found: 72
Yield: 1 Yield: 0 Yield: 2
“Cardiovascular Disorders”
AND “Rehabilitation” AND
“Blacks”
Found: 0
Yield: 0
Cardiovascular Diseases AND Cardiovascular Disorders AND Cardiovascular Diseases AND
Rehabilitation Centers AND Rehabilitation Centers AND Rehabilitation Centers AND
African Americans Blacks Blacks
Found: 10 Found: 0 Found: 20
Yield: 2 Yield: 0 Yield: 0
Cardiovascular Diseases AND Cardiovascular Disorders AND Cardiovascular Diseases AND
Rehabilitation Centers AND Rehabilitation Centers AND Rehabilitation Centers AND
“African Americans” “African Americans” “African Americans”
Found: 10 Found: 0 Found: 7
Yield: 2 Yield: 0 Yield: 0
“Cardiovascular Disorders”
AND “Rehabilitation Centers”
AND “African Americans”
Found: 0
Yield: 0
Cardiovascular Diseases AND Cardiovascular Disorders AND Cardiovascular Diseases AND
Rehabilitation Centers AND Rehabilitation Centers AND Rehabilitation Centers AND
“Blacks” “Blacks” “Blacks”
Found: 13 Found: 0 Found: 26
Yield: 1 Yield: 0 Yield: 0

50
 “Cardiovascular Disorders”
AND “Rehabilitation Centers”
AND “Blacks”
Found: 0
Yield: 0
Cardiovascular Cardiovascular
Diseases/rehabilitation AND Diseases/rehabilitation AND
African Americans Blacks
Found: 47 Found: 57
Yield: 1 Yield: 3
Cardiovascular Cardiovascular
Diseases/rehabilitation AND Diseases/rehabilitation AND
“African Americans” “African Americans”
Found: 53 Found: 22
Yield: 3 Yield: 1
Cardiovascular
Diseases/rehabilitation AND Cardiovascular
“Blacks” Diseases/rehabilitation AND
Found: 72 “Blacks”
Yield: 3 Found: 65
Yield: 3
Myocardial Infarction AND Myocardial Infarctions AND Myocardial Infarction AND
Rehabilitation AND African Rehabilitation AND Blacks Rehabilitation AND Blacks
Americans Found: 0 Found: 4
Found: 1 Yield: 0 Yield: 2
Yield: 0
Myocardial Infarction AND Myocardial Infarctions AND Myocardial Infarction AND
Rehabilitation AND “African Rehabilitation AND “African Rehabilitation AND “African
Americans” Americans” Americans”
Found: 3 Found: 0 Found: 4
Yield: 0 Yield: 0 Yield: 1
“Myocardial Infarctions” AND
“Rehabilitation” AND “African
Americans”
Found: 0
Yield: 0
Myocardial Infarction AND Myocardial Infarctions AND Myocardial Infarction AND
Rehabilitation AND “Blacks” Rehabilitation AND “Blacks” Rehabilitation AND “Blacks”
Found: 6 Found: 0 Found: 5
Yield: 1 Yield: 0 Yield: 2
“Myocardial Infarctions” AND
“Rehabilitation” AND “Blacks”
Found: 0
Yield: 0
Myocardial Infarction AND Myocardial Infarctions AND Myocardial Infarction AND
Rehabilitation Centers AND Rehabilitation Centers AND Rehabilitation Centers AND
African Americans Blacks Blacks
Found: 0 Found: 0 Found: 0
Yield: 0 Yield: 0 Yield: 0

51
Myocardial Infarction AND Myocardial Infarctions AND Myocardial Infarction AND
Rehabilitation Centers AND Rehabilitation Centers AND Rehabilitation Centers AND
“African Americans” “African Americans” “African Americans”
Found: 1 Found: 0 Found: 0
Yield: 1 Yield: 0 Yield: 0
“Myocardial Infarctions” AND
“Rehabilitation Centers” AND
“African Americans”
Found: 0
Yield: 0
Myocardial Infarction AND Myocardial Infarctions AND Myocardial Infarction AND
Rehabilitation Centers AND Rehabilitation Centers AND Rehabilitation Centers AND
“Blacks” “Blacks” “Blacks”
Found: 0 Found: 0 Found: 0
Yield: 0 Yield: 0 Yield: 0
“Myocardial Infarctions” AND
“Rehabilitation Centers” AND
“Blacks”
Found: 0
Yield: 0
Myocardial Myocardial
Infarction/rehabilitation AND Infarction/rehabilitation AND
African Americans Blacks
Found: 3 Found: 4
Yield: 1 Yield: 3
Myocardial Myocardial
Infarction/rehabilitation AND Infarction/rehabilitation AND
“African Americans” “African Americans”
Found: 4 Found: 1
Yield: 2 Yield: 1
Myocardial Myocardial
Infarction/rehabilitation AND Infarction/rehabilitation AND
“Blacks” “Blacks”
Found: 5 Found: 4
Yield: 2 Yield: 3
Coronary Disease AND Heart Disorders AND Coronary Disease AND
Rehabilitation AND African Rehabilitation AND Blacks Rehabilitation AND Blacks
Americans Found: 0 Found: 5
Found: 3 Yield: 0 Yield: 1
Yield: 0 “Coronary Disease” AND
Rehabilitation AND Blacks
Found: 0
Yield: 0
Coronary Disease AND Heart Disorders AND Coronary Disease AND
Rehabilitation AND “African Rehabilitation AND “African Rehabilitation AND “African
Americans” Americans” Americans”
Found: 5 Found: 0 Found: 6
Yield: 0 Yield: 0 Yield: 1
“Heart Disorders” AND
“Rehabilitation” AND “African

52
 “Americans”
Found: 0
Yield: 0
“Coronary Disease” AND
Rehabilitation AND “African
Americans”
Found: 0
Yield: 0
“Coronary Disease” AND
“Rehabilitation” AND “African
“Americans”
Found: 0
Yield: 0
Coronary Disease AND Heart Disorders AND Coronary Disease AND
Rehabilitation AND “Blacks” Rehabilitation AND “Blacks” Rehabilitation AND “Blacks”
Found: 6 Found: 0 Found: 5
Yield: 1 Yield: 0 Yield: 1
“Heart Disorders” AND
“Rehabilitation” AND “Blacks”
Found: 0
Yield: 0
“Coronary Disease” AND
Rehabilitation AND “Blacks”
Found: 0
Yield: 0
“Coronary Disease” AND
“Rehabilitation” AND “Blacks”
Found: 0
Yield: 0
Coronary Disease AND Heart Disorders AND Coronary Disease AND
Rehabilitation Centers AND Rehabilitation Centers AND Rehabilitation Centers AND
African Americans Blacks Blacks
Found: 1 Found: 0 Found: 0
Yield: 1 Yield: 0 Yield: 0
“Coronary Disease” AND
Rehabilitation Centers AND
Blacks
Found: 0
Yield: 0
Coronary Disease AND Heart Disorders AND Coronary Disease AND
Rehabilitation Centers AND Rehabilitation Centers AND Rehabilitation Centers AND
“African Americans” “African Americans” “African Americans”
Found: 2 Found: 0 Found: 0
Yield: 1 Yield: 0 Yield: 0
“Heart Disorders” AND
“Rehabilitation Centers” AND
“African Americans”
Found: 0
Yield: 0
“Coronary Disease” AND

53
 Rehabilitation Centers AND
“African Americans”
Found: 0
Yield: 0
“Coronary Disease” AND
“Rehabilitation Centers” AND
“African Americans”
Found: 0
Yield: 0
Coronary Disease AND Heart Disorders AND Coronary Disease AND
Rehabilitation Centers AND Rehabilitation Centers AND Rehabilitation Centers AND
“Blacks” “Blacks” “Blacks”
Found: 1 Found: 0 Found: 0
Yield: 1 Yield: 0 Yield: 0
“Heart Disorders” AND
“Rehabilitation Centers” AND
“Blacks”
Found: 0
Yield: 0
“Coronary Disease” AND
Rehabilitation Centers AND
“Blacks”
Found: 0
Yield: 0
“Coronary Disease” AND
“Rehabilitation Centers” AND
“Blacks”
Found: 0
Yield: 0
Coronary Disease/rehabilitation Coronary Disease/rehabilitation
AND African Americans AND Blacks
Found: 4 Found: 2
Yield: 1 Yield: 1
Coronary Disease/rehabilitation Coronary Disease/rehabilitation
AND “African Americans” AND “African Americans”
Found: 5 Found: 1
Yield: 1 Yield: 0
Coronary Disease/rehabilitation Coronary Disease/rehabilitation
AND “Blacks” AND “Blacks”
Found: 7 Found: 2
Yield: 3 Yield: 1
Heart Failure AND “Heart Failure” AND Heart Failure AND
Rehabilitation AND African Rehabilitation AND Blacks Rehabilitation AND Blacks
Americans Found: 0 Found: 3
Found: 6 Yield: 0 Yield: 0
Yield: 0

54
Heart Failure AND “Heart Failure” AND Heart Failure AND
Rehabilitation AND “African Rehabilitation AND “African Rehabilitation AND “African
Americans” Americans” Americans”
Found: 11 Found: 0 Found: 5
Yield: 0 Yield: 0 Yield: 0

“Heart Failure” AND

“Rehabilitation” AND “African
Americans”
Found: 0
Yield: 0
Heart Failure AND “Heart Failure” AND Heart Failure AND
Rehabilitation AND “Blacks” Rehabilitation AND “Blacks” Rehabilitation AND “Blacks”
Found: 10 Found: 0 Found: 4
Yield: 0 Yield: 0 Yield: 0
“Heart Failure” AND
“Rehabilitation” AND “Blacks”
Found: 0
Yield: 0
Heart Failure AND “Heart Failure” AND Heart Failure AND
Rehabilitation Centers AND Rehabilitation Centers AND Rehabilitation Centers AND
African Americans Blacks Blacks
Found: 0 Found: 0 Found: 0
Yield: 0 Yield: 0 Yield: 0
Heart Failure AND “Heart Failure” AND Heart Failure AND
Rehabilitation Centers AND Rehabilitation Centers AND Rehabilitation Centers AND
“African Americans” “African Americans” “African Americans”
Found: 0 Found: 0 Found: 0
Yield: 0 Yield: 0 Yield: 0
“Heart Failure” AND
“Rehabilitation Centers” AND
“African Americans”
Found: 0
Yield: 0
Heart Failure AND “Heart Failure” AND Heart Failure AND
Rehabilitation Centers AND Rehabilitation Centers AND Rehabilitation Centers AND
“Blacks” “Blacks” “Blacks”
Found: 0 Found: 0 Found: 0
Yield: 0 Yield: 0 Yield: 0
“Heart Failure” AND
“Rehabilitation Centers” AND
“Blacks”
Found: 0
Yield: 0
Heart Failure/rehabilitation Heart Failure/rehabilitation
AND African Americans AND Blacks
Found: 5 Found: 0
Yield: 0 Yield: 0

55
Heart Failure/rehabilitation Heart Failure/rehabilitation
AND “African Americans” AND “African Americans”
Found: 5 Found: 0
Yield: 0 Yield: 0
Heart Failure/rehabilitation" Heart Failure/rehabilitation
AND “Blacks” AND “Blacks”
Found: 5 Found: 0
Yield: 0 Yield: 0
Heart Diseases AND Heart Diseases AND
Rehabilitation AND African Rehabilitation AND Blacks
Americans Found: 12
Found: 17 Yield: 2
Yield: 0
Heart Diseases AND Heart Diseases AND
Rehabilitation AND “African Rehabilitation AND “African
Americans” Americans”
Found: 24 Found: 15
Yield: 0 Yield: 2
Heart Diseases AND Heart Diseases AND
Rehabilitation AND “Blacks” Rehabilitation AND “Blacks”
Found: 29 Found: 14
Yield: 1 Yield: 2
Heart Diseases AND Heart Diseases AND
Rehabilitation Centers AND Rehabilitation Centers AND
African Americans Blacks
Found: 1 Found: 1
Yield: 1 Yield: 0
Heart Diseases AND Heart Diseases AND
Rehabilitation Centers AND Rehabilitation Centers AND
“African Americans” “African Americans”
Found: 3 Found: 0
Yield: 2 Yield: 0
Heart Diseases AND Heart Diseases AND
Rehabilitation Centers AND Rehabilitation Centers AND
“Blacks” “Blacks”
Found: 1 Found: 1
Yield: 1 Yield: 0
Heart Diseases/rehabilitation Heart Diseases/rehabilitation
AND African Americans AND Blacks
Found: 0 Found: 5
Yield: 0 Yield: 3
Heart Diseases/rehabilitation Heart Diseases/rehabilitation
AND “African Americans” AND “African Americans”
Found: 0 Found: 2
Yield: 0 Yield: 1
Heart Diseases/rehabilitation Heart Diseases/rehabilitation
AND “Blacks” AND “Blacks”
Found: 0 Found: 5
Yield: 0 Yield: 3

56
Myocardial Ischemia AND “Myocardial Ischemia” AND Myocardial Ischemia AND
Rehabilitation AND African Rehabilitation AND Blacks Rehabilitation AND Blacks
Americans Found: 0 Found: 8
Found: 0 Yield: 0 Yield: 2
Yield: 0
Myocardial Ischemia AND “Myocardial Ischemia” AND Myocardial Ischemia AND
Rehabilitation AND “African Rehabilitation AND “African Rehabilitation AND “African
Americans” Americans” Americans”
Found: 0 Found: 0 Found: 10
Yield: 0 Yield: 0 Yield: 2
“Myocardial Ischemia” AND
“Rehabilitation” AND “African
Americans”
Found: 0
Yield: 0
Myocardial Ischemia AND “Myocardial Ischemia” AND Myocardial Ischemia AND
Rehabilitation AND “Blacks” Rehabilitation AND “Blacks” Rehabilitation AND “Blacks”
Found: 0 Found: 0 Found: 9
Yield: 0 Yield: 0 Yield: 2
“Myocardial Ischemia” AND
“Rehabilitation” AND “Blacks”
Found: 0
Yield: 0
Myocardial Ischemia AND “Myocardial Ischemia” AND Myocardial Ischemia AND
Rehabilitation Centers AND Rehabilitation Centers AND Rehabilitation Centers AND
African Americans Blacks Blacks
Found: 0 Found: 0 Found: 0
Yield: 0 Yield: 0 Yield: 0
Myocardial Ischemia AND “Myocardial Ischemia” AND Myocardial Ischemia AND
Rehabilitation Centers AND Rehabilitation Centers AND Rehabilitation Centers AND
“African Americans” “African Americans” “African Americans”
Found: 0 Found: 0 Found: 0
Yield: 0 Yield: 0 Yield: 0
“Myocardial Ischemia” AND
“Rehabilitation Centers” AND
“African Americans”
Found: 0
Yield: 0
Myocardial Ischemia"[Mesh]) “Myocardial Ischemia” AND Myocardial Ischemia AND
AND Rehabilitation Centers Rehabilitation Centers AND Rehabilitation Centers AND
AND “Blacks” “Blacks” “Blacks”
Found: 0 Found: 0 Found: 0
Yield: 0 Yield: 0 Yield: 0
“Myocardial Ischemia” AND
“Rehabilitation Centers” AND
“Blacks”
Found: 0
Yield: 0

57
Myocardial Myocardial
Ischemia/rehabilitation AND Ischemia/rehabilitation AND
African Americans Black
Found: 7 Found: 5
Yield: 1 Yield: 3
Myocardial Myocardial
Ischemia/rehabilitation AND Ischemia/rehabilitation AND
“African Americans” “African Americans”
Found: 9 Found: 2
Yield: 3 Yield: 1
Myocardial Myocardial
Ischemia/rehabilitation AND Ischemia/rehabilitation AND
“Blacks” “Blacks”
Found: 11 Found: 5
Yield: 4 Yield: 3
Coronary Artery Disease AND “Coronary Artery Disease” Coronary Arteriosclerosis AND
Rehabilitation AND African AND Rehabilitation AND Blacks Rehabilitation AND Blacks
Americans Found: 0 Found: 1
Found: 0 Yield: 0 Yield: 0
Yield: 0
Coronary Artery Disease AND “Coronary Artery Disease” Coronary Arteriosclerosis AND
Rehabilitation AND “African AND Rehabilitation AND Rehabilitation AND “African
Americans" “African Americans” Americans”
Found: 0 Found: 0 Found: 1
Yield: 0 Yield: 0 Yield: 0
“Coronary Artery Disease”
AND “Rehabilitation” AND
“African Americans”
Found: 0
Yield: 0
Coronary Artery Disease AND “Coronary Artery Disease” Coronary Arteriosclerosis AND
Rehabilitation AND “Blacks” AND Rehabilitation AND Rehabilitation AND “Blacks”
Found: 0 “Blacks” Found: 1
Yield: 0 Found: 0 Yield: 0
Yield: 0
“Coronary Artery Disease”
AND “Rehabilitation” AND
“Blacks”
Found: 0
Yield: 0
Coronary Artery Disease AND “Coronary Artery Disease” Coronary Arteriosclerosis AND
Rehabilitation Centers AND AND Rehabilitation Centers Rehabilitation Centers AND
African Americans AND Blacks Blacks
Found: 0 Found: 0 Found: 0
Yield: 0 Yield: 0 Yield: 0
Coronary Artery Disease AND “Coronary Artery Disease” Coronary Arteriosclerosis AND
Rehabilitation Centers AND AND Rehabilitation Centers Rehabilitation Centers AND
“African Americans” AND “African Americans” “African Americans”
Found: 1 Found: 0 Found: 0
Yield: 0 Yield: 0 Yield: 0

58
 “Coronary Artery Disease”
AND “Rehabilitation Centers”
AND “African Americans”
Found: 0
Yield: 0
Coronary Artery Disease AND “Coronary Artery Disease” Coronary Arteriosclerosis AND
Rehabilitation Centers AND AND Rehabilitation Centers Rehabilitation Centers AND
“Blacks” AND “Blacks” “Blacks”
Found: 0 Found: 0 Found: 0
Yield: 0 Yield: 0 Yield: 0
“Coronary Artery Disease”
AND “Rehabilitation Centers”
AND “Blacks”
Found: 0
Yield: 0
Coronary Artery Coronary
Disease/rehabilitation AND Arteriosclerosis/rehabilitation
African Americans AND Black
Found: 1 Found: 1
Yield: 0 Yield: 0
Coronary Artery Coronary
Disease/rehabilitation AND Arteriosclerosis/rehabilitation
“African Americans” AND “African Americans”
Found: 1 Found: 1
Yield: 0 Yield: 0
Coronary Artery Coronary
Disease/rehabilitation AND Arteriosclerosis/rehabilitation
“Blacks” AND “Black”
Found: 1 Found: 1
Yield: 0 Yield: 0
Coronary Artery Bypass AND Heart Surgery AND Coronary Artery Bypass AND
Rehabilitation AND African Rehabilitation AND Blacks Rehabilitation AND Blacks
Americans Found: 0 Found: 0
Found: 0 Yield: 0 Yield: 0
Yield: 0 “Coronary Artery Bypass” AND
Rehabilitation AND Blacks
Found: 0
Yield: 0
Coronary Artery Bypass AND Heart Surgery AND Coronary Artery Bypass AND
Rehabilitation AND “African Rehabilitation AND “African Rehabilitation AND “African
Americans” Americans” Americans”
Found: 0 Found: 0 Found: 1
Yield: 0 Yield: 0 Yield: 1
“Heart Surgery” AND
“Rehabilitation” AND “African
“Americans”
Found: 0
Yield: 0
“Coronary Artery Bypass” AND
Rehabilitation AND “African

59
 Americans”
Found: 0
Yield: 0
“Coronary Artery Bypass” AND
“Rehabilitation” AND “African
“Americans”
Found: 0
Yield: 0
Coronary Artery Bypass AND Heart Surgery AND Coronary Artery Bypass AND
Rehabilitation AND “Blacks” Rehabilitation AND “Blacks” Rehabilitation AND “Blacks”
Found: 0 Found: 0 Found: 0
Yield: 0 Yield: 0 Yield: 0
“Heart Surgery” AND
“Rehabilitation” AND “Blacks”
Found: 0
Yield: 0
“Coronary Artery Bypass” AND
Rehabilitation AND “Blacks”
Found: 0
Yield: 0
“Coronary Artery Bypass” AND
“Rehabilitation” AND “Blacks”
Found: 0
Yield: 0
Coronary Artery Bypass AND Heart Surgery AND Coronary Artery Bypass AND
Rehabilitation Centers AND Rehabilitation Centers AND Rehabilitation Centers AND
African Americans Blacks Blacks
Found: 0 Found: 0 Found: 0
Yield: 0 Yield: 0 Yield: 0
“Coronary Artery Bypass” AND
Rehabilitation Centers AND
Blacks
Found: 0
Yield: 0
Coronary Artery Bypass AND Heart Surgery AND Coronary Artery Bypass AND
Rehabilitation Centers AND Rehabilitation Centers AND Rehabilitation Centers AND
“African Americans” “African Americans” “African Americans”
Found: 1 Found: 0 Found: 0
Yield: 1 Yield: 0 Yield: 0
“Heart Surgery” AND
“Rehabilitation Centers” AND
“African “Americans”
Found: 0
Yield: 0
“Coronary Artery Bypass” AND
Rehabilitation Centers AND
“African Americans”
Found: 0
Yield: 0
“Coronary Artery Bypass” AND

60
 “Rehabilitation Centers” AND
“African “Americans”
Found: 0
Yield: 0
Coronary Artery Bypass AND Heart Surgery AND Coronary Artery Bypass AND
Rehabilitation Centers AND Rehabilitation Centers AND Rehabilitation Centers AND
“Blacks” “Blacks” “Blacks”
Found: 0 Found: 0 Found: 0
Yield: 0 Yield: 0 Yield: 0
“Heart Surgery” AND
“Rehabilitation Centers” AND
“Blacks”
Found: 0
Yield: 0
“Coronary Artery Bypass” AND
Rehabilitation Centers AND
“Blacks”
Found: 0
Yield: 0
“Coronary Artery Bypass” AND
“Rehabilitation Centers” AND
“Blacks”
Found: 0
Yield: 0
Coronary Artery Coronary Artery
Bypass/rehabilitation AND Bypass/rehabilitation AND
African Americans Blacks
Found: 0 Found: 0
Yield: 0 Yield: 0
Coronary Artery Coronary Artery
Bypass/rehabilitation AND Bypass/rehabilitation AND
“African Americans” “African Americans”
Found: 1 Found: 0
Yield: 1 Yield: 0
Coronary Artery Coronary Artery
Bypass/rehabilitation AND Bypass/rehabilitation AND
“Blacks” “Blacks”
Found: 0 Found: 0
Yield: 0 Yield: 0
Thoracic Surgery AND “Thoracic Surgery” AND Thoracic Surgery AND
Rehabilitation AND African Rehabilitation AND Blacks Rehabilitation AND Blacks
Americans Found: 0 Found: 1
Found: 0 Yield: 0 Yield: 0
Yield: 0
“Thoracic Surgery” AND Thoracic Surgery AND
Rehabilitation AND “African Rehabilitation AND “African
Thoracic Surgery AND Americans” Americans”
Rehabilitation AND “African Found: 0 Found: 4
Americans” Yield: 0 Yield: 1
Found: 0 “Thoracic Surgery” AND
Yield: 0

61
 “Rehabilitation” AND “African
Americans”
Found: 0
Yield: 0
Thoracic Surgery AND “Thoracic Surgery” AND Thoracic Surgery AND
Rehabilitation AND “Blacks” Rehabilitation AND “Blacks” Rehabilitation AND “Blacks”
Found: 0 Found: 0 Found: 1
Yield: 0 Yield: 0 Yield: 0
“Thoracic Surgery” AND
“Rehabilitation” AND “Blacks”
Found: 0
Yield: 0
Thoracic Surgery AND “Thoracic Surgery” AND Thoracic Surgery AND
Rehabilitation Centers AND Rehabilitation Centers AND Rehabilitation Centers AND
African Americans Blacks Blacks
Found: 0 Found: 0 Found: 0
Yield: 0 Yield: 0 Yield: 0
Thoracic Surgery AND “Thoracic Surgery” AND Thoracic Surgery AND
Rehabilitation Centers AND Rehabilitation Centers AND Rehabilitation Centers AND
“African Americans” “African Americans” “African Americans”
Found: 0 Found: 0 Found: 0
Yield: 0 Yield: 0 Yield: 0
“Thoracic Surgery” AND
“Rehabilitation Centers” AND
“African Americans”
Found: 0
Yield: 0
Thoracic Surgery AND “Thoracic Surgery” AND Thoracic Surgery AND
Rehabilitation Centers AND Rehabilitation Centers AND Rehabilitation Centers AND
“Blacks” “Blacks” “Blacks”
Found: 0 Found: 0 Found: 0
Yield: 0 Yield: 0 Yield: 0
“Thoracic Surgery” AND
“Rehabilitation Centers” AND
“Blacks”
Found: 0
Yield: 0
Thoracic Surgery/rehabilitation Thoracic Surgery/rehabilitation
AND African Americans AND Blacks
Found: 0 Found: 0
Yield: 0 Yield: 0
Thoracic Surgery/rehabilitation Thoracic Surgery/rehabilitation
AND "African Americans" AND "African Americans"
Found: 0 Found: 0
Yield: 0 Yield: 0
Thoracic Thoracic
Surgery/rehabilitation" AND Surgery/rehabilitation" AND
“Blacks” “Blacks”
Found: 0 Found: 0
Yield: 0 Yield: 0

62
Cardiac Surgical Procedures “Cardiac Surgical Procedures” Surgery, cardiovascular AND
AND Rehabilitation AND AND Rehabilitation AND Blacks Rehabilitation AND Blacks
African Americans Found: 0 Found: 1
Found: 1 Yield: 0 Yield: 0
Yield: 0
“Cardiac Surgical Procedures” Surgery, cardiovascular AND
AND Rehabilitation AND Rehabilitation AND “African
“African Americans” Americans”
Found: 0 Found: 3
Yield: 0 Yield: 1
Cardiac Surgical Procedures “Cardiac Surgical Procedures”
AND Rehabilitation AND AND “Rehabilitation” AND
“African Americans” “African Americans”
Found: 1 Found: 0
Yield: 0 Yield: 0
Cardiac Surgical Procedures “Cardiac Surgical Procedures” Surgery, cardiovascular AND
AND Rehabilitation AND AND Rehabilitation AND Rehabilitation AND “Blacks”
“Blacks” “Blacks” Found: 1
Found: 1 Found: 0 Yield: 0
Yield: 0 Yield: 0
“Cardiac Surgical Procedures”
AND “Rehabilitation” AND
“Blacks”
Found: 0
Yield: 0
Cardiac Surgical Procedures “Cardiac Surgical Procedures” Surgery, cardiovascular AND
AND Rehabilitation Centers AND Rehabilitation Centers Rehabilitation Centers AND
AND African Americans AND Blacks Blacks
Found: 0 Found: 0 Found: 0
Yield: 0 Yield: 0 Yield: 0
Cardiac Surgical Procedures “Cardiac Surgical Procedures” Surgery, cardiovascular AND
AND Rehabilitation Centers AND Rehabilitation Centers Rehabilitation Centers AND
AND “African Americans” AND “African Americans” “African Americans”
Found: 1 Found: 0 Found: 0
Yield: 1 Yield: 0 Yield: 0
“Cardiac Surgical Procedures”
AND “Rehabilitation Centers”
AND “African Americans”
Found: 0
Yield: 0
Cardiac Surgical Procedures “Cardiac Surgical Procedures” Surgery, cardiovascular AND
AND Rehabilitation Centers AND Rehabilitation Centers Rehabilitation Centers AND
AND “Blacks” AND “Blacks” “Blacks”
Found: 0 Found: 0 Found: 0
Yield: 0 Yield: 0 Yield: 0
“Cardiac Surgical Procedures”
AND “Rehabilitation Centers”
AND “Blacks”
Found: 0
Yield: 0

63
Cardiac Surgical Surgery,
Procedures/rehabilitation AND cardiovascular/rehabilitation
African Americans AND Blacks
Found: 0 Found: 0
Yield: 0 Yield: 0
Cardiac Surgical Surgery,
Procedures/rehabilitation AND cardiovascular/rehabilitation
“African Americans” AND “African Americans”
Found: 1 Found: 0
Yield: 1 Yield: 0
Cardiac Surgical Surgery,
Procedures/rehabilitation AND cardiovascular/rehabilitation
"Blacks" AND “Blacks”
Found: 0 Found: 0
Yield: 0 Yield: 0
Cardiovascular Surgical “Cardiovascular Surgical Heart Surgery AND
Procedures AND Rehabilitation Procedures” AND Rehabilitation AND Blacks
AND African Americans Rehabilitation AND Blacks Found: 1
Found: 1 Found: 0 Yield: 0
Yield: 0 Yield: 0
Cardiovascular Surgical “Cardiovascular Surgical Heart Surgery AND
Procedures AND Rehabilitation Procedures” AND Rehabilitation AND “African
AND “African Americans” Rehabilitation AND “African Americans”
Found: 1 Americans” Found: 3
Yield: 0 Found: 0 Yield: 1
Yield: 0
“Cardiovascular Surgical
Procedures” AND
“Rehabilitation” AND “African
Americans”
Found: 0
Yield: 0
Cardiovascular Surgical “Cardiovascular Surgical Heart Surgery AND
Procedures AND Rehabilitation Procedures” AND Rehabilitation AND “Blacks”
AND “Blacks” Rehabilitation AND “Blacks” Found: 1
Found: 1 Found: 0 Yield: 0
Yield: 0 Yield: 0
“Cardiovascular Surgical
Procedures” AND
“Rehabilitation” AND “Blacks”
Found: 0
Yield: 0
“Cardiovascular Surgical Heart Surgery AND
Cardiovascular Surgical Procedures” AND Rehabilitation Centers AND
Procedures AND Rehabilitation Rehabilitation Centers AND Blacks
Centers AND African Americans Blacks Found: 0
Found: 0 Found: 0 Yield: 0
Yield: 0 Yield: 0

64
Cardiovascular Surgical “Cardiovascular Surgical Heart Surgery AND
Procedures AND Rehabilitation Procedures” AND Rehabilitation Centers AND
Centers AND “African Rehabilitation Centers AND “African Americans”
Americans” “African Americans” Found: 0
Found: 1 Found: 0 Yield: 0
Yield: 1 Yield: 0
“Cardiovascular Surgical
Procedures” AND
“Rehabilitation Centers” AND
“African Americans”
Found: 0
Yield: 0
Cardiovascular Surgical “Cardiovascular Surgical Heart Surgery AND
Procedures AND Rehabilitation Procedures” AND Rehabilitation Centers AND
Centers AND “Blacks” Rehabilitation Centers AND “Blacks”
Found: 0 “Blacks” Found: 0
Yield: 0 Found: 0 Yield: 0
Yield: 0
“Cardiovascular Surgical
Procedures” AND
“Rehabilitation Centers” AND
“Blacks”
Found: 0
Yield: 0
Cardiovascular Surgical Heart Surgery/rehabilitation
Procedures/rehabilitation AND AND Blacks
African Americans Found: 0
Found: 0 Yield: 0
Yield: 0
Cardiovascular Surgical Heart Surgery/rehabilitation
Procedures/rehabilitation AND AND “African Americans”
“African Americans” Found: 0
Found: 1 Yield: 0
Yield: 1
Cardiovascular Surgical Heart Surgery/rehabilitation
Procedures/rehabilitation AND AND “Blacks”
"Blacks" Found: 0
Found: 0 Yield: 0
Yield: 0
“Cardiovascular “Cardiovascular “Cardiovascular
Rehabilitation” AND “African Rehabilitation” AND “African Rehabilitation” AND “African
Americans” Americans” Americans”
Found: 74 Found: 0 Found: 0
Yield: 2 Yield: 0 Yield: 0
“Cardiovascular “Cardiovascular “Cardiovascular
Rehabilitation” AND “Blacks” Rehabilitation” AND “Blacks” Rehabilitation” AND “Blacks”
Found: 89 Found: 0 Found: 2
Yield: 2 Yield: 0 Yield: 0

65
“Cardiac Rehabilitation” AND “Cardiac Rehabilitation” AND “Cardiac Rehabilitation” AND
“African Americans” “African Americans” “African Americans”
Found: 68 Found: 0 Found: 40
Yield: 3 Yield: 0 Yield: 4
“Cardiac Rehabilitation” AND “Cardiac Rehabilitation” AND “Cardiac Rehabilitation” AND
“Blacks” “Blacks” “Blacks”
Found: 83 Found: 6 Found: 69
Yield: 4 Yield: 0 Yield: 3

Total for in-depth abstract/full text review from all databases: 40

Total articles that meet final criteria: 7

66
 Table 2

Subject Heading Equivalencies by Database

Medline via PubMed PsycINFO via EBSCO CINAHL via EBSCO

African Americans Blacks Blacks
Cardiac Surgical Procedures Heart Surgery; “Cardiac Surgical Procedures” Surgery, Cardiovascular; Heart Surgery
Cardiovascular Diseases Cardiovascular Disorders Cardiovascular Diseases
Cardiovascular Surgical Procedures Heart Surgery; “Cardiovascular Surgical Procedures” Surgery, Cardiovascular; Heart Surgery
Coronary Artery Bypass Cardiovascular Disorders; Heart Surgery; “Coronary Artery Bypass” Coronary Artery Bypass
Coronary Artery Disease Cardiovascular Disorders; Heart Disorders; “Coronary Artery Disease” Coronary Arteriosclerosis
Coronary Disease Cardiovascular Disorders; Heart Disorders; “Coronary Disease” Coronary Disease
Heart Diseases Heart Disorders Heart Diseases
Heart Failure “Heart Failure” Heart Failure
Myocardial Infarction Myocardial Infarctions Myocardial Infarction
Myocardial Ischemia “Myocardial Ischemia” Myocardial Ischemia
Rehabilitation Rehabilitation Rehabilitation
Rehabilitation Centers Rehabilitation Centers Rehabilitation Centers
Thoracic Surgery Heart Surgery; “Thoracic Surgery” Thoracic Surgery
67
 Table 3

Study Quality Criteria

Representative Defined Blinded > 85% Appropriate Outcome data Multivariate Total
sample1 sample2 outcome follow-up outcome reported at analysis, w/
assessment3 rate4 measures5 follow-up6 adj. for
confounds7
Allen et al. 1 1 0 1 1 1 1 6
(2004)
Bittner et al. 1 1 0 0 1 0 1 4
(1999)
Cannistra et 1 1 0 0 1 1 1 5
al. (1995)
Evenson et al. 1 1 0 1 1 1 0 5
(2006)
Gregory et al. 1 1 0 1 1 1 1 6
(2006)
68

Rankin et al. 1 1 0 0 1 1 1 5
(2002)
Young et al. 1 1 0 0 1 1 1 5
(1991)
Note: ‘1’ signifies that the author met the stated criteria, whereas ‘0’ indicates the criteria have not been met.
1
“Participants selected as consecutive or random cases” (Hall, Ferreira, Maher, Latimer, & Ferreira, 2010, p. 1103).
2
“Description of participant source and inclusion and exclusion criteria” (p. 1103).
3
“Assessor was unaware of prognostic factors at the time of outcome assessment” (p. 1103).
4
“Outcome data were available for at least 85% of participants at one follow-up point” (p. 1103).
5
“Appropriate choice of outcome measures” (p. 1103).
6
“Reporting of outcome data at follow up” (p. 1103).
7
“Multivariate analysis conducted, with adjustment for potentially confounding variables” (p. 1103).
 Table 4

Article Summaries

Referral/ Sample size Participant Participant Demographic and Findings

enrollment/ (n) characteristics: characteristics: biopsychosocial-
attendance/ race/ethnicity Cardiovascular spiritual variable(s)
completion and gender condition

Allen et al. Referral/ 253 AA and W MI, angina, PCI, Race/ethnicity; AA women half as likely to be
(2004) enrollment women CABG Income; depression referred to CR; AA = lower
enrollment; Income = predictor of
referral/enrollment; no interaction
between race and income or race
and depression.
Bittner et al. Referral 1,329 AA and W men MI, angina, Race/ethnicity; 9.5% of W participants were
(1999) and women CAGB distance to CR, referred compared with 7.4% of AA
69

insurance coverage, participants but this difference was

discharging not statistically significant.
physician’s specialty
Cannistra et Attendance, 82 AA and W MI, angina, PCI, Race/ethnicity; AA women = more CV risk factors
al. (1995) completion women CABG, valve Factors impacting at program entry; more likely to not
surgery; dx of CR participation = complete CR and cited work
cardiomyopathy, medical, work, conflict and personal reasons; less
or multiple CV personal, logistical likely to lose weight from CR than
risk factors. W women. Both AA and W women
= improved functional capacity with
CR.
Evenson et Attendance 61 = 2004; CR program Eligible for CR Race/ethnicity; CR participants = 90% W, 9% AA;
al. (2006) 45 = Both directors in NC gender; availability 72% of program directors cited
1999 and of transportation policy issues as primary barrier to
2004 participation; work conflicts =
primary reason for drop-out.
 Gregory et Referral 1,933 AA and W MI, Race/ethnicity; W participants = 2x more likely to
al. (2006) men and women revascularization, insurance status be referred to CR; AA participants
in past year; Dx more likely to have Medicaid or no
of HF insurance than W participants.
Rankin et al. Enrollment 76 AA and W MI Race/ethnicity No AA participants enrolled in CR
(2002) women during yearlong study compared
with approximately 20% of W
participants.
Young et al. Enrollment 246 AA and W MI Race/ethnicity, SES Lower SES AA participants were
(1991) men and women least likely to be enrolled in CR;
Higher SES AA participants and
lower SES W participants had an
equal likelihood of being enrolled.
Key of abbreviations: AA = African American; W = White; CR = Cardiac Rehabilitation; CV = Cardiovascular; CABG = Coronary Artery Bypass
Grafting; MI = Myocardial Infarction; PCI = Percutaneous Coronary Intervention; Dx = Diagnosis; SES = Socioeconomic status
70
 Titles and abstracts
identified and screened Subject Heading/Keyword Search
Medline (n = 1,082)
PscycINFO (n = 8)
CINAHL (n = 661) Title and Abstract Review
n = 1,751 Duplicates Inclusion criteria
excluded = 111
n = 1,640 1. African Americans or a mixed
racial/ethnic sample, with
African American subsample
Did not meet 2. Participants aged 18 and older
inclusion with one or more of the
criteria = 1,600 diagnoses for which CR is
n = 40 indicated
3. CR program referral or
participation as an outcome
Full documents retrieved and
variable
assessed for eligibility
4. Measured at least one
71

n = 40
Excluded in full demographic or
text review = 33 biopsychosocial-spiritual
variable
No mention of CR 5. Peer-reviewed and in English
referral or 6. Original empirical research,
participation = 24 either quantitative or
qualitative.
Did not
quantify/analyze
racial/ethnic
subgroup = 9
Citation tracking from 40 collected
articles. Added to analysis = 0
Articles meeting inclusion
criteria n = 7
Fidelity check applied

Figure 2. Flow Chart of Included Articles for Review.

 CHAPTER THREE: METHODOLOGY
Although Cardiac Rehabilitation (CR), a secondary prevention and treatment program,

has been demonstrated to improve physical and psychological health outcomes for patients with

cardiovascular disease (CVD) (Brown, Clark, Dalal, Welch, & Taylor, 2011; Heran et al., 2011;

Whalley et al., 2011), CR referral and participation rates have remained low, reflecting about one

third of eligible patients (Ayala, Xie, McGruder, & Valderrama, 2008; Suaya et al., 2007).

Cardiac Rehabilitation is especially underutilized by racial/ethnic minorities (Beswick et al.,

2004; Evenson, Johnson, & Aytur, 2006; Suaya et al., 2007). African Americans have a 20%

higher age-adjusted death rate from coronary heart disease than Non-Hispanic Whites (Centers

for Disease Control and Prevention [CDC], 2013), but they are less likely than Non-Hispanic

Whites to be referred to (Allen, Scott, Stewart, & Young, 2004; Gregory, LaVeist, & Simpson,

2006), participate in (Cannistra, O’Malley, & Balady, 1995; Evenson et al., 2006), or benefit

from CR (Cannistra et al., 1995; Sanderson, Mirza, Fry, Allison, & Bittner, 2007).

This chapter presents the methodology for this mixed methods dissertation research on

African American patients’ CR referral and participation. The researchers will provide the

rationale for mixed methods research, as well as the design, data collection and procedures, the

lead researcher’s and triangulated researcher’s statements of bias, and ethical considerations for

this dissertation research. As a mixed methods study, this research was comprised of a

quantitative and qualitative portion: (a) self-report surveys from African American and Non-

Hispanic White patients with CVD (quantitative) and (b) audio-recorded, in-depth, open-ended

phenomenological interviews (Colaizzi, 1978) with African American patients recovering from

cardiac events and/or surgeries (qualitative). The overarching research question for this

dissertation was: “What demographic and biopsychosocial-spiritual factors impact CR referral

and participation for/among adult African American patients with CVD?” The research question
guiding the qualitative portion of this study was: “What is the lived experience of African

American patients recovering from cardiac events and/or surgeries?”

Mixed Methods Research

Mixed methods researchers combine quantitative and qualitative research methods in

order to address complex problems in the social and behavioral sciences (Creswell, 2009).

According to Creswell (2009), a mixed methods approach may be especially instrumental when

“the use of either quantitative or qualitative approaches by themselves is inadequate to address

this complexity” (p. 203). In contrast, “combined use [of methods] provides an expanded

understanding of research problems” (Creswell, 2009, p. 203). Historically, many researchers

and theorists have considered quantitative and qualitative methods to be incompatible due to

contrasting theoretical origins (i.e., positivism and constructivism, respectively) (Tashakkori &

Teddlie, 1998). More recently, however, others have argued for a pragmatic approach founded

in (a) paradigm relativism, “or the use of whatever philosophical and/or methodological

approach works for the particular research problem under study” (p. 5) and (b) the compatibility

thesis of quantitative and qualitative methods (Tashakkori & Teddlie, 1998). This pragmatism

has opened the door for combined quantitative and qualitative approaches (Tashakkori & Teddlie,

1998).

Tashakkori and Teddlie (1998) have offered a broad definition of mixed methods studies:

“studies that are products of the pragmatist paradigm and that combine qualitative and

quantitative approaches within different phases of the research process” (p. 19). Creswell (2009)

has provided a number of typologies for categorizing mixed methods studies based on the

following aspects: (a) timing (i.e., sequencing of data collection methods); (b) weighing (i.e.,

amount of emphasis and/or importance given to each method); (c) mixing (i.e., when/how the

73
methods are mixed for study conceptualization and data interpretation); and (d) theorizing (i.e.,

the underlying theoretical perspective for the study). According to these typologies, the

proposed study follows a concurrent transformative strategy (Creswell, 2009).

This concurrent transformative strategy was characterized by: (a) overlapping

quantitative and qualitative phases (i.e., timing is concurrent); (b) variable weight given to each

method; (c) connected data mixing (e.g., methods are connected or merged in the analysis

process so findings from one inform findings from the other); and (d) guided by a theoretical lens

that “is introduced in the introduction to a proposal, shapes a directional research question aimed

at exploring a problem (e.g., inequality, discrimination, injustice), creates sensitivity to collecting

data from marginalized or underrepresented groups, and ends with a call to action” (p. 212).

According to Creswell (2009), this strategy is adopted to “give voice to diverse perspectives, to

better advocate for participants, or to better understand a phenomenon or process that is changing

as a result of being studied” (Creswell, 2009, p. 213). This study strongly aligned with the first

two objectives of this strategy.

In accordance with a concurrent transformative strategy, the lead researcher conducted

this study in overlapping phases with the quantitative and qualitative portions running

concurrently. Greater weight was given to the quantitative portion, with the qualitative portion

designed to supplement and provide insight into the quantitative data. The Biopsychosocial-

Spiritual (BPSS) approach provided the theoretical lens that guided this study (Engel, 1977,

1980; Wright, Watson, & Bell, 1996). The BPSS approach conceptualizes health-related

experiences through the consideration of multiple factors (i.e., biological, psychological, social,

and spiritual) intersecting on different levels of the natural systems hierarchy (i.e., societal-

national, cultural-subcultural, community and family, and individual levels [Engel, 1977, 1980]).

74
The researchers designed this study to not only investigate but also to make recommendations for

rectifying a glaring health disparity in African Americans access to cardiovascular secondary

prevention and treatment, specifically CR.

Study Design

A mixed methods approach was adopted to address the complexity of this research, and,

specifically, a concurrent transformative strategy was selected in order to “give voice to diverse

perspectives [and] to better advocate for participants” (Creswell, 2009, p. 213). This mixed

methods concurrent transformative study (Creswell, 2009) incorporated self-report surveys from

African American and Non-Hispanic White patients with CVD (quantitative portion) and semi-

structured phenomenological interviews with African American patients recovering from cardiac

events and/or surgeries (qualitative portion). The qualitative portion of this study was designed

in alignment with Husserl’s (1970) descriptive phenomenology. The research question that

guided the study as a whole was: “What demographic and biopsychosocial-spiritual factors

impact CR referral and participation for/among adult African American patients with CVD?”

The research question for the qualitative portion of this study was: “What is the lived experience

of African American patients recovering from cardiac events and/or surgeries?”

This mixed methods dissertation research study consisted of a quantitative portion (read-

aloud surveys) and a qualitative portion (audio-recorded, in-depth, open-ended

phenomenological interviews). The lead researcher or research assistants enrolled patients with

CVD in the study one to two days pre-discharge from an inpatient cardiac service. The

quantitative portion consisted of two surveys. The “Time 1” (T1) portion of the survey was

conducted in person, pre-hospital discharge immediately following study enrollment. The lead

researcher or research assistants delivered the survey using a read-aloud process. The “Time 2”

75
(T2) portion was conducted approximately six weeks post-discharge also using a read-aloud

survey process that was carried out over the telephone. The qualitative portion of this study

consisted of open-ended, semi-structured phenomenological interviews with African Americans

patients recovering from cardiac events and/or surgeries. Subsequent to completion of the six-

week post-discharge survey (T2), the lead researcher or research assistants invited eligible

participants to participate in the qualitative portion of the study. Additionally, eligible

participants were also recruited for the qualitative portion of the study directly from a nearby CR

facility. The lead researcher conducted all interviews by flexibly using an interview guide to

ensure all participants addressed similar topics and issues related to their cardiac and CR

perspectives and experiences.

The initial hypotheses for the quantitative portion of the study were:

1. African American race will be associated with lower incidence of revascularization

procedures (i.e., coronary artery bypass grafting [CABG] or percutaneous coronary

intervention [PCI]), and lower incidence of revascularization procedures will be

associated with lower levels of CR referral.

2. African American race, lack of insurance, lower levels of education, unemployment,

lower annual income, and no follow-up appointment with a cardiologist or cardiac

surgeon will be associated with lower levels of both referral to and participation in (e.g.,

enrollment, attendance, and completion) CR.

3. Higher levels of anxiety, depression, and helpless inevitability, and lower levels of social

support will be more strongly associated with lower levels of participation in CR among

African American participants than among Non-Hispanic White participants.

76
This study was approved by the East Carolina University and Medical Center Institutional

Review Board (IRB) before participant recruitment commenced (see Appendix A).

Setting

The settings for this dissertation research were (a) a Southeastern academic medical

center serving a population of nearly one and a half million people from a primarily rural and

lower-income area, and (b) a nearby, affiliated CR facility. At the time of the study, over half of

the medical center’s care was provided without payment, as either charity care, unreimbursed

Medicaid care, or care through other need-based government programs. The medical center

housed two cardiac inpatient units: a Cardiovascular Intensive Care Unit (CVICU) (24 beds, 8 of

which were used for patients preparing for discharge) and a Cardiac Intermediate Unit (CIU) (56

beds all of which could be used for patients preparing for discharge). The CVICU typically

served and discharged CABG and PCI patients, while myocardial infarction (MI) patients moved

to the CIU before discharge and, therefore, typically discharged from the CIU. The CR facility

was the only facility of its kind in the county where the academic medical center was located and

was one of two CR facilities serving the county. The CR facility located in the academic

medical center had 147 participants complete the CR program in the 2013-2014 fiscal year.

Participants

The participants in the quantitative portion of the study were patients with CVD

preparing for discharge (i.e., discharge scheduled that day or within the next two days) from one

of the two cardiac inpatient units housed within a Southeastern academic medical center.

Patients were considered eligible for participation in the quantitative portion of the study if they

met the following inclusion criteria: (a) English-speaking; (b) aged 18 and older; (c) prepared for

discharge from a cardiac event or surgery for which CR was indicated (MI, coronary artery

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bypass grafting [CABG], stable angina, heart valve repair/replacement, percutaneous coronary

intervention [PCI] (including percutaneous transluminal coronary angioplasty [PCTA]), heart

transplant, and/or coronary artery disease [adapted from American Association of Cardiovascular

and Pulmonary Rehabilitation [AACVPR], 2014]); and (d) resident of a city or town in the

county where the academic medical center was located. The researchers geographically

restricted study participant recruitment, because the outcome variables of CR referral and

participation were measured by consulting the electronic health record (EHR) and paper records

of the two CR facilities that served that particular county.

Exclusion criteria for this study included: (a) a discharge diagnosis of heart failure or a

heart-lung transplant (heart failure patients at this academic medical center were sometimes

referred to pulmonary rehabilitation and heart-lung transplants patients could also be referred to

pulmonary rehabilitation rather than CR) or (b) cognitive impairment that would interfere with

the individual’s ability to consent to the study and participate in surveys and interviews. Upon

enrollment, participants were asked to consent to T1 and T2 surveys and, if they met inclusion

criteria, invited to participate in one audio-recorded, in-depth, open-ended telephone interview.

However, the lead researcher or research assistants explained to the participant that he or she was

not obligated to complete all portions of the study and could elect to discontinue enrollment at

any point without consequence.

Anticipated enrollment for the quantitative portion of the study was 75 participants.

Participants for the qualitative portion of the study were recruited (a) from an initial pool of 75

patients recovering from cardiac events and/or surgeries and (b) directly from a nearby CR

facility affiliated with the academic medical center. Regarding recruitment from the initial pool

of study participants, African American patients who were already enrolled in the study were

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asked at the time of the six-week post-discharge survey (T2) if they were willing to participate in

an audio-recorded, in-depth, open-ended interview of about one hour in duration. Additionally,

participants were directly recruited from a nearby CR facility for the qualitative portion of the

study. Eligibility criteria for participants recruited from the CR facility was identical to the

eligibility criteria used for recruitment from the initial pool, with the following exception: a pre-

discharge timeframe criterion was substituted for a post-discharge timeframe criterion. The

researchers selected a time period of approximately two months post-discharge in order to ensure

that participants who were recruited from the initial pool (at six to seven weeks post discharge)

would be in the same stage of recovery as those recruited directly from the facility.

Participants were recruited and semi-structured interviews were conducted until the

saturation of themes was reached. Saturation was affirmed when the analysis of additional data

(in this case, participant interviews) yielded no new themes (Creswell, 2009). Although the

number of interviews needed to reach saturation could not be predicted, Mason’s (2010) content

analysis of qualitative studies provided some guidelines. In a review of 57 phenomenology

studies, Mason (2010) found that the average number of interviews associated with a

phenomenology was 25, while the median number was 20, and range was seven to 89. Due to

the high specificity of the topic, anticipated homogeneity of the purposively selected sample, and

the inclusion criteria for this phenomenological study, the researchers estimated that saturation

would be reached within 8 to 12 interviews. The lead researcher planned to conducted one

additional interview past the point of saturation to test comprehensiveness of themes (Morse,

Barrett, Mayan, Olson, & Spiers, 2002).

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Measures

The quantitative variables that were measured in this study were anxiety and depression

using the Patient Health Questionnaire for Anxiety and Depression (PHQ-4; Kroenke, Spitzer,

Williams, & Lowe, 2009); social support using the MOS Social Support Survey (Sherbourne &

Stewart, 1991); helpless inevitability using the Religious Health Fatalism Questionnaire

(Franklin, Schlundt, & Wallston, 2008). Patient self-report revealed the type of cardiac event

and/or surgery the patient experienced and whether or not patients received and/or attended a

post-discharge follow-up appointment with a cardiologist, cardiac surgeon, or primary care

provider. The diagnosis at discharge was based on the EHR, and CR referral and participation in

CR was based on the EHR and paper record data kept by the CR facilities serving the county in

which the academic medical center was located. Data were also collected on the following

demographic variables: sex/gender, age, race/ethnicity, insurance status, relationship status,

highest level of education, employment status, household income, health insurance status, and

number of household occupants. Permission was obtained for the use of the copyrighted

measures (see Appendix B).

Independent Variables

Independent variables for this study included: (a) demographic information (e.g.,

sex/gender, age, race/ethnicity); (b) type of cardiac event/surgery; (c) follow-up appointment

with cardiologist or cardiac surgeon; (d) anxiety; (e) depression; (f) social support; (g) helpless

inevitability; and (h) diagnosis at discharge. The researchers used diagnosis at discharge as

reported in the EHR to confirm the type of cardiac event/surgery indicated by patient self-report.

In the event that diagnosis at discharge and patient self-report conflicted, the lead researcher

deferred to the diagnosis at discharge listed in the EHR.

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 Demographic information. Demographic information was gathered from patients as

part of the administration of the T1 survey. Information collected included sex/gender, age,

race/ethnicity, insurance status, relationship status, highest level of education, employment status,

household income, health insurance status, relationship status, and number of household

occupants.

Type of cardiac event/surgery. Type of cardiac event/surgery was measured on the T1

survey with the question: “What was your recent hospitalization for?” The possible responses

included: (a) heart attack (MI); (b) coronary artery bypass (CABG); (c) coronary stenting (“stent,”

PCTA/angioplasty, or other PCI); (d) heart attack with revascularization (CABG, PCTA, or other

PCI); (e) stable angina; (f) heart valve repair/replacement; (g) heart transplant; or (h) peripheral

artery disease. Diagnosis at discharge (collected using the EHR) was used to confirm the type of

cardiac event and/or surgery indicated by patient self-report on the T1 survey. In the event that

diagnosis at discharge and patient self-report conflicted, the lead researcher deferred to the

diagnosis at discharge listed in the EHR (see Hypothesis 1).

Follow-up appointment with a cardiologist or cardiac surgeon. The T2 survey asked

participants about their attendance at a post-discharge follow-up appointment (yes/no) and with

whom they had the appointment. For the latter question, the following options were given: (a)

cardiologist; (b) cardiac surgeon; (c) primary care provider; and (d) other. Follow-up

appointment and type of provider was included as an independent variable due to research that

supported follow-up appointments with a cardiologist or cardiac surgeon as predictive of CR

referral (Barber, Stommel, Kroll, Holmes-Rovner, & McIntosh, 2001) (See Hypothesis 2).

Anxiety and depression. The PHQ-4 (Kroenke, Spitzer, Williams, & Lowe, 2009) was

included in both the T1 and T2 survey in order to measure symptoms of anxiety and depression.

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Developed as a brief screener for anxiety and depression, the PHQ-4 is a composite of the PHQ-

2 (brief screener for depressive symptoms) and the GAD-2 (brief screener for anxiety symptoms).

The measure asked participants to rate the frequency with which they had been bothered by

anxiety and depression symptoms over the past two weeks on a four-point Likert scale (0 = not at

all, 1 = several days, 2 = more than half the days, 3 = nearly every day). Although this screener

is not intended to be diagnostic, its effectiveness as an “indicator for further inquiry” (p. 613) has

been demonstrated in the PHQ-2’s sensitivity (83%) and specificity (90%) for major depressive

disorder (Kroenke, Spitzer, & Williams, 2003) and the GAD-2’s sensitivity and specificity for a

variety of anxiety disorders (sensitivity = 88% for generalized anxiety disorder, 76% for panic

disorder, 70% for social anxiety disorder, and 59% for posttraumatic stress disorder; specificity =

81-83% for above anxiety disorders) (Kroenke, Spitzer, Williams, Monahan, & Lowe, 2007).

The PHQ-4 has a Cronbach’s alpha (measurement of internal reliability) of 0.85 and has

been demonstrated to correlate more strongly with results of longer screeners, such as the SF-20,

in measuring mental health (Kroenke et al., 2009). The clinical cut off score for the PHQ-4 is 3

or more on the 0-to-12 point scale (normal = 0-2, mild = 3-5, moderate = 6-8, severe = 9-12)

(Kroenke et al., 2009). Because the PHQ-4 asks participants to report on their experience over

the past two weeks, the lead researcher or research assistants administered it as part of the T1

survey and also the T2 survey six weeks later.

Social support. Social support was measured on the T1 and T2 surveys using the MOS

Social Support Survey (Sherbourne & Stewart, 1991). The MOS Social Support Survey is a

multidimensional survey designed to measure four components of functional support:

emotional/informational, tangible, and affectionate support, and positive social interaction. The

overall social support index consisting of the four dimensions of support has high internal

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reliability with a Cronbach’s alpha of 0.97 (Sherbourne & Stewart, 1991). In the development of

this measure, the highest correlations were found between the overall social support index and

variables of loneliness, marital functioning, family functioning, and mental health. Scoring is

done on a 5-point Likert scale (1 = none of the time, 2 = a little of the time, 3 = some of the time,

4 = most of the time, 5 = all of the time). The stem “How often is each of the following kinds of

support available to you if you need it?” is used to prompt answers to items. A sample item is,

“Someone to help you if you were confined to bed” (Sherbourne & Stewart, 1991). Social

support was measured in both the T1 and T2 surveys to ensure any changes in participants’

social support were noted and accounted for in analysis.

Helpless inevitability. Helpless inevitability was measured on the T1 and T2 surveys

using the Religious Health Fatalism Questionnaire (RHFQ) (Franklin et al., 2008). The RHFQ

was designed specifically for African American participants through a process that included

consultation with focus groups and key informants within African American churches and pilot

testing with 276 African American participants (Franklin et al., 2008). The RHFQ consists of

three subscales that were identified using exploratory factor analysis of measure items: (a) divine

provision; (b) destined plan; and (c) helpless inevitability. The latter subscale, helpless

inevitability, was identified as “the subscale contributing the most to the prediction of health

behaviors when compared to the other two subscales” (Franklin et al., 2008, p. 332). This

subscale consists of two questions only, which likely contributes to its low Cronbach’s alpha

of .52. When tested against Multidimensional Health Locus of Control (MHLC) (Wallston,

2005), helpless inevitability was positively and significantly correlated with MHLC’s measures

of Chance Externality and Powerful Others. The two items which comprise this subscale are: “I

don’t need to try to improve my health because I know it is up to God” and “I can control a small

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health issue, but only God can control a big health issue” (Franklin et al., 2008). Helpless

inevitability was measured in both the T1 and T2 surveys to ensure any changes in participants’

helpless inevitability were noted and accounted for in analysis.

Dependent Variable Measures

The dependent variable measures for this study were referral to and participation in CR

per the EHR and paper records kept by the CR facilities. Referral to CR was defined as a

medical provider’s referral that was submitted to a CR facility. It was noted if the patient

received a letter from the CR facility and/or an inpatient consultation regarding CR after being

identified as a patient eligible for CR services. However, the researchers did not consider the

patient’s receipt of a letter or inpatient consultation only as a referral; rather, these were coded as

recommendations. Referral was quantified as the dichotomous variable, “referred/not referred.”

Cardiac Rehabilitation participation was operationalized into three dichotomous

variables: (a) enrolled (i.e., chart opened and assessment session scheduled for patient after

confirming patient’s interest in participating)/did not enroll; (b) attended (i.e., attended

assessment session and at least one subsequent CR session)/did not attend; and (c) completed

(i.e., finished CR program according to CR facility assessment of patient completing the goals

mutually determined by the patient and the CR staff)/did not complete. All participation

variables were measured using the EHR and CR facilities’ paper records. Enrollment was

measured six weeks post-discharge, while attendance and completion were measured five

months post-discharge.

Data Collection and Procedures

Recruitment, Enrollment, and Consent

The researchers recruited participants who were awaiting discharge from the cardiac

inpatient service that day or within the subsequent one to two days. The lead researcher or

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research assistants consulted the EHR to determine which patients on the cardiac inpatient

service were residents of the county from which participants were sampled for the study. Next,

the nurses on the hospital unit where those patients were located were asked whether or not these

patients were (a) preparing for discharge that day or within the subsequent one to two days and

(b) had a diagnosis consistent with study inclusion criteria. Having located eligible patients’

rooms, the lead researcher or research assistant explained the study to each potential participant

and asked whether or not he or she would be willing to participate in the study (see Appendix C

for Recruitment Script). Those who were willing to participate were given the opportunity to

enter a drawing for one of ten $25 gas cards to be drawn at the end of the survey data collection.

Only participants who completed both the T1 and T2 surveys were eligible for the gas card

drawing.

If participants were interested in entering their names into the drawing, the lead

researcher or research assistants collected their name and contact information (telephone number,

address) on separate sheets to be kept in a lockbox in a locked cabinet at the CIU, and later, a

locked file cabinet in the research assistants’ locked office. Ten names were drawn from the

participants who completed both the T1 and T2 surveys, and gas cards were mailed to the

addresses provided. Regarding the qualitative portion of the study, participants who completed a

telephone interview were automatically mailed a $25 gas card directly following the interview.

At the time of study enrollment, participants reviewed and signed the informed consent

document after the lead researcher or research assistant addressed any questions or concerns (see

Appendix D for informed consent document). The informed consent document included consent

to participate in the T1 and T2 surveys and the audio-recorded, qualitative telephone interview, if

the participant later met the inclusion criteria for the qualitative portion of the study. Contact

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information, best times to call, and permission to leave a message were also obtained at the time

of enrollment into the study and recorded on the study participant list. The enrollment process

took approximately 10 to 15 minutes.

Data Collection

This study involved the collection of data from surveys, qualitative interviews, the

academic medical center/CR facilities’ EHR, and the paper records kept by the CR facilities.

The researchers ensured participants’ confidentiality by using sequentially assigned numbers in

place of names to de-identify participants for the quantitative portion of the study. The lead

researcher asked participants to select pseudonyms for themselves that were used in the

transcript and the write-up of the analysis. A number was assigned to participants when they

were enrolled in the study and was the only identifying information used on surveys and

interview audio files and transcripts. The identifying numbers were recorded with the

corresponding participant’s name and contact information and kept in a password-protected file

on the lead researcher’s secure Pirate Drive.

Concerning storage of paper data, T1 surveys were initially stored in a lockbox in a

locked cabinet on the CIU, but were later transported by the lead researcher or research

assistant(s) in a lockbox to a locked file cabinet in the research assistants’ locked office.

Transfer of surveys took place when the administration of the T2 surveys began at six weeks

post-discharge, and continued approximately every six weeks for the remainder of the study. T2

surveys (paper) were also stored in the research assistants’ office while interview transcripts

were stored a locked file cabinet in the lead researcher’s locked office. Interview audio files and

digital versions of interview transcripts were password-protected and stored on the lead

researcher’s secure Pirate Drive.

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 Phase 1: Surveys (Time 1 [T1] and Time 2 [T2]). The T1 survey (35 items) was

administered when participants were preparing to discharge from the inpatient cardiac service

that day or within the subsequent one to two days (see Appendix E for surveys). This survey

took participants about10 to 15 minutes to complete and consisted of demographic items (i.e.,

sex/gender, age, race/ethnicity, insurance status, relationship status, highest level of education,

employment status, household income, health insurance status, relationship status, number of

household occupants, and type of cardiac event/surgery the participant experienced), the PHQ-4

(Kroenke et al., 2009), the MOS Social Support Survey (Sherbourne & Stewart, 1991), and the

helpless inevitability subscale from the Religious Health Fatalism Questionnaire (Franklin et al.,

2008).

The lead researcher or research assistant administered the T2 survey (30 items) over the

telephone approximately six weeks following each participant’s discharge date (see Appendix C

for telephone script). The T2 survey took 10 to 15 minutes for participants to complete and

consisted of questions about the individual’s receipt and/or attendance of a follow-up

appointment, which provider that appointment was with (e.g., cardiologist, cardiac surgeon,

primary care provider, or other provider), the date of any rehospitalizations, as well as a

readministration of the PHQ-4 (Kroenke et al., 2009), the MOS Social Support Survey

(Sherbourne & Stewart, 1991), and the helpless inevitability subscale from the Religious Health

Fatalism Questionnaire (Franklin et al., 2008). Six weeks post-discharge was chosen for the

administration of the T2 survey, because, at this point, participants should have had at least one

follow-up appointment with a primary care provider, cardiologist, and/or cardiac surgeon per the

academic medical center protocol.

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 If, in attempting to administer the T2 survey, the participant was not reachable upon the

first telephone call, the lead researcher or research assistant attempted to contact the participant

two additional times over the course of one week. If during the first or subsequent telephone call

attempted, someone other than the participant answered the telephone, the lead

researcher/research assistant identified herself by her first name and as a student researcher or

research assistant who was following up with the participant. The lead researcher/research

assistant asked if there was a better time to call back and also left a callback number. If no one

answered and the participant had given permission for the lead researcher or research assistant to

leave messages, a message and call back number was left by the caller regarding participation in

the T2 survey. The lead researcher or research assistant left no more than two voicemail

messages in the process of attempting to contact the participant. Messages were only left on the

participant’s voicemail if he or she gave permission for this possibility during study enrollment.

The callback number given to participants was for a confidential telephone located in the

research assistants’ office. During the survey data collection, only the lead researcher or

research assistant answered calls on this line. Further, the voicemail connected to the line was

password-protected and accessed by only the lead researcher and research assistant. If a

participant called back and was administered the T2 survey after the one week designated for

contacting and administrating the survey (six- to seven-weeks post-discharge), this was noted on

the survey as a possible confound, due to the fact that a period of approximately six-weeks post-

discharge was held as a constant in comparing participants’ responses from T1 and T2 surveys.

When the T2 survey had been successfully administered, the researchers paired T1 and

T2 surveys using the sequentially assigned number given to each participant at the time of study

enrollment. It was also at this point that participants eligible for the qualitative portion of the

88
study were asked if they were interested in scheduling an interview with the lead researcher.

Interviews were conducted over the telephone and were scheduled in accordance with the

participant’s availability, either directly following the T2 survey administration or at a later date.

In the case that a participant scored above the clinical cutoff score of three or above on

the PHQ-4 during the administration of the T1 survey, the lead researcher or research assistant:

(a) gave the participant a behavioral health resource sheet (see Appendix F) and (b) alerted a

member of the participant’s care team to this concern so that the care team could coordinate

appropriate resources and referrals for the participant prior to discharging the patient, as needed.

If a participant scored above the clinical cutoff score on the PHQ-4 during the administration of

the T2 survey, the lead researcher or research assistant: (a) explained that behavioral health

support may be useful to patients experiencing mood changes after a cardiac event or surgery

and (b) offered contact numbers for local behavioral health resources (see Appendix F).

Electronic Health Record and paper records. Data on CR referral and participation

(e.g., enrollment, attendance, and completion) were collected using the EHR and paper records

kept by the two CR facilities accessible to patients from the county where the academic medical

center was located. The lead researcher and research assistants tracked referral data on a regular

basis and documented CR enrollment at approximately two months post-discharge. By this time,

participants should have had follow-up appointments with their primary care provider,

cardiologist, and/or cardiac surgeon (per academic medical center protocol) and would have

begun CR, if they had been referred and chose to act on the referral.

The lead research and research assistants measured CR attendance and completion at

five months post-discharge. The lead researcher selected this time point based on the Centers for

Medicare and Medicaid Services’ (2006) CR reimbursement structure (36-session program to be

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completed over 12 to 18 weeks, or approximately four to five months post-discharge in the event

that patients began CR several weeks after their cardiac event/surgery). In the event that a

participant enrolled in CR after two months post-discharge, his or her enrollment data was

corrected at five months post-discharge when attendance and completion data are collected.

Phase 2: In-depth, Open-ended, Semi-structured Interviews. The lead researcher

conducted all audio-recorded, qualitative telephone interviews with African American

participants who were recovering from cardiac events and/or surgeries. Following data

collection, the lead researcher transcribed interviews and coded them in collaboration with a

triangulated researcher and a peer debriefer until the saturation of themes was reached. Every

interview began with the same grand tour question: “How would you describe your experience

recovering from your cardiac event or surgery after being discharged from the hospital?” (see

Appendix G for interview guide). A brief demographic questionnaire was also administered at

the end of the telephone interview (i.e., type of cardiac event/surgery, sex/gender, age,

race/ethnicity, insurance status, relationship status, highest level of education, employment status,

household income, health insurance status, number of household occupants, receipt/attendance of

a follow-up appointment, and re-hospitalizations following discharge) (see Appendix E for

questionnaire).

The lead researcher facilitated the interviews, encouraging participants to expand on

different elements of their experience. Participants were also informed that, upon completion of

the interview, they would have the opportunity to participate in a member checking process

(Creswell, 2009; Lincoln & Guba, 1985) once all interviews had been transcribed and coded and

analysis was completed. Participants who wished to be involved in the member checking

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process were provided a summary of the results to confirm that the results reflected the essence

of their lived experience.

Data Analysis

This mixed methods dissertation research includes a phase 1 (quantitative) and phase 2

(qualitative) analysis. The phase 1 analysis consisted of regressions and path analyses of self-

reported survey data from the initial pool of participants. The phase 2 analysis consisted of a

phenomenological analysis of verbatim transcriptions of audio-recorded, in-depth, open-ended

interviews conducted with African American participants who were recovering from cardiac

events and/or surgeries. The phenomenological analysis entailed transcription and coding of

audio recorded interviews using Colaizzi’s (1978) phenomenological analysis method.

Phase 1. For the quantitative portion of this study, the researchers used regressions and

path analyses to examine the moderating effect of the independent variables (i.e., type of cardiac

event/surgery, anxiety, depression, social support, and helpless inevitability) between race (i.e.

African American or Non-White Hispanic) and the dependent variables of referral and

participation (i.e., enrollment, attendance, and completion). The causal modeling technique of

path analysis enables researchers to test the fit of a model consisting of the direct and indirect

relationships between endogenous (dependent) and exogenous (independent) variables. Fit of

the model is tested by comparing reproduced (theoretical) and empirical (observed) correlations

and trimming the model of non-significant correlations (Mertler & Vannatta, 2009).

Separate path analyses were run for referral, enrollment, attendance, and completion.

The following fit indices were used to test goodness of fit: Non-normed fit index, Chi-square

tests, and Tucker Lewis TLI. A correlation table was also constructed to look at associations

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between demographic variables (e.g., insurance status, relationship status, highest level of

education, employment status, household income, etc.), and participant referral and participation.

Phase 2. For the qualitative portion of this study, the lead researcher transcribed, coded

interview transcripts, and analyzed the coded data for themes using Colaizzi’s (1978)

phenomenological analysis method. This method consisted of: (a) reading the transcripts; (b)

identifying significant statements; (c) forming meaning statements from the significant

statements; (d) clustering themes from the meaning statements and forming emerging themes; (e)

creating an exhaustive description; (f) creating a statement of identification; and (g) validating

the findings (Colaizzi, 1978).

Reading the transcript. Consistent with Colaizzi (1978), the researchers read the

transcript in full “in order to acquire a feeling for [the participant’s descriptions of the

phenomenon], a making sense out of them” (p. 59), before beginning to lift themes from the text.

Identifying significant statements. Next, in keeping with Colaizzi’s (1978) second step,

the researchers identified and coded the statements that pertained to the phenomenon being

studied. In this step, repetitions of the same theme were coded equally and statements grounded

in specific context were coded in terms of “more general formulations” (p. 59) relating to the

phenomenon.

Forming meaning statements. In the third step (Colaizzi, 1978), the researchers formed

meaning statements from significant statements. This entailed the researcher using “creative

insight” (p. 59) to “leap from what the [participants] say to what they mean” (p. 59). Colaizzi

(1978) cautions researchers against being too strident in this step. In order to maintain fidelity to

the phenomenon (and the participants’ experiences), the researchers ensured these statements

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“discover and illuminate those meanings hidden within the various contexts and horizons of the

investigated phenomenon which are announced in the original protocols [transcripts]” (p. 59).

Clustering themes. After steps one through three have been completed for each

transcript, the researchers clustered common themes and subthemes that cut across participants’

experiences (Colaizzi, 1978). Once themes and subthemes were identified, the researchers

“validated” themes by returning to the transcripts and asking themselves, “whether there is

anything contained in the original protocols that isn’t accounted for in the clusters of themes” (p.

59). As recommended by Colaizzi (1978) the researchers maintained a “tolerance for ambiguity”

(p. 61) in this stage by resisting the temptation to discount disconfirming evidence or

“prematurely generating a theory which would merely conceptually-abstractly eliminate the

discordance of [the researchers’] findings thus far” (p. 61).

Creating an exhaustive description. In the fifth step, “the results of everything so far

[were] integrated into an exhaustive description of the investigated topic” (Colaizzi, 1978, p. 61).

An exhaustive description was written as a list of statements that captured all the themes lifted

from participants’ transcripts in the preceding steps (Colaizzi, 1978).

Creating a statement of identification. The statement of identification is intended to

“formulate the exhaustive description of the phenomenon in as unequivocal a statement of

identification of its fundamental structure as possible” (Colaizzi, 1978, p. 61). The researchers

captured the essence of the participants’ lived experience in this one inclusive and overarching

statement.

Validating the findings. Colaizzi’s (1978) final step is similar to member checking, as

defined by Lincoln and Guba (1985) and Creswell (2009). In this step, the lead researcher

consulted participants on the telephone about the exhaustive description. The lead researcher

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asked participants whether or not the exhaustive description included the participants’

experiences. Additional findings gleaned at this final stage were incorporated into the study

findings (Colaizzi, 1978).

Verification Processes

In accordance with Lincoln and Guba’s (1985) recommendations for trustworthiness of

data, the researcher used verification processes to ensure credibility, transferability,

dependability, and confirmability. The verification processes selected to ensure credibility

included: (a) triangulation; (b) peer debriefing; (c) and member checking. Transferability was

ensured through the use of thick description. Dependability and confirmability were ensured

through maintaining an audit trail which included keeping a research log, a detailed accounting

of the analysis process, writing analysis and interpretation memos, and maintaining a reflexive

journal. Analysis and interpretation memos included reactions to the analysis process and

emerging themes that surfaced through interaction with the data. The lead researcher kept a

reflexive journal throughout the study in order to document continuing self-awareness of

assumptions, biases, values, and beliefs.

Firstly, to ensure credibility, the lead researcher triangulated the data collection and

analysis process. Triangulation strategies entailed using multiple sources of data collection and

more than one researcher (Lincoln & Guba, 1985). Triangulation of data sources was achieved

by interviewing multiple participants (Lincoln & Guba, 1985). Triangulation of analysts was

achieved by involving a triangulated researcher in the analysis process. For every interview, the

triangulated researcher coded approximately one quarter of the transcript pages, effectively

auditing the lead researcher’s work. Next, the lead researcher and triangulated researcher met to

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discuss and resolve differences in coding. If the lead researcher and triangulated researcher were

unable to reach agreement, the peer debriefer was consulted.

Secondly, credibility was bolstered by using peer debriefing which took the form of

ongoing conversations between the lead researcher and co-researchers. Peer debriefing entailed

a peer researcher reviewing the lead researcher’s and triangulated researcher’s analysis “for the

purpose of exploring aspects of the inquiry that might otherwise remain only implicit within the

inquirer's [lead researcher’s and triangulated researcher’s] mind” (Lincoln & Guba, 1985, p. 308).

The lead researcher consulted with the peer debriefer after initiating each phase of the analysis

process and again upon each phase’s completion to ensure fidelity of the analysis process and

that the themes were grounded in the data. The peer debriefer was also the third party consulted

when the lead researcher and triangulated researcher were unable to reach coding agreement.

According to Lincoln and Guba (1985), transferability is the extent to which findings can

be applied to other cases beyond the current research study. In this research, transferability was

addressed through the use of thick description. Thick description in qualitative research refers to

the thoroughly detailed presentation of findings to the extent that a reader can determine whether

or not the findings would be transferable to other cases. In her write-up of the results, the lead

researcher employed thick description by describing the context of the findings in great detail

and grounding the findings in the words of participants.

Finally, to ensure dependability and confirmability, the lead researcher maintained an

audit trail consisting of a research log, analysis and interpretation memos, and a reflexive journal.

The research log contained documentation of contacts made throughout the research process and

decisions made regarding protocol. Analysis and interpretation memos contained the lead

researcher’s and co-researchers’ reflections and ideas regarding interpretation of the data.

95
Finally, the lead researcher engaged in reflexive journaling as a method of continual engagement

with her own experiences vis à vis the research process. Reflexive journaling included the lead

researcher’s reactions to and understanding of the participants and data, biases and insights, and

her ongoing self-awareness in bracketing those biases. Selected entries from the lead researcher’s

reflexivity journal are included in the write-up of this dissertation research (see Appendix H).

Statements of Bias

Lead Researcher

The lead researcher’s position both as a researcher and as a White, college-educated

female from the Northeastern United States are salient to the conceptualization and

implementation of this study. An important preliminary step in phenomenological research

process is “bracketing” or identifying and “stepping away” from one’s biases to increase the

likelihood that they will not interfere with data analysis (Bernard & Ryan, 2010, p. 259).

According to Colaizzi (1978), questioning of one’s presuppositions regarding the phenomenon of

study allows researchers to approach the study more objectively (Colaizzi, 1978). As Colaizzi

(1978) defines it, “objectivity is fidelity to phenomena. It is a refusal to tell the phenomenon

what it is, but a respectful listening to what the phenomenon speak of itself” (p. 52).

Throughout the conceptualization of this study, the lead researcher engaged in reflexivity

or “conscious self-reflection on the part of the researcher to make explicit their potential

influence on the research process” (Hennink, Hutter, & Bailey, 2011, p. 19). This process has

included (a) ongoing reflexive journaling, and (b) a photo-reflexivity project that assisted the

lead researcher in exploring her beliefs, assumptions, values, and biases associated with her

dissertation topic. These activities have elucidated the following insights into the lead

researcher’s perceptions: (a) a bias against health promotion interventions that are inaccessible to

96
socially disadvantaged patients; (b) an assumption that religion is important for many African

Americans living in the Southeastern United States; (c) a belief that most disparities in health

outcomes and health care can be explained by limited access to resources; and (d) a bias favoring

early intervention for the management of health problems and the need for integrated medical

and behavioral health care. The lead researcher challenged these biases and maintained an

awareness of them throughout the study in order to manage the undue influence of these biases

on herself as the qualitative research instrument and the study in general.

The lead researcher also engaged in ongoing reflexivity and peer dialogue regarding her

position as a White researcher doing research with African American participants. Considering

the historical trauma experienced by African Americans in the context of medical and scientific

research (Washington, 2006), the lead researcher acknowledged the need for particular

sensitivity in approaching both this research topic and research participants. First and foremost,

she held an awareness of racial/ethnic disparities in power and privilege, and specifically, how

her own White privilege could inadvertently silence others (e.g., McGoldrick & Hardy, 2008).

She believed it was her charge to do everything possible to ensure that this silencing did not take

place. In taking a stance of cultural humility and curiosity, tentatively offering ideas, asking

questions to foster greater understandings, and including a methodological component that

explored participants’ experiences as they understand them (phenomenology), she endeavored to

promote minority voices within this socially complex dynamic.

Triangulated Researcher

When conducting research, it is important to examine and question biases that may

involve particular topics within the study at hand. Becoming more aware of personal beliefs and

values can help researchers recognize how their backgrounds may affect their perspective on

97
their research. The triangulated researcher’s position as a White, college-educated female in the

South affected her perspective on health and health disparities in several ways. First, she

realized that her race inherently allowed her opportunities and experiences that people of color

may not have. A degree in Anthropology has enabled her to become more aware of limitations

and restrictions that racial minorities may encounter in many environments, including healthcare

settings. This has led the triangulated researcher to believe that African Americans may have to

deal with implicit institutional oppression and inequality when trying to recover from a cardiac

event or surgery. Consequently, the triangulated researcher believed that there were more

complex issues for African Americans than for their White counterparts when considering how

and why rehabilitation services were used after hospital discharge.

Additionally, growing up in a small Southern town reinforced the triangulated

researcher’s beliefs about the importance of religion in a healthy life and family system. Living

in the South for 23 years contributed to her understanding that the majority of families in this

region value religion and the significance of prayer and reliance on God in the recovery process.

Because of this, the triangulated researcher believed that an emphasis needed to be placed on

having conversations about spirituality, perceptions about healthcare, and other factors that

patients believed influenced their recovery (Statements of Bias also available in Appendix I).

Ethical Considerations

This study was designed with careful consideration for the wellbeing of the participants

involved and in accordance with the ethical guidelines of the American Association for Marriage

and Family Therapy and East Carolina University’s University & Medical Center Institutional

Review Board. The risks to participants in this study were anticipated to be minimal (i.e., time

and energy to complete surveys and interviews, possible discomfort with answering questions,

98
and/or negative emotions from talking about recovery experiences), and a number of safe guards

were put in place to ensure participants’ safety.

Firstly, participants were informed that they could skip questions, take a break, stop a

survey or interview, or discontinue study enrollment at any time. Secondly, if participants felt

more comfortable having a family member or friend present for the survey ad ministration or

interview process, this allowance was granted. Thirdly, participants who scored above the

clinical cutoff on the PHQ-4 (Kroenke et al., 2009) and/or experienced emotional distress during

the survey or interview process were offered behavioral health resource information. If this

occurred pre-discharge from the medical center, the participant was given a behavioral health

resource sheet and the care team was informed of this concern so they could coordinate

appropriate resources and referrals for the participant prior to discharging the patient, as needed;

if this occurred post-discharge, the participant was given contact numbers for local behavioral

health resources over the telephone [see Appendix G].

Additional safe guards were extended throughout the recruitment, enrollment, and data

collection process, and included the de-identification of participant data, password-protecting

documents and audio files and storing them on a secure server, storing paper documents in

double-locked systems, and using sequentially assigned identification numbers (quantitative) or

pseudonyms (qualitative) instead of participants’ names to identify electronic and paper data. It

was the lead researcher’s primary concern that the participants involved in this study (as well as

their family members) felt safe, supported, and able to ask for accommodations at any point in

the research process.

99
 Summary

This mixed methods concurrent transformative study was designed to investigate a

disparity in CR referral and participation for/among African American patients with CVD. The

inclusion of both a quantitative and qualitative portion allowed for: (a) the further investigation

of demographic and biopsychosocial-spiritual factors that have been suggested to impact CR

referral and cardiovascular health behavior participation for this population, and (b) the

exploration of the lived experience of African American patients recovering from cardiac events

and/or surgeries. This qualitative portion, in turn, assisted the lead researcher in identifying

additional factors impacting CR participation for this population. Ultimately, the combined

results of this mixed methods study were used to make policy-level and programmatic

recommendations to support the development of interventions and best practices for African

American patients with CVD.

100
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 CHAPTER FOUR: AFRICAN AMERICAN PATIENTS’ LIVED EXPERIENCE THROUGH

CARDIAC EVENT/SURGERY AND RECOVERY

Heart disease is the number one leading cause of death in the United States (Centers for

Disease Control and Prevention [CDC], 2011) and a “Healthy People 2020” target for

improvement (U.S. Department of Health and Human Services [U.S. DHHS], 2014). Among

African Americans, the rates of cardiovascular disease (CVD) risk and mortality are higher than

for Non-Hispanic Whites, making CVD an even more troubling concern for this population. For

example, during 2007–2010, African Americans had a higher rate of hypertension (41.3% among

African Americans compared to 28.6% among Non-Hispanic Whites), and a lower rate of

controlled hypertension (42.5% of African Americans compared with 52.6% of Non-Hispanic

Whites) (CDC, 2013). Additionally, African Americans had a 20% higher age-adjusted death

rate from coronary heart disease than Non-Hispanic Whites (141.3 per 100,000 population and

117.7 per 100,000 population, respectively) (CDC, 2013).

Cardiac Rehabilitation (CR) is a Class I secondary treatment and prevention program

recommended by the American College of Cardiology/American Heart Association that has been

demonstrated to improve health outcomes for patients with CVD (American Association of

Cardiovascular and Pulmonary Rehabilitation [AACPR], 2014; Brown, Clark, Dalal, Welch, &

Taylor, 2011; Heran et al., 2011; Kwan & Balady, 2012). However, only one third of eligible

patients are referred to or participate in CR (Ayala, Xie, McGruder, & Valderrama 2008; Cortés

& Arthur, 2006; Suaya et al., 2007). These rates are even lower for racial/ethnic minorities

(Beswick et al., 2004; Suaya et al., 2007) and for African Americans, in particular (Evenson,

Johnson, & Aytur, 2004; Gregory, LaVeist, & Simpson, 2006). In fact, Koehler, Hodgson,

Dodor, Knight, and Rappleyea (2014) found in their review of the literature that African
American patients with CVD not only had a lower likelihood for CR referral, but also had a

higher likelihood of enrolling in CR with more cardiovascular risk factors, and a lower

likelihood of CR participation and completion due to factors related to low socioeconomic status

(e.g., lack of insurance, work conflicts, lower level of education) when compared with Non-

Hispanic White patients (Allen, Scott, Stewart, & Young, 2004; Bittner, Sanderson, Breland, &

Green, 1999; Cannistra, O’Malley, & Balady, 1995; Evenson et al., 2004; Gregory et al., 2006;

Rankin, 2002; Young, Waller, & Kahana, 1991).

Although CR is the recommended intervention for recovery from CVD-related events

and surgeries and for prevention of future events (AACVPR, 2014; Kwan & Balady, 2012), it

appears to be less accessible to the African American population. Some researchers have

hypothesized that different factors may contribute to this gap in health and care. Among African

Americans, researchers have reported disparities in recommendation and receipt of medically-

indicated care (Hannan et al., 1999; Ibrahim et al., 2003; Peterson et al., 1997; Schneider et al.,

2001; van Ryn, Burgess, Malat, & Griffin, 2006); negative associations between depressive

symptoms and cardiovascular self-care (Dickson, McCarthy, Howe, Schipper, & Katz, 2013;

Dickson, McCarthy, & Katz, 2013); positive associations between depressive symptoms and

CVD risk factors (Weinstein, Abraham, Diao, Zeno, & Deuster, 2011); positive associations

between social support and improved cardiovascular health and health behaviors (Grewen,

Anderson, Girdler, & Light, 2003; Liu & Newschaffer, 2011; Tkatch et al., 2011); and

spirituality as a coping strategy for managing stress associated with CVD-related health

problems (Dickson, McCarthy, Howe, et al., 2013; Johnson, Elbert-Avila, & Tulsky, 2005;

Warren-Findlow & Issel, 2010), but also a potential source of fatalistic beliefs contributing to a

passive approach to self-care (Dickson, McCarthy, Howe, et al., 2013; Polzer & Miles, 2007).

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 Little has been published on the demographic and biopsychosocial-spiritual factors

impacting CR referral and participation among adult African American patients. In their

systematic review, Koehler and colleagues (2014) identified only seven studies that addressed

this topic. Among these studies, the impact of demographic characteristics (i.e., sex/gender,

race/ethnicity) and biomedical and social factors on African Americans patients’ CR referral and

participation were addressed most frequently (Allen et al., 2004; Bittner et al., 1999; Cannistra et

al., 1995; Evenson et al., 2004; Gregory et al., 2006; Rankin, 2002; Young et al., 1991),

psychological factors were addressed to a limited extent (Allen et al., 2004), and spiritual factors

were not addressed at all (Koehler et al., 2014).

Because few studies have been conducted related to factors impacting African American

patients’ CR referral and participation (Koehler et al., 2014), a descriptive phenomenological

design (Husserl, 1970) was conducted to explore the lived experience of African American

patients recovering from cardiac events and/or surgeries (including, but not limited to

experiences related to CR referral and participation). The following section details the method

of this study.

Method

Within descriptive phenomenology (Husserl, 1970), the researchers’ focus of inquiry is

individuals’ subjective experience of reality. From this perspective, what individuals understand

to be real is viewed as essential in making sense of their motivations and actions (Lopez & Willis,

2004). Because heart disease mortality rates in the rural Southeastern state where this study was

conducted significantly surpassed national rates (168 deaths per 100,000 and 193.2 deaths per

100,000 for African Americans and Non-Hispanic Whites, respectively in 2009-2013 [NC

DHHS, 2014]) and were 20% higher among African Americans than Non-Hispanic Whites, the

108
researchers determined that a qualitative method honoring the cultural landscape of those

impacted was most appropriate. Therefore, the lead researcher selected a qualitative study

designed to explore the following research question: “What is the lived experience of African

American patients recovering from cardiac events and/or surgeries?” Approval was obtained

from the East Carolina University and Medical Center Institutional Review Board (IRB) for this

qualitative study as well as a larger mixed method study (see Appendix A–G).

Participants

A purposive sampling strategy was used to enroll participants from two different

locations: (a) a Southeastern academic medical center serving a population of nearly one and a

half million people and (b) a nearby, affiliated CR facility. Potential participants receiving care

at the academic medical center and the local CR facility were identified as eligible for the study

using data extracted from each facility’s electronic and paper record system. Participants were

eligible if they were: (a) English-speaking; (b) African American; (c) aged 18 and older; (d)

approximately two months post-discharge for a cardiac event or surgery for which CR was

indicated (myocardial infarction [MI], coronary artery bypass grafting [CABG], stable angina,

heart valve repair/replacement, percutaneous coronary intervention [PCI] (including

percutaneous transluminal coronary angioplasty [PCTA]), heart transplant, and/or coronary

artery disease [adapted from [AACVPR], 2014]); and (e) a resident of a city or town in the

county where the academic medical center was located.

Exclusion criteria included: (a) a discharge diagnosis of heart failure or a heart-lung

transplant (heart failure patients at this academic medical center were sometimes referred to

pulmonary rehabilitation and those with heart-lung transplants could also be referred to

109
pulmonary rehabilitation rather than CR) and/or (b) cognitive impairment that would interfere

with the individual’s ability to consent to the study and participate in surveys and interviews.

The lead researcher conducted the audio-recorded, in-depth, open-ended interviews until

saturation of themes was reached. She understood saturation to have occurred when the analysis

of additional data (i.e., participant interviews) yielded no new themes (Creswell, 2009). Ideally,

a confirmatory interview is also conducted for the purpose of validating identified themes and

decreasing the likelihood that themes were missed or overlooked in analysis (Morse, Barrett,

Mayan, Olson, & Spiers, 2002). Out of 15 eligible patients, seven patients participated in the

study. Eight patients were not enrolled because the lead researcher or research assistant were not

able to contact these individuals to schedule an interview or they could not be contacted at the

time the interview had been scheduled or upon follow-up.

Participants were African American residents of cities or towns in the county where the

academic medical center from which they were recruited was located. This county is primarily

rural and lower income. Participants in the study included four men and three women who

ranged in age from 37 to 64 years. The severity of their events and/or surgeries ranged from MI

(heart attack) or stent placement only (done with a catheter and without a large incision), to a

combination of MI and CABG (bypass surgery which requires the patient’s sternum to be opened

and wired back together). For the seven study participants, CR status was as follows: two

individuals had not been referred to CR and were not enrolled; three individuals had been

referred but were pending medical action or clearance for enrollment or continued attendance;

and two individuals were referred, enrolled, and attending (see Table 1 for participant

demographics).

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 Participants were extended an incentive to participate in the study in appreciation of their

time and energy. The incentive took the form of a $25 gas card directly mailed to participants

following interview completion.

Data Collection and Procedures

Enrollment and consent. The researchers recruited five eligible patients from the

academic medical center. After consenting to participate in the study prior to their discharge

from the hospital (see Appendix D for informed consent), they were contacted by telephone six-

weeks post-discharge to set up interviews. Six weeks post-discharge was chosen because, at this

point, participants were anticipated to have had at least one follow-up appointment with a

primary care provider, cardiologist, and/or cardiac surgeon per the academic medical center

protocol and had the opportunity to receive a referral to CR or to discuss recovery alternatives

with their medical provider(s).

Two patients were also recruited directly from the CR facility either by telephone or

when a research assistant approached them directly at the CR facility at approximately two

months post discharge. This time point was selected to ensure that individuals recruited from the

initial pool of potential participants (contacted at six to seven weeks post-discharge) would be in

the same stage of recovery as those recruited directly from the facility. If patients were

contacted by telephone, a time was arranged for them to complete the informed consent face-to-

face at the CR facility. Once consent was obtained, interviews were scheduled.

Data collection. The lead researcher conducted audio-recorded, in-depth, open-ended

telephone interviews. Participants who were recruited directly from the CR facility were

administered a demographic questionnaire (e.g., type of cardiac event/surgery, sex/gender, age,

race/ethnicity) (see Appendix E for questionnaire) over the telephone. Participants recruited

111
from the academic medical center had also consented to a mixed method study of which this

qualitative study was one portion. These participants’ demographic data were collected at the

time of study enrollment (pre-discharge).

Prior to conducting the interviews, the lead researcher invited participants to select

pseudonyms for themselves in an effort to mask their identity and protect their confidentiality.

The lead researcher transcribed all interviews verbatim, and coded the transcripts with the help

of a triangulated researcher and a peer debriefer (co-researcher) until thematic saturation was

reached. Each interview began with the same grand tour question: “How would you describe

your experience recovering from your cardiac event or surgery after being discharged from the

hospital?” The lead researcher facilitated the interviews, flexibly using an interview guide to

ensure all participants addressed similar topics and issues related to their cardiac and CR

perspectives and experiences (see Appendix H for interview guide).

Data Analysis

After conducting each interview, the lead researcher transcribed, coded, and initiated data

analysis using Colaizzi’s (1978) phenomenological analysis method. The analysis process

consisted of reading the whole transcript, identifying statements that were significant to the

phenomenon of study, and forming meaning statements to capture the participant’s meaning that

informed the significant statements. Transcripts were coded successively as interviews were

conducted. Saturation was reached when analysis of significant statements yielded no additional

meaning statements. After all the transcripts were coded for significant statements and meaning

statements, meaning statements were categorized by thematic clusters. This yielded 20 thematic

clusters that were subsequently collapsed into six emergent themes (Table 2). Selected examples

of narratives and emergent theme formation are included in Table 3. An exhaustive description

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was developed to capture all the emergent themes identified by participants in narrative form.

Finally, a statement of identification was formulated to communicate the essence of the

participants’ lived experience.

Upon completion of the analysis, the results were validated by participants using member

checking. For the purpose of member checking, the lead researcher called participants in order

to read aloud an exhaustive description of findings and to request feedback. Five out of seven

participants were reached and all five confirmed that the exhaustive description reflected their

lived experience. One participant recommended a clarification in wording (i.e., that the

inaccessibility of interventions discussed in Theme 3 should also be highlighted in Theme 5 for

CR). This change was incorporated into the findings.

The analysis process achieved 100% inter-rater reliability among researchers. For every

interview, a triangulated researcher coded approximately one quarter of the transcript pages,

while the lead researcher coded the entire transcript. Next, the lead researcher and triangulated

researcher reviewed one another’s work and met to discuss any coding differences. If less then

90% of coding was in agreement, the triangulated researcher was asked to audit the full transcript.

The lead and triangulated researchers discussed each coded statement and, in instances in which

the lead researcher and triangulated researcher were unable to reach agreement (10% of the time),

the peer debriefer was consulted to assist with reaching consensus. The peer debriefer also

reviewed each step of the analysis to ensure that it accurately reflected Colaizzi’s (1978) method

and was grounded in the actual data and not the result of researcher assumptions or biases.

Verification processes. In accordance with Lincoln and Guba’s (1985)

recommendations for trustworthiness of data, verification processes were undertaken to increase

confidence in the findings. Three processes were implemented for the purpose of ensuring study

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credibility: (a) triangulation; (b) peer debriefing; and (c) member checking. Firstly, triangulation

involved the use of multiple sources (i.e. participants) in the collection of data and multiple

researchers in the analysis of the data. Triangulation decreased the likelihood that findings were

incidental to the participants contacted or the researchers analyzing the data. Triangulation of

sources was achieved by interviewing multiple participants, while triangulation of researchers

was achieved by involving a triangulated researcher and peer debriefer in the analysis process

(Lincoln & Guba, 1985).

Secondly, peer debriefing took the form of ongoing conversations between the lead

researcher and co-researchers. A peer debriefer was consulted in the case of coding

disagreements between the lead researcher and the triangulated researcher, when the lead

researcher sought consultation regarding the analysis, and to review each step of the analysis

process. Thirdly, member checking entailed sharing the results of the study with participants so

they could confirm that the findings were true to their lived experience. Upon enrollment,

participants were informed that, after all interviews were completed, transcribed, coded, and

analyzed, they would have the opportunity to participate in a member checking process of a

summary of findings (Creswell, 2009; Lincoln & Guba, 1985). The researcher provided

participants who wished to be involved in the member checking process with the study’s

exhaustive description to affirm that the results reflected the essence of their lived experience.

Transferability refers to the likelihood that findings can be appropriately applied to other

individuals outside of study participants. This requires that the findings be grounded in

participants’ contexts in such a way that readers can understand how particular themes emerged

in the interaction between the participants and these contexts. Transferability was ensured

through the use of thick description, or rich and detailed explanations of participants’

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experiences and was left to the reader to determine. Dependability and confirmability (i.e., the

likelihood that the findings could be replicated and are not the result of researcher bias) were

ensured through maintaining an audit trail which included keeping a research log, detailed

accounting of the analysis process, interpretation memos, and a reflexive journal to document

reactions to the analysis process and emerging themes that surfaced through interaction with the

data (Lincoln & Guba, 1985) (see Appendix H).

Findings

Analysis of transcripts from seven participant interviews yielded 535 significant

statements, 69 formulated meaning statements, 20 thematic clusters, and six emergent themes

relevant to the essence of African American patients’ lived experience through cardiac

event/surgery and recovery (see Table 2 for emergent themes and thematic clusters). The

emergent themes were: (a) Participants valued medical providers’ involvement during treatment

and recovery; (b) Social support and participants’ need for it changed post-event/surgery; (c)

Participants’ pre- and post-event/surgery experiences affected health outcomes; (d) Participants’

sense of agency affected their life perspectives and health behaviors; (e) Participants experienced

inconsistent referral to and utilization of Cardiac Rehabilitation; and (f) Participants’ investment

in faith was intensified or maintained. The following section explores each emergent theme, as

well as the thematic clusters categorized under it. It concludes with an exhaustive description

and statement of identification that captures the lived experience of African American patients

recovering from cardiac events and/or surgeries who were living in a primarily rural and lower-

income county in the Southeast.

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Participants Valued Medical Providers’ Involvement during Treatment and Recovery

Participants discussed the importance of medical providers’ help and expertise

throughout and treatment and recovery process. Medical providers included doctors, nurses, and

physical/occupational therapists in inpatient and outpatient settings. Participants valued both the

functional and emotional support providers offered during and after participants’ hospitalizations.

Participants expressed their appreciation for medical providers’ “dedication,” and also pointed

out times when they needed additional support from medical providers.

Medical providers’ interventions impacted cardiac outcomes. Participants described

experiencing medical crises prior to cardiac events/surgeries during which they sought medical

providers for treatment of undiagnosed symptoms. At this time, medical providers were the

source of vital information and interventions, often revealing for participants the cause of their

symptoms. Participants noted that medical providers were often conservative in their

interventions in that they observed patients first and considered less invasive treatments before

proceeding to more invasive ones. Medical providers also adjusted participants’ medications,

starting new medications and/or stopping existing ones, during and after hospitalizations. These

elements of treatment directly impacted cardiac outcomes, from the types of intervention

participants received to their recovery experiences.

Robert, a 60-year-old man, experienced an MI with the consequent placement of

stents—a more conservative treatment, compared to CABG. He highlighted the aforementioned

elements of medical treatment in his description of being hospitalized for, diagnosed with, and

treated for heart problems. He recounted his experience by stating,

[When I went into the hospital for] pressure in my chest…that’s when I found out [I had

heart problems]… After they [medical providers] did the tests and everything, they came

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 back, um, because I had a heart attack… They treat me, you know, they were treatin’ me

and, then, uh, continuing to run tests, and… and give me medications, yeah… they didn’t

do a bypass. They did, uh, well, the stent, I guess.

Lucy, a 41-year-old woman who experienced an MI and then received CABG, also noted that

medical providers tried to select a more conservative intervention (stents) before determining

that a larger intervention (CABG) was necessary. Lucy reported, “When I went in, um, they

tried to do a stent but ended up having have heart surgery [CABG] because I had, um, three

blockage that were severe.”

With regard to medical providers starting and stopping medications, participants

explained that, although the process of tailoring medications was important and valued, it could

present participants with unique challenges. Alberta, a 64-year-old woman who had stents

placed, stated:

They [medical providers in hospital] changed all my medicine [for diabetes] and I,

I still ain’t got that straight yet… They said my doctor could put me back on if

they wanted to, but they were sayin’ that I was takin’ too much medication…

They took me off all, and then at one point they said the medication I was takin’

for my diabetes, they didn’t use that type medicine in the hospital, so they used

the type they used at the hospital.

Robert described a more straightforward process of having a stronger pain medication added to

his medications post-discharge. He stated, “They added a couple of medications… Um, I got

one that’s like a blood thinner, [for] heart. And, uh, and uh, a different- a stronger kind of pain

pill than I usually was takin.’” Robert viewed the addition of these medications as helpful.

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 Medical providers offered guidance on healthy lifestyle changes. Participants recalled

medical providers guiding them on making healthy lifestyle changes after their cardiac event or

surgery. These included heart-healthy diet and exercise modifications and recommendations to

stop drinking and/or smoking. Participants expressed variability in the degree to which medical

providers tailored guidance regarding activity level and exercise to the participants’ individual

needs. Sometimes guidance took the form of general messages, whereas other times guidance

was specific and hands-on. For example, participants Bruce, Mark, Michael, and Lucy were told

to “just walk.” Lucy stated, “It was people [medical providers] that told me to, um, just walk…If

I go to my doctors’ visits or something [they] just say, ‘Well, you need to make sure that you’re

walkin.’” Bruce, a 60-year-old man who had stents placed, was told to, “just, uh, start taking it

easy, if I don’t do nothing but just walk out to the mailbox and walk back, walk out to the

mailbox and walk back, that will help build my strength up and everything and make my heart

pump.”

In contrast to these general messages, Alberta described the existence of continuity of

care from her surgeon to her physical therapist, all of whom referenced and guided her in

exercises from the same pamphlet given to her by a nurse during her hospitalization:

The book that they gave me for to do the arm exercises, the leg exercises… And I did it

[exercises] while I was in the hospital… I was even doing it before he [physical therapist]

got here…The therapist come in. He helped me walk. I walked down the street. I did

everything he asked me to do, and he said I done well with it… I had to do arm exercise,

leg exercise, and then I walked down the street a block.

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Notably, Alberta stated that she had also created her own continuity of care by doing exercises

from the pamphlet between the time she was discharged and the time the physical therapist

started home visits.

Participants perceived support (functional and emotional) offered by medical

providers. In addition to guidance for healthy lifestyle changes, medical providers offered a

combination of functional and emotional support to participants both during hospitalization and

recovery. Functional support included adjusting medications, checking participants’ vitals and

tolerance of treatment, putting in appropriate referrals, providing explanations of the treatment

process to participants, and offering or making home visits (visiting nurses,

physical/occupational therapists). Providers’ emotional support entailed offering encouragement

to participants and positive feedback regarding participants’ cardiac event or surgical outcome

and progress during recovery.

Often, support from medical providers served both functional and emotional purposes

simultaneously. Miss Spunky, a 54-year old woman who experienced an MI, explained that her

body had always been “very sensitive” to what she put on it or in it. Therefore, she appreciated

her medical providers’ care with monitoring her reactions to new treatments and felt emotionally

supported through the functionally supportive actions offered by her providers:

They, um, been thoroughly with, you know, the examination and medication and

makin’ sure that, you know, that, uh, that they handle the, um, monitor my

symptoms and, and reactions from the medicine. I mean, they’ve been a help for

that, you know, consider how my body is: very sensitive to things. So, they,

they’ve been kinda supportive.

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 For some participants, positive feedback seemed to also have a motivating effect,

encouraging them to continue treatment recommendations through recovery. For example,

Bruce stated: “My blood pressure was alright and [he] told me to keep doing what I’ve been

doing [CHUCKLING]… With my, you know, with my diet and everything. Keep doing what

I’m doing.” Other participants seemed to cite positive feedback as reassurance that they did not

need additional resources such as CR, but were equipped to facilitate their own rehabilitation

process. Robert stated, “Every time I went to the doctors they kept tellin’ me, ‘You’re doin’

good.’ And the last one I went to they said, ‘You, actually, you know, your heart’s good.’ Um,

they did a blood test and an EKG, and they said that that it was all good.” This participant said

he was accustomed to working out before his cardiac event/surgery and stated that he planned to

ease back into working out on his own.

Participants appreciated medical providers. Participants expressed their appreciation

for medical providers’ level of “dedication” to participants and their health. One participant,

Bruce, also emphasized the good work that student doctors had done. Specifically, participants

appreciated that medical providers seemed to invest personally in participants’ needs.

Participants frequently spoke about medical providers “really caring” for them. Regarding the

doctors and nurses who cared for him during his hospitalization, Bruce said, “You always know

you’ve got somebody that’s got your back”. Michael, a 37-year-old man who experienced an MI

and had had stents placed, stated that, although he had had previous experiences of

discrimination based on his status as a Medicaid patient, he did not experience any such

discrimination during hospitalization or post-discharge:

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 They really cared about me. I could tell the doctors really cared. They wanted

me to get well…they kept telling me, um, you gotta do this, you gotta take your

medicine. You can tell when someone actually care about you.

“Really caring” also meant that medical providers went above and beyond their job

descriptions to care for participants. Michael recounted the way CR nurses and staff exceeded

expectations in assisting with the coordination of his care: “They didn’t have to do all of that.

They could have just told me to call my physician and set up an appointment, or I should call my

doctor, but they did all the calling for me.”

Connected to participants’ sense of medical providers’ exceptional care was participants

feeling that they were a part of a collaborative team with providers in which participants’

positive health outcomes were a shared goal. Participants’ appreciated that medical providers

involved them in conversations about their care and explained to them what to do and what to

expect medically. Bruce, who referred to his medical providers as “my doctors and nurse

friends,” stated:

They just sit and listen, but they, and what they got to say, they gonna let you know what

they’ve got to say, but they sit and listen to what you’ve got to say, too, and they try to

explain what’s going on. . . [Their approach] make you feel good.

Participants needed additional support from medical providers. Although

participants primarily spoke about the ways in which their medical providers had been

exceptionally helpful, participants also pointed out things with which they would have liked

additional support. Requests for additional support centered on post-event/surgery needs.

Participants stated that it would have been helpful to have had more information about home-

based recovery. For example, Lucy said that she and her family ended up buying a recliner after

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they realized that she could not sleep comfortably in a regular bed for the first few weeks

following discharge. According to this participant, the recliner most closely simulated a hospital

bed by keeping her somewhat upright. She suggested medical providers consider “Lettin’ the

family know, ‘You might want to try to look into rentin’ a recliner for the next couple weeks’…

or something like that. You know, um, just things that they know patients will kinda struggle

with for the first couple weeks.”

Social Support and Participants’ Need for It Changed Post-Event/Surgery

The second theme that emerged in the analysis of interview transcripts was the

importance of social support during recovery. In particular, the social support given to

participants, as well as participants’ need for or experience of social support, changed during this

time. Participants’ social support networks included family members, friends, neighbors, and

faith community members. Following participants’ cardiac events/surgeries, participants noticed

an increase in both functional and emotional support from their networks in the form of help with

daily activities of living, visits/check-ins, and encouragement. However, participants also

expressed a sense of isolation or lack of social support at times, or they expressed challenges

with certain types of social support or interaction that they did not deem helpful.

Social support was increased during recovery process. Following cardiac

events/surgeries, many participants experienced their social networks rallying to support them.

Functional support included assistance with activities of daily living (e.g., bathing, preparing

meals), financial help when/if participants were unable to work for a significant amount of time,

assistance with household chores and yard maintenance, and provision of home-based

accommodations for recovery and gradual transitions back into normal routines. Lucy, who had

also stated that her husband had bought a recliner upon her return home so she could sleep

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upright, described the accommodations her family made around her return to college: “You can’t

lift over 10 pounds, so, um, they would go with me… either my sons or my husband… Go to

school with me and take my books into class and bring ‘em outta class….” Lucy reported

feeling very supported by her family’s team effort in helping her return to school.

Emotional support from social networks included check-in telephone calls and/or visits,

words of encouragement, and advice from others who had had similar cardiac experiences. As

with the functional support, participants noted that the emotional support increased following

their cardiac events/surgeries. Bruce stated that his adult children used to call him monthly, but

“they done stopped that once a month once I went in the hospital. They start calling a whole

lot!...they ask about my appetite and everything.” According to participants, supporters also

made check-in visits. During these visits supporters sometimes offered functional support and

other times sat with the participant and/or offered words of encouragement. Michael stated that

his family helped him by “just being there for me. Um, talking to me, um, not wanting me to

stress, encouraging me to do things, encouraging me to walk.” Mark reported that he got good

advice from his roommate who “had the same thing [cardiac event/surgery]” as the participant

had, and thus, could guide him on the particulars of the recovery process.

Sense of social isolation or limited support during recovery.

According to participants, sense of isolation was often caused or compounded by lifestyle

changes made post-event/surgery and participants’ physical limitations during their recovery

process. Mark found that, upon following his medical providers’ recommendations to stop

smoking and drinking, he lost contact with his friends with whom he used to engage in these

activities. Although Mark recognized these were the “wrong kind of friends” to have if he

wanted to adopt healthy lifestyle behaviors, he still expressed disappointment that they didn’t

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come visit him in the hospital or post-discharge, stating, “the day after I had the heart

attack…they don’t come see me or nothing.’”

In a similar vein, Lucy felt isolation not due to losing friends, but due to feeling that her

friends did not share her new perspective on the consequences of unhealthy lifestyle behaviors:

Some people might have went through the struggle of battling with food, but they

haven’t went through the struggle of knowing that, okay this could really kill

you… Or it could shorten your life. So, basically, by them not realizin’ that, they

don’t take it as serious.

Although Lucy admitted that she “didn’t take [diet] as serious” before her MI and CABG, she

now felt distanced from those who had not had a similar change of perspective. She said, “I had

the realization and then coming back into normal world and normal society and everybody’s just

doin’ what they do,” she said.

Physical limitations also caused participants to feel isolated. In contrast to the example

above, this form of isolation was not a result of friends abandoning the participants, but rather

resulted from participants being unable to engage in their lives as they had been previously

accustomed. Lucy stated that social events were very difficult for her to attend in the first few

weeks following her discharge, because she was not able to move around the gatherings as she

formerly would have. According to Lucy, this left her feeling like she was an outsider at the

gathering, “watching life go by”—a stark contrast to her typical position as being what she

described as, “the center of attention”:

Everybody’s movin’ around socializing, and I’m kinda stuck in this spot waiting

for, ‘Okay, you wanna come talk to me?’ And have one person come talk to me a

little while, then they go off, and then I’m waiting for, ‘Okay, I’m just sitting

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 watching everybody’… it was kinda lonely. And it, uh, you felt like you was, like,

missing a lot of things. Like, you kinda sittin’ there and you watching life go by.

Finally, some participants who were living far away from friends and family

reported limited access to social support from these distant individuals. The geographical

distance between participants and supporters predated participants’ cardiac

events/surgeries, but the cardiac events/surgeries highlighted this distance. In these cases,

participants leaned more heavily on their nearby supporters for assistance. For example,

Robert stated that his family members lived “far, far away” in the Northeast and were

only able to visit him for a short time during his recovery. While they were visiting,

Robert said they helped with cooking. After they left, he said his fiancée “did everything.”

Challenges with social interactions and type of social support. Finally, participants

expressed challenges with the type of support they received from supporters. This thematic

cluster is distinct from the one preceding it; whereas the cluster above refers to sense of social

isolation or limited social support, this cluster refers to the presence of social support that was in

some way challenging for the participant. Participants reported that support that was “pitying,”

disempowering, conflictual, or “humbling,” was challenging to them. Miss Spunky stated that

she felt pitied when her family and friend looked at her “different” and spoke to her in a certain

tone: “It’s like I’m being watched more, or, you know, [they say], ‘How you feelin? You feelin’

alright?’ [and I say], ‘Yeah, I’m fine!’”

Regarding disempowering support, Lucy did not feel supported when those around her

provided her with words of encouragement but not with functional support:

So, a lot of times, like, I could tell somebody [about cardiac event/surgery] and

they’d be like, ‘Oh okay, well, you got this, and you can do this.’ And the way

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 they kinda say it, seem like it’s kinda nonchalant, or, you know, ‘Yeah, you can

do it’ [UNDERWHELMED TONE]. And it’s like, ‘Okay, yeah, I’m telling you

this because, (a) I need a lifeline, I need you to, uh, come on, help me do this.’

According to Lucy, her cardiac event/surgery had “hit” her hard but had not affected

those around her in a similar way. As a result, her supporters were less likely to offer the

functional support she needed to implement healthy lifestyle changes and maintain them.

Support that was “humbling” or conflictual was also a challenge to participants

but was not necessarily seen as ultimately negative. Lucy stated that needing help from

her husband and children with activities of daily living was “humbling” and “a big, big

change…like for instance, you see your husband as your husband, but you don’t want

him to have to wipe you.” Support was conflictual when participants and supporters

disagreed on participants’ treatment recommendations. Lucy reported that, ultimately,

her difference of opinion with her husband regarding exercise (“I would try to walk the

half mile, and he was like, ‘That’s enough, you tired.’”) allowed her to find a “balance”

in implementing recommendations.

While participants reported challenges with social support and interactions, they also

reported that they did not always disclose their authentic feelings. Miss Spunky stated she made

a point of “acting joyful” when she felt pitied by others, “just to, uh, let ‘em know that you don’t

have to have pity [CHUCKLING], you know?” Similarly, Bruce said his friends at church did

not realize how sick he was before receiving his stent because of the smile he put on: “Even the

people at, at the church said – ‘cause I used to always smile so much they never thought I was

ever hurtin’ or anything because they said I kept such a smile.” This inauthenticity may have

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made it more difficult for others to know that their support—or a different type of support and/or

interaction—was needed.

Pre- & Post-Event/Surgery Experiences Affected Health Outcomes

The third emergent theme identified how participants’ cardiac events/surgeries were not

isolated health events but, rather, were a part of participants’ ongoing health experiences.

During interviews, participants reported multiple health problems before events/surgeries, some

of which directly compounded their heart problems. Post-event/surgery health outcomes were

often positive, but participants also reported that some post-event/surgery treatments were either

ineffective, inaccessible, or were not adopted by participants. For example, some participants

expressed that they struggled to cover co-pays for prescribed medications or that their health

insurance plan did not cover adjunctive treatments like weigh loss surgery.

Participants had pre-event/surgery health problems. Pre-event/surgery health

problems endorsed by participants included prior cardiac events, atrial fibrillation, undiagnosed

cardiac problems, high blood pressure, diabetes, obesity, knee problems, prior injuries,

fibromyalgia, and depression. According to participants, these pre-existing health problems had

kept participants from being able to live like they wanted to live. Michael stated that his obesity

and knee problems made it difficult, and then impossible, to work at the physically strenuous job

he had held. Miss Spunky stated that injuries from a car accident (approximately 10 years prior)

and fibromyalgia “kinda, like, put a dent in my exercise.” Before being hospitalized and having

a stent placed, Bruce stated:

I was having so much problems breathing sometimes that if I get excited, my

chest would start hurting, so I can’t breath like I wanted to because my blood

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 pressure going up and down, up and down, I get tired quick, couldn’t-couldn’t

hardly do nothing I wanted to.

Notably, health problems often resulted in participants’ limiting their activity levels, which some

participants observed had an impact on their weight and physical endurance.

Participants also identified specific ways in which their pre-event/surgery health

problems compounded their heart problems. Bruce explained that when pain from an existing

shoulder problem would arise, he would “get aggravated, and it start me breathin’ hard, and then

if I breathin’ extra hard that start messin’ with my heart [LAUGHING].” Lucy stated that the

diet pills prescribed to her by a medical provider “produced” her heart attack, but she saw this as

a blessing because it uncovered heart problems that could have killed her suddenly if they had

continued to go unnoticed and unaddressed:

[The diet pills] helped my blood flow a little bit stronger, but it helped produce

the heart attack… So, if it wasn’t for that, I could’ve died at any moment, because

I didn’t know nothing about, um, the blockage, I have a heart problem.

Lucy explained that her father had died from a massive heart attack, and Lucy felt “that

was getting ready to happen to me if, um, I didn’t have- didn’t take the diet pills and… it, it

could have happened to me.”

Participants experienced post-event/surgery health improvements. Participants

experienced some post-events/surgery health improvements that included successful recoveries

from cardiac events/surgeries, needing fewer medications/interventions to manage health

problems, and increased self-care. Robert stated that his recovery from his heart attack and stent

placement was “quick and good… I guess it had to do with the medication and the doctor that

did the surgery.” The medication Robert was referring to were “pain pills” that helped him in

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early recovery. He stated the surgeon who performed his stent placement was one who had been

recommended to him by others. Due to these factors, Robert stated that post-event/surgery he

was “doin’ real good” and his medical providers had told him that everything “was all good” on

the EKG.

Following cardiac events/surgeries, some participants experienced decreased need for

medications and intervention. This was a result of both participants recovering from their

cardiac events/surgeries and also achieving greater health than they had experienced before their

hospitalization. Alberta stated that, as her health improved following her stent placement, she

had fewer and fewer medical provider appointments to make. Alberta understood this to be sign

that she was doing well enough that she did not need to be so closely monitored:

The nurse that came in, the therapy doctor and all that stuff that came into the

home, they turned me loose all probably about two or three weeks ago… Only

thing I gotta go to now is my heart doctor…To make sure that everything stays

good.

After recovering from his stent placement, Bruce reported overall improvements in the

way that he felt and reduction in the medications he was taking, including some that he was on

before he had his surgery: “By my body adjustin’ to certain things and gettin’ stronger and stuff,

I was able to get, you know them pills, off, off all the pills.”

Post-event/surgery limitations called for lifestyle adjustments. Participants

emphasized that, following their events/surgeries, it was necessary to make adjustments to their

home environments and routines to accommodate temporary and permanent limitations. For

some participants, adjustments included different sleeping accommodations (i.e., lower beds

and/or recliners that were easier to get in and out of for the first few weeks post-discharge), use

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of a walker, riding in vehicles that were easier to get in and out of (i.e. larger versus compact

vehicles), and help with carrying items over 10 pounds. Participants expressed a pervasive shift

in how they moved through their days. Robert reported, “When you have a recovery you have to

really take your time, get around slow and stuff like that, and make sure that you got proper rest.”

Participants stated that their previous personal and familial health experiences contributed

to their adaptability and resilience in not only making these accommodations but accepting them.

Lucy stated that her experience being a caregiver to loved ones and having a history of personal

health problems (i.e., diabetes, fibromyalgia, and knee surgeries) helped her to have a “strong

mind” during her recovery process. According to Lucy, the “humbling” support she received

(e.g., needing her husband and children to help her with activities of daily living) “could make

you depressed” if one had not been strengthen by previous health-related experiences.

Some interventions ineffective or inaccessible post-event/surgery. Some post-

event/surgery treatments were ineffective, inaccessible, or not adopted by participants. Thus,

participants experienced ongoing physical and/or psychological limitations. First, participants

reported difficulties with some medications prescribed to them post-event/surgery. Alberta

stated that her medical providers adjusted her diabetes medications while she was in the hospital

but that these adjustments were problematic after she was discharged. Alberta hypothesized this

may have been because the medications were adjusted when she was in the hospital and was “not

eating.” She stated that, nearly two months post-discharge, her medical providers were still

“trying to get it [the medication] straight.” Medication side effects and interaction effects were

also a concern for participants. Bruce stated that the combination of medications he was taking

post-discharge “was messin’ with me bad.” Bruce described this as a physical (e.g., stomach

aches), as well as psychological (e.g., feeling like he was “floating”) experience. He reported

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feeling much better after he was well enough to taper down his medications; he found that taking

fewer medications made him feel better.

Participants’ access to treatments was sometimes compromised by their ability to pay for

them. Difficulty of access, then, had bearing on whether or not participants were compliant with

medical providers’ treatment recommendations. Michael described his sense of depression

(manifested, he stated, by feelings of hopelessness) when he found he could not afford the

medication that he had been prescribed for his heart:

They was tellin’ me in the hospital it [the medication] was like $100. They gave

me a free month the first time, and then the nurse gave me like a $50 co-pay card.

So, I was thinking, I got $50 from my, one of my family members and he took me

up there to get the medicine, and told me $290 and my heart just dropped. I like,

‘No way I can afford this.’

Luckily, Michael reached out to his medical providers and was able to secure the

medication. Other participants, however, felt their inability to access care compromised

their health both pre- and post-event/surgery. Lucy stated that she had been battling with

her insurance company to get approval for weight loss surgery for years. Lucy believed

the surgery would help her drop the weight that her medical providers told her would kill

her in the next 10 years. She stated, “I’ve been trying to get that [weight loss surgery]

even before the, the heart attack. But, um, by them not taking care of that, then they

spent over $200,000 on a heart surgery that mighta coulda been avoided.” At the time of

the interview, Lucy was actively involved in CR and had made significant changes to her

diet. Although she reported that her weight had not changed, she felt she was getting

stronger.

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Sense of Agency Affected Life Perspectives & Health Behaviors

A fourth theme that emerged from interview transcripts was the impact of participants’

sense of agency on their life perspectives and health behaviors. Participants experienced distress

when they felt they had little or no control over their health outcomes. In contrast, when

participants felt like agents in their own health and care, they were proactive about advocating

for their needs. This agency took the form of participants choosing to opt in or out of treatment

recommendations and how they would incorporate these recommendations into their lives. It

also took the form of participants treating cardiac events/surgeries as “wake-up calls” that

inspired them to take control of their lives and pass their newfound wisdom onto others.

Unpredictability of health challenges and outcomes affected distress level.

Participants reported feeling distressed when they were faced with the unpredictability of their

treatments and/or health outcomes. Distress included anxiety about having limited control over

and knowledge of their cardiac events/surgeries and outcomes; fear that engaging in exercise

would trigger another cardiac event; frustration when physical limitations precluded being able

to exercise as instructed by medical providers; being unsure of medications’ physical and

psychological effects; and feeling depressed as a result of unforeseen health-related hardships.

Words participants used to describe their anxiety about limited control regarding their cardiac

events/surgeries and outcomes included “scary,” “fightful,” “overwhelmed,” and “hard to accept.”

Miss Spunky explained the way in which she could become preoccupied with the

possibility of a second cardiac event, post-discharge:

I thought about, you know, ‘Is this gonna happen again?’ That, that stays in my

mind a lot [CHUCKLING], you know. Yeah, I’m, I’m concerned about it

happenin’ again, or, I mean, I’m anticipating – it’s like every time I feel a little

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 pain, I’m anticipatin’ that, ‘Okay, this may be happenin’. And um, so that’s, that’s

the challenge that I’m facin’ now as, as far as that.’

Miss Spunky stated that, to cope with this concern, it helped her to “stay positive on it.

Tryin’ to not let it bother me…it’s something that keep naggin’ but nothin’ that I stay

focused on. Miss Spunky also continued to exercise in spite of this fear, with the help

and support of her CR nurses and staff (although she stated that even before she went to

CR, she was exercising at home because she was “determined…to build my strength back

up”).

Participants had different levels of proactivity about health and recovery process.

Participants varied in the extent to which they engaged proactively in the implementation of their

care. Whereas some participants researched and implemented recommended diet and lifestyle

changes both pre- and post-intervention (sometimes even before medical providers had

recommended that they do so), others stated that they passively chose not to implement these

changes even though they knew that they “should.” In regard to the latter point, Mark stated, “I

know what I should be doing: get up and walk around more often.” When asked what kept him

from walking more, Mark said, “Nothing. I’m just lazy. I sleep a lot.” When questioned further,

Mark explained that some of his medications made him groggy and a variety of other health

problem caused him physical limitations. Even in the context of these factors, however, Mark’s

approach appeared more like a passive decision to not engage in recommended changes rather

than an active decision to opt out.

In contrast, Robert explained his active decision to opt out of certain care. Robert

explained that his recovery was so successful that he declined home health care after his first

appointment with a visiting nurse. He reported, “They came one time, and I didn’t, actually, I

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didn’t need ‘em.” Regarding exercise, this participant stated that he had high comfort level with

exercise from working out for years prior to his cardiac event/surgery and, therefore, felt he did

not need guidance with exercise. He stated that his medical providers had not talked to him

about CR, but even if they had, he felt he did not need guidance on starting up exercise again

post-event/surgery, because “I pretty much know how to ease my way back in it, like I’m doing.”

It is notable here that Robert’s proactivity was expressed in opting out of (not into) treatments.

Cardiac events/surgeries led to lifestyle changes. Participants

reported that their cardiac events/surgeries led them to actively make lifestyle changes. These

changes involved shifts in both perception and behavior, and included feeling inspired to get

more serious about health following the wake-up calls of cardiac events/surgeries; perceiving

weight changes as connected to greater health and wellbeing and engaging in behavioral

modifications to manage weight; having a new appreciation for peace and quiet; and accepting

and making peace with health-related limitations. In regard to the “wake-up call” of cardiac

events/surgeries, participants explained that they got more “serious” about their health and their

lives when they realized that their behavior leading up to their cardiac events and/or surgeries

could have killed them. Mark said that had he not changed his health behaviors (including

drinking and smoking) following his MI, “I really wouldn’t have, you know, probably would’ve

die young…This might have been a wake-up call.”

Both Michael and Lucy stated that their cardiac events/surgeries jolted them into

improving their lifestyle behaviors, especially their diets. Michael expressed that his MI

precipitated health behavior changes. He said,

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 [The MI] changed the way I do a lot of things. Um, it made me take life a little bit more

serious...just make sure I take my medication all the time. Don’t eat- watch what I eat…

Basically, I was just eating everything.

Lucy stated her wake-up call came when her medical provider told her (after her MI and before

her CABG) that, “if I do not change and get the weight off, that he don’t see me lasting another

10 years after the surgery.” Before her MI, Lucy reported that,

[I] didn’t take it [consequence of unhealthy diet] as serious. I was like, ‘Okay, I know

that I need to get some weight off. I know that this is a problem.’ But until something

serious happened, ‘Okay, now I know it’s really a problem, I really got to deal with this.’

Participants also expressed that they cultivated a new appreciation for peace and quiet

following their cardiac events/surgeries. Mark explained that, before his MI, “I liked noise…

But now that I’ve been sick and I got better, I love the quietness… I can sit on the porch, I don’t

hear a lot of profane language and stuff.” Mark described this change as occurring alongside a

change in the type of people with whom he socialized. According to Mark, when he stopped

drinking and smoking, he also became distant from friends with whom he shared these activities.

Presumably, these activities were “noisier” and stood in contrast to the “peaceful” lifestyle the

participant adopted post-discharge. Although this participant stated he used to like this noisier

lifestyle before his cardiac event, afterwards he shifted to valuing quietness.

In a related vein, participants also noted that they learned to make peace with their health-

related limitations post-event/surgery. Alberta explained that she let go of the expectation that

she would be able to complete all household tasks on her own. Instead, she focused on whether

or not these tasks got done and not on whether or not she was the one to do them: “Somebody

will do it for me, so I don’t worry about it… Long as it gets done, I didn’t worry about it.

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Whether I can do it or not.” Robert stated that his ability to accept his limitations post-

event/surgery helped him to move forward in his recovery. He reported,

I just had to accept the fact of what was going on, and, and then I dealt with it…

whatever’s gonna be is always the way it’s gonna be. By thinking that way, you know,

that, that helps out a lot to me.

Although, at first glance, perspectives of acceptance can seem like a passive process of letting go,

participants described acceptance as an active process of learning contentment and adaptability

in the face of change.

Passing on new knowledge was a part of participants’ recovery process. Finally,

participants stated that they not only gleaned knowledge from the experiences of their cardiac

events/surgeries, they also shared this new knowledge with others. In particular, participants

gave health advice to their children regarding their children’s and future grandchildren’s health-

related behaviors. Lucy reported that it was very important to her that her two teenage sons

internalize healthy lifestyle behaviors, so they would not be faced with the same challenges she

had experienced. “I teach ‘em lessons,” she said. Lucy’s lessons began after the wake-up call of

her cardiac event/surgery and included information on sugar addiction, diabetes, and healthy

cooking and eating. For example, she told her sons,

You gotta kinda retrain your tastebuds, in a sense,’ So it ain’t always, ‘Okay, I want

sugar, sugar, sugar.’ I said, ‘cause, um, ‘You see people out here who don’t have fingers,

toes, hands, arms, legs, and they lost it to diabetes.

Lucy stated that as a result of her lessons, her sons had started cooking healthfully for the family

and would even help her keep track of her own healthy eating goals.

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Participants Experienced Inconsistent Referral to and Utilization of Cardiac Rehabilitation

Participants reported a great deal of variability in referral to and participation in CR.

Those who were referred to and participated in CR reported positive experiences. Those whose

medical providers did not talk to them about CR and/or did not explain to them what CR was in a

way that participants could understand generally did not participate. Other barriers to CR

participation included not being referred to CR or waiting on medical providers for

action/clearance to begin or continue the program. An additional pathway to referral was

learning about CR word-of-mouth in the community, but participants stated they would have

preferred to have learned about CR from medical providers. Participants stated that they were

grateful for the support offered by CR nurses and staff, but sometimes found the presence of

other patients “gloomy” and/or unmotivating.

Participants experienced health-related successes with CR. Participants who were

referred to and participated in CR reported positive experiences with health-related successes and

support from CR nurses and staff. Alberta appreciated the program so much that she stated, “I

would like that the program could last, you know, forever!” Lucy stated that she thought CR

was “very important to help you get, get stronger and back to, not just your own life that you had

before heart surgery, but a better life.” After finishing CR, she planned to transfer the exercise

program she had developed at CR to a local gym. Miss Spunky also reported that CR “did a

tremendous help as far as gainin’ energy back and wantin’ to do things.” In addition to the

support provided by CR nurses and staff, she also cited availability of equipment as a benefit to

participating in CR versus exercising at home.

Functional and emotional support from CR nurses and staff was an important component

of participants’ positive experiences. Miss Spunky also reported this support was a reason CR

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was preferable to exercising at home: “being around the people that, you know, watchin’ you and

pushin’ you and encouragin’ you [CHUCKLING]… Yeah, they [CR nurses and staff] was- they

fun.” Michael also stated that CR nurses and staff went above and beyond his expectation of

medical providers when they helped him to coordinate his care with other outside providers.

Participants experienced barriers to CR participation. Participants also experienced

barriers to CR participation. These included not being referred to CR, medical providers not

talking to participants about CR, not understanding what CR was, or waiting on medical

providers for action/clearance to begin or continue the program. Some participants had not heard

of CR or had a very vague understanding of what it was. Mark was aware that one of his

medical providers had put in a CR referral for him and he was scheduled to attend, but he had a

difficult time articulating exactly what CR was: “He [medical provider] had wanted me to do

somethin’. Uh, some, uh . . oh, man, I can’t explain it…What is it?” Michael, who had attended

an initial assessment session at CR still had difficulty explaining what it was, despite this first

visit and meeting with CR nurses and staff: “Um, once I went in there I see that they exercise- I

saw a lot of exercise equipment…I mean, I just see a lot of exercise equipment, I know they do-

they weigh you and everything like that.”

Lucy stated that she happened to learn about CR word-of-mouth from a woman whom

she met at a salon. According to Lucy, the woman had recently had cardiac surgery, had

attended CR, and “told me [Lucy] how nice the people was and told me to go ask my doctor

about it.” As a result of this chance conversation, Lucy sought a referral from her medical

providers using her online patient portal. She reported that she was given a referral, and then

successfully enrolled in, attended, and completed CR. Although Lucy stated that she was

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grateful to have learned about CR in one way or another, she also reported being disappointed

that none of her medical providers had told her about this resource:

Nobody hadn’t told me about it, um, hadn’t said anything about there’s a rehab

place for it. Nothing… I think that they should let the people know. Especially

right before [discharge]- at the hospital would be great, because somebody have it

on their discharge papers. You know, some type of way to, to let people know

that ‘These services are available, check into it.’

While participants spoke positively about the support received from CR nurses

and staff, they were neutral to negative about interactions with other CR patients.

Participants stated that they did not interact with other patients; they interacted only with

the CR nurses and staff. Despite lack of interactions, the presence of other CR patients

was described as threatening participants’ motivation to exercise or engage in CR. Miss

Spunky stated that other patients she observed at CR were less motivated and/or less able

to exercise than her and this contributed to a “gloomy” feeling. She reported, “I have to

keep my focus on this therapy, and… because- well, I’m not sayin’ all of ‘em in there

[are] like that, but usually complaints. It’s just, some just complain…”

Similarly, Michael reported that when he attended his initial assessment session at

CR, he observed that he was one of the youngest patients present. He stated that this was

particularly upsetting to him: “When I started the rehab thing, um, no disrespect, but

when I ain’t seen nothing but older people in there, like grandmoms and granddaddys,

and I look at my age, I’m saying to myself, ‘I shouldn’t be in here.’…Yeah, it’s kinda,

first day I went there I probably wanted to cry to myself. I was like, ‘Oh man.’” As

Michael described it, his observations of other CR patients highlighted for him the

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untimely nature of his cardiac events/surgeries. Although CR was by no means a causal

agent in creating this reality for Michael, the fact that it triggered this realization for him

may have negatively impacted his associations with CR.

Participants’ Investment in Faith was Intensified or Maintained

A sixth and final theme that emerged in transcripts was the intensification or maintenance

of participants’ investment in their faith throughout the recovery process. Participants reported

ongoing personal and familial involvement in their faith communities. Some even reported the

resolution of pre-event/surgery spiritual challenges. According to participants, their faith was a

source of strength and gratitude during their recovery. Specifically, participants stated that

giving their troubles to God helped them to cope with challenges of their recovery. They also

expressed their praise to God for giving them life.

Involvement in faith and faith communities. Participants maintained involvement in

their faith and faith communities throughout their recoveries. Some participants reported that

their faith community members came into the hospital to visit and pray with them following

cardiac events/surgeries. After discharge, participants stated that faith community members

continued to support them, and participants resumed attending faith-based services and functions

as soon as possible. Lucy described pushing herself to attend a church service in which her sons

were involved approximately a week post-discharge, even though her medical providers had

cautioned her against leaving the house for the first week.

Some participants also reported that, following their cardiac events/surgeries,

involvement with their faith intensified. This included more frequent considerations about faith-

based questions and one’s relationship with God and seeking spiritual guidance and counsel from

others. Bruce reported that, during his recovery, he experienced spiritual “frustration” related to

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his faith in God and his worries for himself and other people. Bruce met periodically with his

pastor, who helped Bruce learn “What to believe, how to believe, and how to put it in faith.”

Through these spiritual conversations, Bruce reported that he was able to put his worries for self

and others in faith. As a result, he also reported better health overall. Bruce stated:

Don’t have to do, deal with too many pills, don’t have to deal with a whole lotta

people, and their problems and stuff. I’ve just been doing a whole lot, lot better…

I ain’t supposed to worry about nobody else’s problems. All you have to do is

just pray about it and just leave it alone.

Faith was a source of strength and gratitude for participants. As was the case with

Bruce in the example above, participants cited faith as a source of strength and gratitude during

their recovery. Participants stated that they gave their troubles to God. For Miss Spunky, saying

to herself “God got it” helped her let go of health-related worries. Mark stated that the best

advice his roommate, who had also gone through a cardiac event, had given him was: “Put it

[faith] in the hands of the Lord.” Alberta stated that, when she first learned that she had had a

MI, she was able to “calm back out” by drawing on her faith in God. She stated, “He’s was

gonna take care of me.” Lucy reported that, in addition to drawing upon previous personal and

familial health experiences for resilience (developing the “strong mind”), her religion and belief

in God helped her with this. Robert added:

Every time, you know, stuff’d go wrong, I’d think about my spiritual relationship

with God, and, um, and, um, the prayer, and, uh, it’s just, like, I, I had no, no fear

in believing that I would be alright, you know?

Participants also offered praise to God for giving them life. Michael emphasized

the gratitude he had for God in giving him the opportunity to see his children grow up:

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“Everyday I wake up I pray, I thank God everyday I wake up. I mean, that’s the way I

look at it…I mean, I got a 7-year-old son and an 18-year-old daughter.” When asked

about spiritual factors associated with his recovery process, Mark answered, “Well, I’m

still livin’. That’s spiritual… I’m just still livin’. The Lord kept me here.” At the close

of his interview, Mark stated, “I thank God everyday… For bringing me back alive and

everything… He really helped me.” God and participants’ faith in God were not only

described as the primary source of participants’ strength, these were also described as the

very power by which their hearts were still beating.

Exhaustive Description

After themes were identified from participants’ interview transcripts, an exhaustive

description was developed. This consisted of a list of statements that capture all the emergent

themes and which reflected the richness of the participants’ lived experiences (Colaizzi, 1978).

The exhaustive description formulated for this study was as follows:

African American participants recovering from cardiac events and/or surgeries did so

with the support of their medical providers and social networks. Medical providers (i.e. doctors,

nurses, physical/occupational therapists) were valued for help and expertise, from treating

cardiac events/surgeries to guiding participants in making healthy lifestyle changes (e.g., diet,

exercise, substance use) during recovery. Support from medical providers was both functional

and emotional and included adjusting medications, checking in with participants, putting in

appropriate referrals, and giving encouragement and explanations of treatment. Participants

expressed appreciation for the “dedication” of medical providers and also pointed out times

when they would have liked additional support from them. For example, some participants

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desired recommendations on how to make appropriate accommodations at home after discharge,

whereas others desired information regarding availability and utility of CR programs.

Support from participants’ social networks (i.e., family members, friends, neighbors, and

faith community members), as well as participants’ need for this support, changed during

recovery. Participants’ social networks offered increased functional and emotional support,

including help with daily activities of living, visits/check-ins, and encouragement. However,

participants also expressed experiences of social isolation and lack of support stemming from

various factors, including making lifestyle behavior changes (resulting in alienation from

individuals who continued to engage in unhealthy behaviors), having limited mobility at social

gatherings, and being geographically distant from family and friends. During recovery,

participants were sensitive to the type of social support they received; support that was “pitying,”

“humbling,” conflictual, or disempowering was challenging for participants. Participants were

not always authentic with their social networks in expressing their health experience and needs.

Participants’ health outcomes following cardiac events and/or surgeries were impacted by

health-related experiences before and after the events and/or surgeries. Participants reported

multiple health problems before events/surgeries, some of which directly compounded

participants’ heart problems. Post-event/surgery, participants made adjustments to their home

environments and routines to accommodate temporary and permanent limitations. Previous

personal and familial health experiences contributed to participants’ adaptability and resilience.

Some positive improvements resulted from cardiac events/surgeries (i.e., recoveries were

successful, fewer medications/interventions were needed to manage health problems, self-care

increased), but some post-event or surgical treatments were ineffective, inaccessible, or not

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adopted by participants, and participants experienced ongoing physical and/or psychological

limitations.

Participants’ sense of agency impacted life perspectives and health behaviors.

Participants experienced distress when they felt they had little or no control over their health

outcomes (e.g., medication had unknown side-effects and exercise was frustrating due to

limitations or a source of fear as a possible trigger for another cardiac event). When participants

felt like agents in their own health and care, they were likely to proactively advocate for their

needs by choosing to opt in or out of treatment recommendations and how they would

incorporate treatment recommendations into their lives (i.e., exercising at CR versus exercising

at home). With this stance of agency, participants saw cardiac events and/or surgeries as “wake-

up calls” that inspired them to take control of their lives. They expressed new perspectives on

what was important in their lives and to their health. They also communicated to others their

wisdom and knowledge about living healthfully.

According to participants, referral to and utilization of CR was inconsistent. Participants

who were referred to and participated in CR reported positive experiences. Participants whose

medical providers did not talk to them about CR generally did not participate. Other barriers to

CR participation included not being referred to CR, not understanding what CR was, CR being

inaccessible due to lack of insurance coverage, waiting on medical providers’ action to begin the

program, or experiencing health problems that required medical clearance for program

continuation. Learning about CR word-of-mouth in the community was an additional pathway to

participants’ referral and participation in CR, although participants stated they would have

preferred to have learned about CR from medical providers. Participants who participated in CR

expressed appreciation for the encouragement and motivation to exercise from CR nurses and

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staff. In contrast, the presence of “gloomy” or less motivated or able patients at CR threatened to

compromise participants’ motivation.

In addition to the importance of biomedical, psychological, and social factors during and

after recovery, participants’ investment in their faith was either intensified or maintained

throughout this process. Participants reported ongoing personal and familial involvement in their

faith communities, and even the resolution of some pre-event/surgery spiritual challenges.

Participants identified their faith as a source of strength and gratitude during recovery. They

reported that giving their troubles to God helped them to work through their recoveries and move

forward in their lives.

Statement of Identification

A statement of identification is intended to reduce the exhaustive description to the

essence of participants’ lived experience. The statement of identification that emerged from this

study incorporated multiple aspects of the description into one inclusive and overarching

statement. The statement of identification for this study was as follows:

Participants who felt supported as agents in their own health care were likely to actively

engage in their recovery by implementing treatment recommendations or alternatives to

recommendations (e.g. exercising at home versus CR, managing symptoms with lifestyle

changes instead of with prescribed medications). Participants’ previous health histories and

involvement in their faith had important bearing on recovery experiences and outcomes, as did

perceived support from medical providers and individuals who comprised their social networks.

Discussion

The themes revealed in this phenomenological study offer important considerations for

the recovery process of African American patients who have experienced a cardiac event and/or

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surgery. Several themes highlighted the importance of medical provider respect, encouragement,

and direct involvement in care as well as the role of the participants’ pre-existing and continuing

health problems during their illness and recovery experience. Although participants did not

always follow through on treatment recommendations (e.g., exercising as indicated), they

generally expressed a great deal of appreciation and respect for their medical providers, as well

as a desire to incorporate their professional recommendations into their lives if possible.

These findings were similar to those from previous researchers who have demonstrated

the importance of medical providers building rapport and bringing culturally-sensitive health

understandings to their communication with African American patients (Collins, Clark, Petersen,

& Kressin, 2002; Lutfiyya, Cumba, McCullough, Barlow, & Lipsky, 2008; Shaw, Armin, Torres,

Orzech, & Vivian, 2012). Participants in this study took these previous findings a step further in

emphasizing the importance of medical providers demonstrating a personal investment in

patients’ wellbeing. Participants praised medical providers for their “dedication,” “really

car[ing]” about them, and going above and beyond the requirements of their job to help them

improve their health.

How or whether or not medical providers offered post-event/surgery recommendations to

participants had important implications for follow-through. For example, when participants were

not referred to CR and/or their medical providers did not discuss CR with them in a way that

they could understand, participants stated that they did not participate in CR. Barriers to CR also

included participants waiting on medical providers’ action to begin the program or health

problems that required medical clearance for program continuation.

While the literature confirmed the existence of racial/ethnic disparity in the rates of CR

referral and participation of African American patients (Allen et al., 2004, Gregory et al., 2006),

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this study illuminated some potential sources of this disparity: level of health literacy (i.e., for

some participants referrals were only made after participants directly requested them; if patients

did not know what to request, they may have been less likely to received a referral) and severity

of health problems upon initiating CR (i.e., participants with multiple health problems were more

likely to require waiting for action/clearance from medical providers to begin or continue CR).

There is a need for studies that build on these findings by investigating the impact of

different types of referral conversations with African American patients on their likelihood to

participate in CR. Studies on the impact of patients’ medical limitations, medical providers’

referral activity, and alternative ways African American patients with CVD may effectively

recover at home are also warranted.

Participant agency was also an important factor identified in the emergent themes and

participants’ health outcomes addressed by participants in this study. When participants believed

they could serve as agents in their own health and care, they were proactive about advocating for

their needs (i.e., requesting CR referrals, changes in medication, and/or other medical

interventions). Participants were most distressed about and passive in their health and care when

they felt that they had little or no control over their cardiac treatments and outcomes.

Participants who understood what was happening to them and why, and who also had a good

understanding of what they could do to affect change in their health, were more apt to make

active decisions about how to implement treatment recommendations into their lives. This has

been confirmed in the literature in studies investigating a passive approach to self-care. Dickson,

McCarthy, Howe, and colleagues (2013), for example, found that African American patients who

believed cardiovascular risk factors or disease were normative or unavoidable adopted a more

passive approach (e.g., “stay in bed,” “relax…let it pass,” p. 115).

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 Notably, a sense of agency did not automatically mean that participants would adopt

recommendations; in some cases, agency appeared to give participants the confidence to choose

alternative ways to obtain the resources medical interventions were designed to offer (e.g.,

exercising at home versus exercising at CR). However, seeking alternative ways to obtain

treatment was often less problematic than participants passively choosing inactivity. This, again,

highlights the importance of medical providers engagement in building rapport and trust with

patients. When participants felt involved in their treatment and recovery process, they were

more likely to take an active role in implementing self-care and healthy lifestyle changes.

Additionally, the support received by medical providers, family members, friends,

neighbors, and faith community members played vital and ongoing roles in participants’

recovery experiences. The positive association between social networks and cardiovascular self-

care has been well documented in the literature (Grewen et al., 2003; Liu & Newschaffer, 2011;

Tkatch et al., 2011). However, participants in this study also stated that the mere presence of

others did not automatically result in feeling supported as agents in their own care. In some

cases, friends were seen as negative influences who continued to make the unhealthy lifestyle

choices that the participant was striving to change (e.g., drinking, using drugs, eating unhealthy

foods). In other cases, participants perceived social networks’ emotional support as “pitying” or

exercising alongside other less motivated and/or less able patients as discouraging. Studies

investigating the impact of different types and/or sources of social support on patients’ post-

event/surgery health behaviors would be useful in implementing best practices for this

population.

Finally, participants expressed that their hospitalizations and recoveries were important

times for them spiritually. This observation was in keeping with other researchers’ findings

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regarding the importance of spirituality as a coping strategy for African Americans managing

stress associated with cardiovascular health problems (Dickson, McCarthy, Howe, et al., 2013;

Johnson, Elbert-Avila, & Tulsky, 2005; Warren-Findlow & Issel, 2010). However, existing

studies have not investigated the relationship between African Americans’ spiritual beliefs and

CR referral and participation. Participants stated that during their recoveries they not only

maintained their spiritual involvement, but also often intensified it, sometimes even resolving

some pre-existing spiritual challenges. Some researchers have posited that fatalistic beliefs

associated with African American patients’ religions can contribute to a passive approach to self-

care (Dickson, McCarthy, Howe, et al., 2013; Polzer & Miles, 2007). Participants in this study

did not endorse this finding. Rather than a source of passivity, the participants portrayed

spirituality as a source of agency for them in accepting what they could not change in order to

actively engage in the areas of their lives in which they did have control.

Limitations

There are several limitations of this study. Firstly, although the experiences of the

individuals in this study may hold true for other individuals recovering from cardiac events

and/or surgeries, generalization of findings is not possible, particularly across demographic lines .

Participants in this study were not only racially but also regionally homogenous. Secondly, all

the participants in this study expressed a strong affiliation with their faith. It is possible that

these findings, then, are reflective of African American patients who living in the Southeastern

United States or who self-identify as religious and/or spiritual and may not apply to African

American patients recovering from cardiac events/surgeries who do not identify in this way.

Thirdly, it is a recommended practice to conduct an additional interview past the point of

saturation to confirm that all themes have been identified (Morse et al., 2002). This confirmatory

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interview was unable to be secured due to availability of eligible patients for recruitment. While

a triangulated researcher and peer debriefer strongly believed that saturation was achieved, it is

possible that apparent saturation was reached before themes were exhausted and an additional

interview would have confirmed this.

Conclusion

This qualitative study investigated the lived experience of African American patients

recovering from cardiac events and/or surgeries in the context of a primarily rural and lower-

income county in the Southeast. Findings underscored the importance of medical provider and

social network support during the treatment and recovery process, the impact of participants’

pre- and post-event /surgery health on their event/surgery outcomes, the need for greater

consistency and clarity in CR referrals and recommendations, and the role of participants’ sense

of agency and spirituality as sources of strength during recovery. In providing care for African

American patients recovering from cardiac events and/or surgeries, medical providers and social

network members should capitalize on patients’ agency, faith, and former resilience to health

challenges in order to restore—and, hopefully, improve—health and wellbeing. Moreover, there

is a need for studies investigating the typology and outcomes of physician-patient referral

conversations, patients’ pre-existing and continuing medical and physical limitations,

professional and personal sources of support, and spiritual beliefs and resources on African

American patients’ likelihood of participation in CR.

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Table 1
Participant Demographics

Pseudonym Gender Age Event/Surgery CR Status

Bruce Male 60 Stents No referral, not
enrolled
Mark Male 60 MI Referred,
enrollment pending
medical action
Michael Male 37 MI, Stents Referred,
enrollment pending
medical action
Alberta Female 64 Stents Referred, enrolled,
attending
Lucy Female 41 MI, CABG Late referral,
enrolled, attending,
nearly completed
Robert Male 60 MI, stents No referral, not
enrolled
Miss Spunky Female 54 MI Referred, enrolled,
continued
attendance pending
medical action

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 Table 2

Emergent Themes and Thematic Clusters

Emergent Themes Thematic clusters

Participants valued medical a) Medical providers’ interventions impacted cardiac outcomes
providers’ involvement during b) Medical providers offered guidance on healthy lifestyle changes
treatment and recovery c) Participants perceived support (functional and emotional) offered by medical providers.
d) Participants appreciated medical providers
e) Participants needed additional support from medical providers

Social support and participants’ need a) Social support was increased during recovery process
for it changed post-event/surgery b) Participants experienced sense of social isolation/limited support during recovery
c) Participants experienced challenges with social interactions and type of social support offered
during recovery

Participants’ pre- and post- a) Participants had pre-event/surgery health problems

event/surgery experiences affected b) Participants experienced post-event/surgery health improvements
health outcomes c) Participants’ post-event/surgery limitations called for lifestyle adjustments.
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d) Participants experienced some interventions as ineffective or inaccessible post-event/surgery

Participants’ sense of agency a) Unpredictability of health challenges and outcomes affected distress level
affected their life perspectives and b) Participants had different levels of proactivity about health and recovery process.
health behaviors c) Cardiac events/surgeries led to lifestyle changes
d) Passing on new knowledge was a part of participants’ recovery process

Participants experienced inconsistent a) Participants experienced health-related successes with CR

referral to and utilization of Cardiac b) Participants experienced barriers to CR participation
Rehabilitation
Participants’ investment in faith was a) Participants and families were involved in their faith and faith communities
intensified or maintained b) Participants experienced faith as a source of strength and gratitude for participants
 Table 3
Selected Examples of Narratives and Emergent Theme Formation
Significant Statements Formulated Meanings Thematic Clusters Emergent Themes
“That doctor would be affirming to telling me Participants appreciated Participants appreciated Participants valued medical
points, what’s gonna happen and what medical providers telling them medical providers providers’ involvement
shouldn’t happen, and if it happens, what, what what to do and what to expect during treatment and
to do if it happens…It make you feel good.” medically. recovery
“Oh Lord yeah, I had people clean my house, Family members increased Social support was increased Social support and
cook for me, too. My brothers come in, they emotional and functional during recovery process participants’ need for it
would sit when my husband couldn’t be here. support to participants through changed post-event/surgery
I had an aunt come and live with me for two intervention and during
weeks after my husband went back to work. recovery
And then, my grandkids, they come and they
help out. I had a bundle of help. I, I couldn’t
ask for any more. I really didn’t have to do
anything.”
“‘Cause I was taking a lot of pain pills for my Participants experienced co- Participants had pre- Participants’ pre- and post-
160

shoulder and stuff. And when my shoulder morbid health problems event/surgery health problems event/surgery experiences
started hurtin’ real bad it would start my heart (medical and behavioral health, affected health outcomes
hurtin’… I get aggravated, and it start me and related medications) that
breathin’ hard, and then if I breathin’ extra compounded and/or contributed
hard that start messin’ with my heart” to the diagnosis of heart
problems.

“I was going to, um, exercise at home myself Participants were comfortable Participants had different Participants’ sense of agency
[if Cardiac Rehabilitation was not exercising before cardiac levels of proactivity about affected their life
available]… Cause I was, I was gonna be events/surgeries and were health and recovery process perspectives and health
determined, either way, regardless, I was, I motivated to exercise behaviors
was determined, you know, to build my afterwards.
strength back up.”
 “My first time going, you know they talk to Participants received referral to Participants experienced Participants experienced
you, I see a nurse, and they asked you were Cardiac Rehabilitation but barriers to Cardiac inconsistent referral to and
you having problems, and I told them I’ve waited for medical provider Rehabilitation participation utilization of Cardiac
been depressed, I’ve been having chest action or clearance to begin or Rehabilitation.
problems, so they called my doctor continue program.
immediately, and need to come in the next day
for appointment, so the doctor talked to me,
checked my heart out. So, I guess I’m just
waiting to hear back from the rehab place.”
“Every time, you know, stuff’d go wrong, I’d Surrendering troubles to God Participants experienced Participants’ investment in
think about my spiritual relationship with gave participants the strength to spirituality as a source of faith was intensified or
God, and, um, and, um, the prayer, and, uh, get through challenges during strength and gratitude maintained
it’s just, like, I, I had no, no fear in believing their recovery.
that I would be alright, you know?... I had no
fear that everything would be alright.”
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 CHAPTER FIVE: PROMOTING ACCESS TO CARDIAC REHABILITATION FOR

AFRICAN AMERICAN PATIENTS: A POLICY BRIEF

Heart disease is not only the number one leading cause of death in the U.S. (Centers for

Disease Control and Prevention [CDC], 2013), it is a disease particularly threatening to African

Americans. African Americans have a 20% higher age-adjusted death rate from coronary heart

disease than Non-Hispanic Whites (141.3 per 100,000 population for African Americans

compared with 117.7 per 100,000 population for Non-Hispanic Whites) (CDC, 2013), putting

this population even further from the “Healthy People 2020” (U.S. Department of Health and

Human Services, Office of Disease Prevention and Health Promotion [DHHS–ODPHP], 2014a)

objective of lowering the death rate to 103.4 per 100,000 people by the year 2020.

Nationwide, rates of cardiovascular disease (CVD) risk, incidence, and mortality are

higher among African Americans than Non-Hispanic Whites (CDC, 2013; U.S. Department of

Health and Human Services–National Institutes of Health [DHHS–NIH], 2012). In terms of

CVD risk factors, African Americans were more likely than Non-Hispanic Whites to have

hypertension but less likely to have their hypertension controlled (CDC, 2013). African

Americans also have a 45% higher prevalence of myocardial infarction (MI) in those 35 to 44

years of age than Non-Hispanic Whites in the same age group (DHHS–NIH, 2012).

Cardiac Rehabilitation (CR) is a secondary prevention and treatment program that has

demonstrated improvement in health outcomes for patients with CVD (Brown, Clark, Dalal,

Welch, & Taylor, 2011; Heran et al., 2011; Whalley et al., 2011). It is an American College of

Cardiology/American Heart Association Class I treatment for multiple cardiovascular conditions

and procedures including MI (Antman et al., 2004), chronic stable angina (Anderson et al., 2007;

Gibbons et al., 2003), coronary bypass grafting (Hillis et al., 2011), heart failure (Hunt et al.,
2009), percutaneous coronary intervention (Levine et al. 2011), and peripheral artery disease

(Hirsch et al., 2006). Unfortunately, CR is significantly underutilized, with only about one third

of eligible participants being referred to or participating in CR (Ayala, Xie, McGruder, &

Valderrama, 2008; Cortés & Arthur, 2006; Suaya et al., 2007).

In addition, researchers have found race/ethnicity to be predictors of both CR referral and

participation (Gregory, LaVeist, & Simpson, 2006; Suaya et al., 2007). According to Gregory

and colleagues (2006), “White patients [were] two times more likely to be referred than Black

patients [to CR]” (p. 707). With regard to participation, Suaya and colleagues (2007) reported

that “Whites were 33% more likely to receive CR than nonwhites after adjustment for age and

sex” (p. 1655). Researchers on a study of CR participation in North Carolina found that the vast

majority of program participants (90%) in both 1999 and 2004 were Non-Hispanic Whites and

only a small minority (9%) were African Americans (Evenson et al., 2006). Considering North

Carolina’s state population is 22% African American (U.S. Census Bureau, 2013) and African

Americans in North Carolina have higher coronary heart disease mortality rates than Non-

Hispanic Whites (NC DHHS, 2014), the proportionally low percentage of African American CR

participants is striking.

Researchers have observed that those African American patients who participate in CR

begin their programs with more cardiovascular risk factors than Non-Hispanic Whites (e.g.,

hypertension and diabetes) and also end CR with less improvements than Non-Hispanic Whites

across a variety of measures (e.g., BMI level, waist circumference, and hemoglobin A1C)

(Sanderson, Mirza, Fry, Allison, & Bittner, 2007). Sanderson and colleagues (2007) argued for

further research on this “benefit gap” (p. 985) for African Americans and recommended

amelioration through the development of population-specific interventions. Thus, the purpose of

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this policy brief is to (a) draw on available research to substantiate a case for tailoring CR to the

needs of the African American population and (b) make recommendations for outpatient

treatment of CVD in African Americans.

Method

Between 2012 and early 2015, the authors conducted a systematic review of the literature

(Koehler, Hodgson, Dodor, Knight, & Rappleyea, 2014) and a mixed methods study (Koehler et

al., 2015) in order to: (a) identify existing literature on the demographic and biopsychosocial-

spiritual factors impacting African American patients’ CR referral and participation; (b)

investigate these factors; and (c) explore emergent themes associated with this population’s

recovery from cardiac events and/or surgeries.

The systematic review of the literature followed Cooper’s (2010) seven-step protocol for

research synthesis to answer the following question: “What demographic and biopsychosocial-

spiritual factors impact CR referral and participation for adult African American patients with

CVD?” Three databases—Medline via PubMed, PsycINFO via EBSCO, and CINAHL via

EBSCO—were searched using a combination of subject headings and keywords (see Table 1 for

summary of search terms and equivalencies by database). These searches yielded 1,751 articles

once duplicates were removed. From these articles, 40 were identified for full review and then

read in consideration of criteria for final inclusion. A second reviewer was also enlisted to check

the first author’s steps and to provide inter-rater reliability for the articles admitted into the

review.

The mixed methods study was a two-phase quantitative and qualitative study consisting of:

(a) self-report surveys completed by patients with CVD who were discharging from the hospital

following cardiac events and/or surgeries (quantitative) and (b) semi-structured

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phenomenological interviews with African American patients recovering from cardiac events

and/or surgeries (qualitative). The research question guiding the study as a whole was: “What

demographic and biopsychosocial-spiritual factors impact CR referral and participation

for/among adult African American patients with CVD?”

Inclusion criteria for the study were: (a) English-speaking; (b) aged 18 and older; (c)

being prepared for discharge from a cardiac event and/or surgery for which CR is indicated (MI,

coronary artery bypass grafting [CABG], stable angina, heart valve repair/replacement,

percutaneous coronary intervention [PCI] (including percutaneous transluminal coronary

angioplasty [PCTA]), heart transplant, and/or coronary artery disease [adapted from American

Association of Cardiovascular and Pulmonary Rehabilitation [AACVPR], 2014]); and (d) a

resident of a city or town in the county where the academic medical center was located.

Exclusion criteria included: (a) a discharge diagnosis of heart failure or a heart-lung transplant

(heart failure patients at this academic medical center were sometimes referred to pulmonary

rehabilitation and heart-lung transplants may also have been referred to pulmonary rehabilitation

rather than CR) and/or (b) cognitive impairment that would interfere with the individual’s ability

to consent to the study and participate in surveys and interviews.

The qualitative portion of this study was designed in alignment with Husserl’s (1970)

descriptive phenomenology, in which the focus of inquiry was on individuals’ subjective

experiences of reality as they defined those experiences (Lopez & Willis, 2004). The above

criteria for the quantitative portion were held consistent for the qualitative portion with the

additional inclusion criterion of African American race. The following research question guided

the qualitative portion of the research: “What is the lived experience of African American

patients recovering from cardiac events and/or surgeries?”

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 Results

The results from the mixed methods study confirmed and helped to expand upon Koehler

and colleagues’ (2014) systematic review findings, which highlighted the importance of social

and biological factors in African American patients’ CR referral and participation. Quantitative

results from the mixed methods study highlighted the importance of social factors, specifically

the relationship between CR attendance and participants’ household income and highest level of

education. Qualitative results yielded six emergent themes, three of which centered on social

factors, two on biological factors, and one each on social and spiritual factors. These qualitative

findings derived from a broader investigation of African American patients’ recovery from

cardiac events and/or surgeries (and less specifically of CR referral and participation), but again

highlighted the effect of social and biological factors on this population’s experience of recovery

following cardiac events and/or surgeries.

Systematic Review Findings

According to Koehler and colleagues (2014), the seven studies that fit the systematic

review’s eligibility criteria demonstrated that African American patients had a lower likelihood

for CR referral, a higher likelihood of enrolling in CR with more cardiovascular risk factors, and

a lower likelihood of CR participation and completion due to factors related to low

socioeconomic status (e.g., lack of insurance, work conflicts, lower level of education) when

compared with Non-Hispanic Whites.

In addition to identifying social and biological factors salient to CR referral and

participation, Koehler and colleagues (2014) found psychological factors were cited to a limited

extent in the literature. One study demonstrated no interaction among variables of depression,

race/ethnicity, and CR referral or enrollment (Allen, Scott, Stewart, & Young, 2004). In contrast,

166
another study demonstrated higher levels of mood disturbance in African American female

patients with CVD compared to White female patients (Rankin, 2002). Unfortunately, this study

did not investigate the interaction between mood disturbance and the observed racial/ethnic

disparity in CR participation (Rankin, 2002). Spiritual factors were not identified at all in the

articles identified for this systematic review (see Table 2 for a summary of included articles).

While these findings may indicate that social and biological factors were most salient to CR

referral and participation for African American patients with CVD, they may also indicate a lack

of comprehensive studies on the many and varied factors contributing to these phenomena.

Quantitative Findings

Demographic data was collected from 50 patients (14 African American, 35 White, and 1

Asian American; see Table 3 for participants’ demographic information) recovering from cardiac

events and/or surgeries in a primarily rural and lower-income county in the Southeast. Data was

tested for linearity, normality, and homoscedasticity. There were no missing data. Normality

plots (standardized residuals plotted against standardized predicted values) demonstrated that

data points were scattered randomly about the regression line. To test for outliers, Mahalanobis

distances were calculated and compared against the chi-square critical value for 50 cases; all

calculated distances were well below the critical value. Based on observations from these tests,

data appeared to be normal.

Chi-square tests for independence were run to investigate the relationship between

independent variables (i.e., race, relationship status, insurance status, employment status, highest

level of education, and household income) and dependent, outcome variables (i.e.,

recommendation, referral, enrollment, and attendance). These variables were operationalized as

follows: (a) recommended = patient received a letter from the CR facility and/or had an inpatient

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consult in which CR was recommended; (b) referred = patient received a documented, formal

referral from medical provider for CR; (c) enrolled = chart opened and assessment session

scheduled for patient after confirming patient’s interest in participating; and (d) attended =

patient attended assessment session and at least one subsequent CR session. Chi-square tests

were selected in order to run preliminary analyses on a small sample (N = 50). Income data was

recoded from increments of $10,000 (e.g, less than $10,000, $10-19,000) to low, medium, and

high based on the national poverty guidelines (U.S. Department of Health and Human Services,

Office of the Assistant Secretary for Planning and Evaluation, 2014) and average annual

household income in the U.S. (DeNavas-Walt & Proctor, 2014).

Chi-square tests indicated no significant association between race and recommendation,

referral, enrollment, or attendance. Significant associations, however, were found between

highest level of education and attendance ( [4, N = 50] = 8.638, p = .07) and between annual

household income and attendance ( [5, N = 50] = 6.225, p = .044) (see Figures 1 and 2 and

Table 4 for descriptive statistics on the education, income, and attendance). These findings

suggest that while race did not have a direct bearing on CR referral or participation, education

level and household income may have bearing on who attends CR after being referred.

It should be noted that there was a limitation in the way outcome data was collected.

Recommendation, referral, enrollment, and attendance were measured at approximately two

months post-discharge. It is possible that the outcome variables measured at this time point later

changed, for example if a participant received a late referral or a referral was made but not

immediately acted on due to medical or psychosocial barriers to participation.

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Qualitative Findings

In order to gain a richer understanding of the barriers to participating in CR for African

American patients, the lead researcher conducted interviews with seven African American

participants who were in the process of recovering from cardiac events and/or surgeries.

Analysis of resultant transcripts, using Colaizzi’s (1978) phenomenological analysis method,

yielded six emergent themes related to African American patients’ lived experience of cardiac

event/surgery recovery. The emergent themes were: (a) Participants valued medical providers’

involvement during treatment and recovery; (b) Social support and participants’ need for it

changed post-event/surgery; (c) Participants’ pre- and post-event/surgery experiences affected

health outcomes; (d) Participants’ sense of agency affected their life perspectives and health

behaviors; (e) Participants experienced inconsistent referral to and utilization of Cardiac

Rehabilitation; and (f) Participants’ investment in faith was intensified or maintained (see Table

5 for emergent themes, definitions, and selected quotations).

As is common to phenomenological studies, an exhaustive description was developed to

help consolidate the participants’ experiences into a cohesive narrative incorporating the

emergent themes. Overall, what was reflected in the findings was the importance of medical

providers (i.e. doctors, nurses, physical/occupational therapists) and social networks (i.e., family

members, friends, neighbors, and faith community members) in supporting participants through

cardiac events/surgeries and recovery. Medical providers were valued for their help and

expertise, from treating cardiac events/surgeries to guiding participants in making healthy

lifestyle changes (e.g., diet, exercise, substance use) during recovery. Support from participants’

social networks, as well as participants’ need for this support, changed during recovery and

included help with daily activities of living, visits/check-ins, and encouragement.

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 The findings also revealed that participants’ health outcomes following cardiac

events/surgeries were impacted by health-related experiences before and after the

events/surgeries. Participants reported multiple health problems before events/surgeries, some of

which directly compounded participants’ heart problems. Some participants experienced post-

event/surgery improvements; others had post-event/surgery limitations that called for lifestyle

adjustments. Participants’ sense of agency during intervention and recovery impacted life

perspectives and health behaviors. When participants felt like agents in their own health and

care, they were more likely to proactively advocate for their needs by choosing to opt in or out of

treatment recommendations and how they would incorporate these into their lives (i.e.,

exercising at CR versus exercising at home).

According to participants, referral to and utilization in CR was inconsistent. When

participants were referred to and participated in CR, they reported positive experiences.

Participants whose medical providers did not talk to them about CR generally did not participate.

Other barriers to CR participation included not being referred to CR, not understanding what CR

was, or waiting on medical providers for action/clearance to begin or continue the program.

Learning about CR word-of-mouth in the community was an additional pathway to referral and

participation, although participants stated that they would have preferred to have learned about

CR from medical providers. Participants who attended CR expressed appreciation for the

encouragement and motivation to exercise that CR nurses and staff provided. In contrast, the

presence of “gloomy,” less motivated patients at CR threatened to compromise participants’

motivation.

In addition to the importance of biomedical, psychological, and social factors during and

after recovery, participants’ investment in their faith was either intensified or maintained

170
throughout this process. Participants reported ongoing personal and familial involvement in their

faith communities, and even the resolution of some pre-event/surgery spiritual challenges.

Participants identified their faith as a source of strength and gratitude during recovery. They

reported that giving their troubles to God helped them to work through their recoveries and move

forward in their lives. Participants also praised God for giving them life.

Invisible Findings: Reflections on Data Collection

Before discussing the implications of these findings, the invisible findings of this study

warrant some discussion. When this mixed method study was first conceived, the lead

researcher had hoped to have a large enough sample to perform a comparative racial analysis.

Unfortunately, over the course of an eight-month-recruitment at a Southeastern academic

medical center, relatively few participants were recruited (N = 58, 8 of whom were later deemed

ineligible for the study for a final N = 50), and, more notably, only 13 of those 50 were African

American.

The county in which this academic medical center is located is comprised of

approximately 61.1% White and 34.6% African Americans. Given these proportions, one could

expect to see approximately 18 African American in a sample of 50 recruited participants.

Further, considering the proportionally higher burden of CVD on African Americans in

comparison to Non-Hispanic Whites, 18 would be a conservative estimate.

There are several speculations as to why fewer-than-anticipated African American

patients were available for study recruitment (i.e. hospitalized in the academic medical center

where this study was based during the eight month recruiting period and eligible for enrollment

per the study’s inclusion criteria). Firstly, it is possible that the African American individuals in

need of CVD care either did not seek their care at the academic medical center where this study

171
was based or did not seek care at all. Another medical center may have been preferred by

African Americans in this community, or was more accessible financially, geographically, or

otherwise. However, considering the distant proximity of other facilities with a cardiac

specialization in this region, this is unlikely. Regarding not seeking care, researchers have

reported disparate findings on treatment seeking behaviors for African American patients with

CVD. Some findings suggest that African Americans patients with congestive heart failure

(CHF) are more likely than Non-Hispanic Whites to seek medical support for symptoms

(Artinian, Magnan, Sloan, & Lange, 2002). Other researchers reported that African American

heart failure patients delayed treatment-seeking longer than Non-Hispanic Whites (Evangelista,

Dracup, & Doering, 2002).

Secondly, it is also possible that this study’s exclusion criteria of CHF may have cut back

on African American participants in this study. Congestive heart failure was an exclusion

criterion for this study because, at this academic medical center, patients with CHF were

sometimes referred to pulmonary rehabilitation rather than CR. Whether or not medical

providers were more or less likely to refer to pulmonary rehabilitation versus CR (and whether or

not patients were more likely to participate in one over the other) was a question beyond the

scope of this brief. However, considering the support for CR as an effective intervention (Brown

et al., 2011; Heran et al., 2011; Whalley et al., 2011), further exploration is warranted.

Thirdly, the challenge of recruiting African Americans into medical and scientific

research studies is both well documented and understandable given the counts of historical and

medical trauma committed against this population (Washington, 2006). It is possible that more

African Americans opted out of this study for fear of exploitation. Although the National

Institutes of Health have set forth guidelines for research requiring the recruitment of women and

172
minorities in clinical research (DHHS–NIH, 2001), these do not offer solutions to problems of

recruitment and retention.

Implications and Recommendations

Healthy People 2020’s administrators have set a goal to “increase the proportion of adult

heart attack survivors who are referred to a cardiac rehabilitation program at discharge” (DHHS–

ODPHP, 2014b). Although CR is just one of many possible interventions that may improve

health outcomes, it is currently the best practice secondary treatment and prevention program for

patients with CVD (AACPR, 2014; Brown et al., 2011; Heran et al., 2011; Kwan & Balady,

2012). Therefore, the following recommendations put emphasis on CR referral and participation,

while also offering broader suggestions for improving outcomes for African American patients

with CVD.

These recommendations should also be considered within the context of this study’s

quantitative findings. Chi-square tests did not demonstrate a significant relationship between

race and CR referral, enrollment, or attendance. Instead, survey participants’ highest level of

education and annual household income were significant predictors of attendance. Both

education and income levels are measurements of socioeconomic status. Further, the distribution

of education and income levels often fall down racial/ethnic lines, with lower levels of education

and income disproportionately represented among racial/ethnic minorities. In a larger sample, an

association may have been observed between race and attendance due to the indirect and

confounding effects of education and household income levels on attendance. The following

recommendations, therefore, are made with an awareness to the socioeconomic disparities

disproportionately experienced by African Americans. However, some policy recommendations

may also be useful for non-African American populations confronting similar disparities.

173
1. Although patients ultimately determine whether or not they choose to follow through on

medical providers’ treatment recommendations, it is essential that hospitals/medical centers:

(a) adopt automatic CR orders for patients discharging with CR eligible diagnoses; (b) have

orders printed on discharge summaries; and (c) disseminate information regarding CR to

non-medical settings (e.g., flyers or pamphlets in grocery stores, beauty salon, churches).

Implementing automatic orders at discharge increases the likelihood that post-discharge care

is systematic and consistent. Orders should also be printed clearly on discharge summaries

and written and explained in a way that is clear to patients and their caregivers (i.e., taking

into account literacy levels and, specifically, health literacy). Finally, making information

regarding CR available to people within their communities may increase utilization of this

resource by bolstering patient awareness of CR.

2. The 2014 Medicare expansion of CR coverage to include patients with CHF was a boon for

CR access (Centers for Medicare & Medicaid Services, 2014). However, implementation of

national guidelines is still inconsistent state to state and often program to

program. Differences in reimbursement from private insurance companies also increase the

challenge despite the presence of an eligible diagnosis. Policy administrators on the state and

national level can support legislation that increases CR coverage and reimbursement, while

not-for-profit hospital/medical center administrators may consider extending philanthropy

towards sponsoring outpatient CR care for eligible patients.

3. Regarding treatment recommendations, patients’ comorbid medical and mental health

conditions, as well as their former and ongoing experiences in the medical world, should be

considered. Medical providers can do this by asking patients, either at the inpatient or

outpatient level, what barriers to health and/or implementing treatment recommendations

174
 they have experienced in the past (e.g., access to medical and behavioral health care, lack of

social support and/or motivation). This may give medical providers a context in which to

present their own recommendations. This information may also be relevant in assisting

medical providers and patients to successfully troubleshoot these barriers together.

4. In both inpatient and outpatient settings, medical providers should be encouraged to reinforce

CR orders and to communicate these, and other treatment recommendations, clearly to

patients. Further, recommendations to participate in CR should be backed with documented,

formal referrals. Some hospitals and CR facilities offer inpatient CR consults or send letters

to patients post-discharge regarding CR. These recommendations may be compelling for

some patients, while others may view them as suggestions only, and still others may not have

the level of health literacy required to turn this suggestion into action. Also, in the case that

patients are referred and must wait on medical providers for action/clearance to begin or

continue CR, it is important that patients understand why they are waiting (e.g., for insurance

coverage to be verified, for a medical concern to be assessed before a patient begins or

resumes exercise) and who will be contacting them regarding their action/clearance. When

patients are helped to understand treatment recommendations and the process surrounding

the implementation of these recommendations, they are more likely to feel like collaborators

in their own health and care. As a result of this, they may also be more likely to incorporate

treatment recommendations into their lives in sustainable and helpful ways.

5. Medical providers and members of patients’ support networks can capitalize on the power of

agency by involving patients directly in their care by giving explanations, choices, and

empowering support (i.e., assisting patients in gaining higher levels of independence and

improved health and self-care). This may take the form of medical providers, families, and

175
 patients sitting down together to gather data on potential barriers; filling gaps in

understanding; addressing misunderstandings regarding treatment recommendations; and

developing, implementing, and reinforcing care plans. Although family office visits may

strike medical providers as time consuming, this approach may result in more efficient and

effective care in the long-term.

6. It is extremely important that patients’ levels of social support are assessed and accounted for

before patients are discharged. The physical limitations and emotional experiences of

recovery can be in and of themselves isolating. If patients are also geographically distant

from family or friends, feel set a part from their communities, or do not have the financial

means to access needed care, this isolation can be compounded. Measures to connect

patients with functional (e.g., home health care) and emotional support (e.g., contact with

others who have recovered from similar events/surgeries) may help patients to gain access to

important resources, including CR.

7. Medical providers, social network members, and program developers should also take into

account the importance of patients’ perceptions of support. Support that felt pitying,

conflictual, or disempowering to participants was viewed negatively. In other words, the

mere presence of others (even well-meaning others) did not automatically result in patients

feeling supported as agents in their own care. For example, participants stated that it was

challenging to exercise alongside others who were less motivated and/or less able to exercise

than themselves. This may be an important consideration for CR classes and for

formatting/programming of support groups or other group-level interventions. Some patients

may benefit from being paired with a peer who is further along in recovery than they are.

8. Medical providers and social network members should check in with patients about the big-

176
 picture questions with which they are grappling. Providing space for patients to discuss

existential questions can combat isolation and can also help with care planning, as these

larger questions are also often related to a patients’ sense of agency in their lives, health, and

care. A provider or supporter might ask, “How are you making sense of this? What has this

experience meant for you and your life?” Finally, if a patient is already involved in a faith

community, this can be a tremendous resource. Program developers may consider building

on existing relationships between patients and their faith communities by partnering with

these communities to offer exercise-based programs or other interventions promoting healthy

lifestyle changes. The following studies offer additional recommendations on weaving

spirituality/religion into interventions for African Americans: Kalenderian et al., 2009;

Peterson & Cheng, 2011; Plescia et al., 2008; Yanek et al, 2001.

The above recommendations have been made particularly with African Americans in

mind and may be applicable to other populations experiencing similar health disparities. In

implementing these recommendations, hospital/medical center administrators, medical providers,

and social network members should maintain awareness to the context of oppression in which

African American patients have been steeped. As a population, African Americans have

experienced countless medical and historical traumas in the United States, from a century of

enslavement to exploitation by medical and scientific research communities (e.g., Marion Sims’

experimental fistula operations on female slaves, the Tuskegee Syphilis study on lower SES

African American males) (Washington, 2006). Given this history, African Americans may be

understandably cautious about participating in research studies and/or medical interventions.

Here the importance of care, understanding, establishing trust, and building rapport with this

population is paramount, especially for medical providers (Collins, Clark, Petersen, & Kressin,

177
2002; Lutfiyya, Cumba, McCullough, Barlow, & Lipsky, 2008; Shaw, Armin, Torres, Orzech, &

Vivian, 2012). The role of policy change is also essential in creating a sociopolitical climate in

which the above provider and patient level changes can be best supported.

Conclusion

This policy brief has offered recommendations for the treatment of African American

patients recovering from cardiac events and/or surgeries. From CVD risk factors to prevalence,

interventions, and outcomes, African Americans as a population experience significant gaps in

health, health care, and access to treatment. It is the hope of the researchers writing this brief

that policy, programmatic, and individual-level changes will be made to help lift the burden of

disease and close the gap in care for this population. There is little use to a best practice

intervention if it is not accessible to a population who needs it most. This brief is a call to

meeting a healthcare need with a resource, through advocacy, understanding, and care.

178
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Figure 1. Education and CR Attendance Participant Descriptives.

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Figure 2. Income and CR Attendance Participant Descriptives.

188
 Table 1

Summary of Search Terms and Equivalencies by Database

Medline via PubMed PsycINFO via EBSCO CINAHL via EBSCO

African Americans Blacks Blacks
Cardiac Surgical Procedures Heart Surgery; “Cardiac Surgical Procedures” Surgery, Cardiovascular; Heart Surgery
Cardiovascular Diseases Cardiovascular Disorders Cardiovascular Diseases
Cardiovascular Surgical Procedures Heart Surgery; “Cardiovascular Surgical Procedures” Surgery, Cardiovascular; Heart Surgery
Coronary Artery Bypass Cardiovascular Disorders; Heart Surgery; “Coronary Artery Bypass” Coronary Artery Bypass
Coronary Artery Disease Cardiovascular Disorders; Heart Disorders; “Coronary Artery Disease” Coronary Arteriosclerosis
Coronary Disease Cardiovascular Disorders; Heart Disorders; “Coronary Disease” Coronary Disease
Heart Diseases Heart Disorders Heart Diseases
Heart Failure “Heart Failure” Heart Failure
Myocardial Infarction Myocardial Infarctions Myocardial Infarction
Myocardial Ischemia “Myocardial Ischemia” Myocardial Ischemia
Rehabilitation Rehabilitation Rehabilitation
189

Rehabilitation Centers Rehabilitation Centers Rehabilitation Centers

Thoracic Surgery Heart Surgery; “Thoracic Surgery” Thoracic Surgery
 Table 2

Article Summaries

Referral/ Sample size Participant Participant Demographic and Findings

enrollment/ (n) characteristics: characteristics: biopsychosocial-
attendance/ race/ethnicity Cardiovascular spiritual variable(s)
completion and gender condition

Allen et al. Referral/ 253 AA and W MI, angina, PCI, Race/ethnicity; AA women half as likely to be
(2004) enrollment women CABG Income; depression referred to CR; AA = lower
enrollment; Income = predictor of
referral/enrollment; no interaction
between race and income or race
and depression.
Bittner et al. Referral 1,329 AA and W men MI, angina, Race/ethnicity; 9.5% of W participants were
(1999) and women CAGB distance to CR, referred compared with 7.4% of AA
190

insurance coverage, participants but this difference was

discharging not statistically significant.
physician’s specialty
Cannistra et Attendance, 82 AA and W MI, angina, PCI, Race/ethnicity; AA women = more CV risk factors
al. (1995) completion women CABG, valve Factors impacting at program entry; more likely to not
surgery; dx of CR participation = complete CR and cited work
cardiomyopathy, medical, work, conflict and personal reasons; less
or multiple CV personal, logistical likely to lose weight from CR than
risk factors. W women. Both AA and W women
= improved functional capacity with
CR.
Evenson et Attendance 61 = 2004; CR program Eligible for CR Race/ethnicity; CR participants = 90% W, 9% AA;
al. (2006) 45 = Both directors in NC gender; availability 72% of program directors cited
1999 and of transportation policy issues as primary barrier to
2004 participation; work conflicts =
primary reason for drop-out.
 Gregory et Referral 1,933 AA and W MI, Race/ethnicity; W participants = 2x more likely to
al. (2006) men and women revascularization, insurance status be referred to CR; AA participants
in past year; Dx more likely to have Medicaid or no
of HF insurance than W participants.
Rankin et al. Enrollment 76 AA and W MI Race/ethnicity No AA participants enrolled in CR
(2002) women during yearlong study compared
with approximately 20% of W
participants.
Young et al. Enrollment 246 AA and W MI Race/ethnicity, SES Lower SES AA participants were
(1991) men and women least likely to be enrolled in CR;
Higher SES AA participants and
lower SES W participants had an
equal likelihood of being enrolled.
Key of abbreviations: AA = African American; W = White; CR = Cardiac Rehabilitation; CV = Cardiovascular; CABG = Coronary Artery Bypass
Grafting; MI = Myocardial Infarction; PCI = Percutaneous Coronary Intervention; Dx = Diagnosis; SES = Socioeconomic status
191
Table 3

Survey Participants’ Demographic Information

Characteristics n %
Gender
female 14 28.0
male 36 72.0
Race
Non-Hispanic White 35 70.0
African American 14 28.0
Asian 1 2.0
Relationship Status
married 30 60.0
separated 3 6.0
divorced 5 10.0
widowed 6 12.0
never married 2 4.0
cohabiting 4 8.0
Insurance Status
none 8 16.0
private 11 22.0
Medicare 11 22.0
Medicare & private 15 30.0
Medicaid & private 1 2.0
Medicare & Medicaid 4 8.0
Employment Status
full time 12 24.0
self-employed 2 4.0
out of work >1 yr. 4 8.0
retired 21 42.0
unable to work 11 22.0
Education
<high school 7 14.0
high school/GED 15 30.0
some college 12 24.0
college graduate 11 22.0
graduate school 5 10.0
Income
low ($0-19,000) 15 30.0
medium ($20-59,000) 20 40.0
high ($60-149,000) 15 30.0

192
Table 4

Survey Participants’ Income, Education, and Cardiac Rehabilitation Attendance

Characteristics Did not Attended % Attended

Attend
Education
<high school 7 0 0
high school/GED 14 1 12.5
some college 7 5 62.5
college graduate 10 1 12.5
graduate school 4 1 12.5
Income
low ($0-19,000) 15 0 0
medium ($20-59,000) 17 3 37.5
high ($60-149,000) 10 5 62.5

193
 Table 5
Emergent Themes, Definitions, and Selected Quotations
Emergent theme Definition Selected quotation
Participants valued medical Medical providers (i.e. doctors, nurses, “They [medical providers] really cared about me. I could
providers’ involvement during physical/occupational therapists) offered tell the doctors really cared. They wanted me to get
treatment and recovery interventions, support, and guidance to well…they kept telling me, um, you gotta do this, you gotta
participants during treatment and recovery. take your medicine. You can tell when someone actually
Participants expressed gratitude for this support care about you.”
and sometimes requested additional support.
Social support and participants’ Support from participants’ social networks (i.e., “You can’t lift over 10 pounds, so, um, they would go with
need for it changed post- family members, friends, neighbors, and faith me… either my sons or my husband… Go to school with
event/surgery community members), as well as participants’ me and take my books into class and bring ‘em outta
need for this support, changed during recovery. class….”
Support from social networks included help
194

with daily activities of living, visits/check-ins, “Everybody’s movin’ around socializing, and I’m kinda
and encouragement. Sometimes participants stuck in this spot waiting for, ‘Okay, you wanna come talk
felt isolated by lack of social support, physical to me?’ And have one person come talk to me a little while,
limitations, or new lifestyle changes. then they go off … it was kinda lonely. And it, uh, you felt
like you was, like, missing a lot of things. Like, you kinda
sittin’ there and you watching life go by.”
Participants’ pre- and post- Participants’ health outcomes following cardiac “I was having so much problems breathing sometimes
event/surgery experiences events/surgeries were impacted by health- [pre-surgery] that if I get excited my chest would start
affected health outcomes related experiences before and after the hurting, so I can’t breath like I wanted to because my
events/surgeries that sometimes directly blood pressure going up and down, up and down, I get
compounded heart problems. Some participants tired quick, couldn’t-couldn’t hardly do nothing I wanted
experienced post-event/surgery improvements; to.”
others had post-event/surgery limitations that
called for lifestyle adjustments. “‘Cause I was taking a lot of pain pills for my shoulder
and stuff. And when my shoulder started hurtin’ real bad
it would start my heart hurtin.’ And [medical providers]
took me off that right there [post-surgery]. Now that I’ve
been doing a whole lot better ‘cause I take me a Tylenol
either, and a Bayer and I’m a’ight.”
 Participants’ sense of agency Participants’ sense of agency during “It [cardiac event/intervention] changed the way I do a lot
affected their life perspectives intervention and recovery impacted life of things. Um, it made me take life a little bit more
and health behaviors perspectives and health behaviors. When serious...just make sure I take my medication all the time.
participants felt like agents in their own health Don’t eat- watch what I eat… Basically, I was just eating
and care, they were more likely to proactively everything.”
advocate for their needs by choosing to opt in or
out of treatment recommendations and how
they would incorporate these into their lives
(i.e., exercising at CR vs. exercising at home).
Participants experienced Participants whose medical providers did not “Nobody hadn’t told me about it, um, hadn’t said anything
inconsistent referral to and talk to them about CR generally did not about there’s a rehab place for it. Nothing… I think that
utilization of Cardiac participate. Other barriers to CR participation they should let the people know. Especially right before
Rehabilitation included not being referred to CR, not [discharge]- at the hospital would be great, because
understanding what CR was, or waiting on somebody have it on their discharge papers. You know,
medical providers for action/clearance to begin some type of way to, to let people know that ‘These
or continue the program. services are available, check into it.’”

Participants’ investment in faith “Every time, you know, stuff’d go wrong, I’d think about
195

Participants reported ongoing personal and

was intensified or maintained familial involvement in their faith communities, my spiritual relationship with God, and, um, and, um, the
and even the resolution of some pre- prayer, and, uh, it’s just, like, I, I had no, no fear in
event/surgery spiritual challenges. Participants believing that I would be alright, you know?”
identified their faith as a source of strength and
gratitude during recovery. “Everyday I wake up I pray, I thank God everyday I wake
up. I mean, that’s the way I look at it…I mean, I got a 7-
year-old son and an 18-year-old daughter.”
 APPENDIX A: IRB APPROVAL

EAST CAROLINA UNIVERSITY

University & Medical Center Institutional Review Board Office
4N-70 Brody Medical Sciences Building· Mail Stop 682
600 Moye Boulevard · Greenville, NC 27834
Office 252-744-2914 · Fax 252-744-2284 · www.ecu.edu/irb

Notification of Initial Approval: Expedited

From: Biomedical IRB

To: Aubry Koehler
CC: Jennifer Hodgson
Date: 4/17/2014
Re: UMCIRB 14-000159
Cardiac Rehabilitation Referral and Participation for/among African American Patients
I am pleased to inform you that your Expedited Application was approved. Approval of the study and any consent
form(s) is for the period of 4/16/2014 to 4/15/2015. The research study is eligible for review under expedited
category #5,6,7. The Chairperson (or designee) deemed this study no more than minimal risk.

Changes to this approved research may not be initiated without UMCIRB review except when necessary to
eliminate an apparent immediate hazard to the participant. All unanticipated problems involving risks to
participants and others must be promptly reported to the UMCIRB. The investigator must submit a continuing
review/closure application to the UMCIRB prior to the date of study expiration. The Investigator must adhere to
all reporting requirements for this study.

Approved consent documents with the IRB approval date stamped on the document should be used to consent
participants (consent documents with the IRB approval date stamp are found under the Documents tab in the
study workspace).

The approval includes the following items:

Name Description
Koehler.InformedConsent4.16.14.doc Consent Forms
Koehler.InterviewGuide2.11.14.docx Interview/Focus Group Scripts/Questions
Koehler.Phonescript.T2.2.12.14.docx Recruitment Documents/Scripts
Koehler.ProposalIRB 2.12.14.docx Study Protocol or Grant Application
Koehler.RecruitmentScript2.12.14.docx Recruitment Documents/Scripts
Koehler.RequestforPrepwork.pdf HIPAA Authorization
Koehler.Surveys.2.11.14.docx Surveys and Questionnaires
Koehler.WaiverofAuthroization4.8.14.pdf HIPAA Authorization

The Chairperson (or designee) does not have a potential for conflict of interest on this study.

IRB00000705 East Carolina U IRB #1 (Biomedical) IORG0000418

IRB00003781 East Carolina U IRB #2 (Behavioral/SS) IORG0000418
 EAST CAROLINA UNIVERSITY
University & Medical Center Institutional Review Board Office
4N-70 Brody Medical Sciences Building· Mail Stop 682
600 Moye Boulevard · Greenville, NC 27834
Office 252-744-2914 · Fax 252-744-2284 · www.ecu.edu/irb

Notification of Amendment Approval

From: Biomedical IRB

To: Aubry Koehler
CC: Jennifer Hodgson
Date: 11/25/2014
Re: Ame10_UMCIRB 14-000159
UMCIRB 14-000159
Cardiac Rehabilitation Referral and Participation for/among African American Patients

Your Amendment has been reviewed and approved using expedited review for the period of 11/25/2014 to
4/15/2015. It was the determination of the UMCIRB Chairperson (or designee) that this revision does not impact
the overall risk/benefit ratio of the study and is appropriate for the population and procedures proposed.

Please note that any further changes to this approved research may not be initiated without UMCIRB review
except when necessary to eliminate an apparent immediate hazard to the participant. All unanticipated problems
involving risks to participants and others must be promptly reported to the UMCIRB. A continuing or final review
must be submitted to the UMCIRB prior to the date of study expiration.The investigator must adhere to all
reporting requirements for this study.

Approved consent documents with the IRB approval date stamped on the document should be used to consent
participants (consent documents with the IRB approval date stamp are found under the Documents tab in the
study workspace).

The approval includes the following items:

Document Description
Koehler.Demographicquestions.docx(0.01) Surveys and Questionnaires
Koehler.InformedConsent.QualOnly11.20.14.doc(0.04) Consent Forms

The Chairperson (or designee) does not have a potential for conflict of interest on this study.

IRB00000705 East Carolina U IRB #1 (Biomedical) IORG0000418

IRB00003781 East Carolina U IRB #2 (Behavioral/SS) IORG0000418

197
APPENDIX B: PERMISSION TO USE MEASURES

Permission to Use PHQ-4

Permission to Use MOS Social Support Survey

199
Permission to Use Religion Health Fatalism Questionnaire

200
 APPENDIX C: RECRUITMENT/TELEPHONE SCRIPTS
Recruitment Script

Hi, Ms./Mr. {insert name}. My name is Aubry Koehler and I am a student at ECU. I am

working on a study that looks at which medical services cardiac patients use while they are

recovering from a cardiac event (like a heart attack) or surgery (like a stent placement). I am

wondering if it would be alright if I sit down with you and tell you a little more about this study,

so you can make the decision whether or not you would like to participate.

[If the patient agrees for the PI to continue with the recruitment process, she will do so. If the

patient does not agree, the PI will thank the patient for his or her time and leave the room].

This study has a few different parts to it. If you agree to participate today, I will ask you

to sign a form documenting your agreement, and then I will read a survey to you and mark down

your answers. The survey asks some questions about you like your age, gender, mood, social

support, and spirituality. This survey will take about 15 minutes. Six weeks after you go home,

either my research assistant or I will call you to ask you some of the same questions and some

new questions about the medical services you have used. During this phone call, you may be

asked to be a part of an individual interview to learn more about their experience. If you are

asked to participate in an interview we would schedule a time and place of your choosing to have

the interview. Individuals who complete an interview will be given a $25 gas card for their

participation directly following the interview.

Because we want to learn more about how participants use medical services, we would

also need to be able to check your Vidant Medical Center electronic health record and paper

records at Vidant Health Groups to see what services you use. Only with your consent to

participate in the study, will my research assistant and I check your health records up until eight

months after your discharge. This private information will not be shared with anyone outside of
the research team. We will never use your name or any other information that could be used to

identify you when we publish or present the study’s results. If you provide us with your contact

information, we can mail you a summary of the results as well.

Individuals who decide to participate in this study, and who complete both surveys (today

and six weeks from now), will be entered in a drawing to win a $25 gas card. This is a small gift

to show our appreciation for your time. If you would like to be entered in the drawing, we will

take your name and contact information down today. Then, after we finish giving surveys to all

the participants, we will draw 10 names, call you if your name was drawn, and send you the gas

card. If you are asked to participate in an interview and complete the interview we will

automatically give you a $25 gas card immediately after you finish the interview.

Please know that your decision whether or not to participate will not affect your care in

any way. We want you to feel comfortable saying “no” if you decide not to participate. Also, if

you do decide to participate, know that you may choose to stop participating in the study at any

time. It is your choice and you always have the right to change your mind.

I have just summarized the basic information in the informed consent document. If you

would like, you can read it in its entirety, or I can read it to you. What would you prefer?

[If the patient asks to have the informed consent document read to him or her, PI will do

so. If the patient elects to read the informed consent document him or herself, the PI will not

read the informed consent document verbatim].

202
 Do you have any questions about what I have just told you? Do you have any concerns?

[PI will pause for questions and concerns. If patient has questions or concerns, PI will answer

and address them to the best of her ability. If patient does not have questions or concerns, PI

will continue with recruitment process].

Would you like to participate? If so, we will need you to sign this informed consent

document to show your agreement.

[If patient agrees to participate, he or she will sign the informed consent document and a

copy will be given to him or her for later reference. If the patient declines to participate, the PI

will thank him or her for her time and leave the room].

203
 Telephone Script (for T2 survey)

Hello, Ms./Mr. {insert name}. My name is Aubry Koehler and I am an ECU student

working on a study that looks as use of medical services by cardiac patients during their recovery.

I met with you before you left the hospital, and at that time you agreed to participate in this study

and answered a survey. *OR* My name is Michelle Tracy and I am a research assistant working

on a study that looks at use of medical services by cardiac patients during their recovery. My

colleague, Aubry Koehler, met you before you left the hospital. At that time, you agreed to

participate in this study and answered a survey about yourself, and your mood, social support,

and spirituality.

Today, I would like to ask you some questions about the medical services you have been

using since you left the hospital. They are the same survey questions you answered when you

were in the hospital. This will take about 15 minutes. Is it alright if I continue?

[If the participant agrees, the PI/Research Assistant will administer the survey. If the

participant does not have time at the moment, the PI/Research Assistant will ask if there is a

better time to call back.]

[After completing the survey questions]. Thank you so much for participating in the

survey.

[If participant entered his/her name in the $25 gas card drawing]. Once we enrolling

participants (in approximately two months), we will be drawing names for the $25 gas cards. If

204
your name is drawn, we will call you, and then send you the gas card at the address you provided

when you entered your name.

[If participant is eligible for an interview]. Also, you may remember when you first

agreed to participate in this study, that Aubry said some participants will be asked to participate

in an individual interview. You were identified as someone we could learn a lot from and would

like to interview you about your experience recovering from a cardiac event (like a heart attack)

or surgery (like a stent placement). Interviews will be facilitated by me and Aubry/my Research

Assistant. They will last about one hour and will take place over the phone at a time of your

choosing. Participants who complete an interview will be given a $25 gas card to compensate

them for their time. Are you interested in scheduling an interview with us?

[If participant is willing to schedule an interview, the PI/Research Assistant will work

with the participant to select a time for the interview. This may be during the T2 survey call or

another time scheduled by the participant. If the participant is unwilling to schedule an

interview, the PI/Research Assistant will thank the participant for his or her time].

205
 APPENDIX D: INFORMED CONSENTS
East Carolina University Informed Consent to Participate in Research
Information to consider before taking part in research that has no more
than minimal risk.

Title of Research Study: Cardiac Rehabilitation Referral and Participation for/among African American
Patients
Principal Investigator: Aubry N. Koehler, MA, LMFTA
Institution/Department or Division: Child Development & Family Relations
Address: 108 Rivers Building, Mail Stop 505, East Carolina University, Greenville, NC 27858
Telephone #: (252) 737-1415
Study Sponsor/Funding Source: N/A

Researchers at East Carolina University (ECU), Vidant Medical Center, and Vidant Medical Groups
study problems in society, health problems, environmental problems, behavior problems, and the human
condition. Our goal is to try to find ways to improve the lives of you and others. To do this, we need the
help of volunteers who are willing to take part in research.

Why is this research being done?

The purpose of this research is to better understand what medical services cardiac patients use while they
are recovering. The decision to take part in this research is yours to make. By doing this research, we
hope to learn what kind of factors affect the type of medical services cardiac patients with different
backgrounds use.

Why am I being invited to take part in this research?

You are being invited to take part in this research because you are getting ready to discharge from the
hospital after a cardiac event (such as a heart attack) or a cardiac surgery (such as a bypass or stent
placement). If you volunteer to take part in this research, you will be one of about 200 people to do so.

Are there reasons I should not take part in this research?

I understand I should not volunteer for this study if I am: (a) a non-English speaker, (b) under 18 years of
age, (c) a non-Pitt County resident, (c) being discharged with a diagnosis of heart failure or following a
heart-lung transplant, and/or (d) cognitively impaired such that it may interfere with my ability to consent
to the study and participate in surveys and interviews.

What other choices do I have if I do not take part in this research?

Participation in this research project is voluntary. You may choose not to participate at any time.

Where is the research going to take place and how long will it last?
The research will occur at the following times and places: today at Vidant Medical Center, over the phone
for a follow-up call, and again over the phone if you are selected for an interview. If you do volunteer to
participate, you will complete a short survey today (estimated to take about 15-20 minutes). Then, about
six weeks after you go home from the hospital, we will call you to ask you some follow-up questions
about your recovery (estimated to take about 10-15 minutes). During that phone call, we may ask you if
you would be willing to participate in an individual audio-recorded, over-the-phone interview so we can
learn more about your personal recovery experience (estimated to take about one hour). The total amount
of time you will be asked to volunteer is between 30 minutes and one hour and 30 minutes depending on
whether or not you are selected for an interview.

What will I be asked to do?

You are being asked to do the following:
 Complete a short survey that I will read aloud to you today. This survey asks about your
demographic information (age, gender) and also about your mood, your social support, and
your spiritual beliefs.
 Complete a short follow-up survey over the phone when we call you approximately six weeks
after your hospital discharge. This survey asks about your mood and medical services used
during your recovery.
 Allow us to view your electronic health record and paper records kept by Vidant Medical
Center/Health Groups to see what medical services you used for your recovery (until eight
months after this discharge).
 If you are selected for an audio-recorded interview, we will inform you during the six-week
follow-up call. At that time, you may elect to complete the interview during the phone call or
schedule another time for the phone interview. During the phone interview, we will ask you
about your personal experience recovering from a cardiac event. We will type up your audio-
recorded interview for analysis and keep it in a password-protected file. Audio files will be
password-protected and stored on a secure server at East Carolina University.
 If you participate in a phone interview and are willing to be involved in the process of
double-checking the results (“member checking”), we will contact you over the phone and
read you a summary of the results. This will give you an opportunity to share any additional
information or help us make corrections. Audio files will be erased after they are typed and
the member checking process is completed. The typed interviews will be stored
electronically on a secure server at East Carolina University, accessed only by my computer,
which is password-protected. The typed interview documents will be kept in a locked filing
cabinet in my locked office. Documents will be shredded and electronic files containing
identifying information will be erased six years after the project is completed.

What possible harms or discomforts might I experience if I take part in the research?
There are possible risks (the chance of harm) when taking part in this research. This research will require
your time and energy to complete. Some participants who have completed surveys and interviews on
topics of mood, social support, and spirituality may experience discomfort with answering questions.
Some participants may also experience negative feelings (such as anger, fear, grief, or sadness) from
being asked to recall and talk about a difficult time (such as recovering from a cardiac event). Please
know you may always ask to “skip” questions you are not comfortable with answering. You can also ask
to stop a survey or interview at any time. Additionally, you may choose to have a family member or
friend present during the survey or interview if this makes you feel more comfortable.

In the case that you experience negative emotions or your survey answers indicate that you are
experiencing symptoms of anxiety or depression, we will help connect you with behavioral health
resources that you may choose to use. If you are still in the hospital when this occurs, we will let your
care team know so they can connect you with appropriate resources. If you are out of the hospital when
this occurs, we will give you contact information for resources over the phone or in person.

What are the possible benefits I may experience from taking part in this research?
We do not know if you will get any benefits by taking part in this study. Hopefully, this research will
help us learn more about how to best serve cardiac patients from different backgrounds. There may be no
personal benefit from your participation but the information gained by doing this research may help

207
others in the future. However, other people who have participated in this type of research have
experienced benefit from being able to talk about their experience with researchers. By participating in
this research study, you may also experience these benefits.

Will I be paid for taking part in this research?

We will not be able pay you for the time you volunteer while being in this study. However, you do have
the opportunity to enter your name into a drawing for a $25 gas card. Participants who complete both the
survey today and the follow-up survey six weeks after you leave the hospital are eligible for this drawing.
After the survey data collection, we will do the drawing and will notify you and send you the gas card if
your name was drawn. If you are asked to participate in an interview and you complete the interview,
you will be mailed a gas card at the time of interview completion. Participants who are interested in
being entered into the drawing will give their name and contact information (phone number, address)
today.

We would also like to share the results of this study with you. If you are interested in receiving a
summary of the results from this study, we are more than happy to send you a copy. Please provide a
email address or mailing address here:_____________________________________________________
____________________________________________________________________________________

What will it cost me to take part in this research? It will not cost you any money to be part of the
research. This research study is not for profit and is being completed as part of the Principal
Investigator’s degree requirements. All researchers are donating their time to the study.

Who will know that I took part in this research and learn personal information about me?
To do this research, ECU and the people and organizations listed below may know that you took part in this
research and may see information about you that is normally kept private. With your permission, these
people may use your private information to do this research:
 The University & Medical Center Institutional Review Board (UMCIRB) and its staff, who have
responsibility for overseeing your welfare during this research, and other ECU staff who oversee
this research.
 Any agency of the federal, state, or local government that regulates human research. This includes
the Department of Health and Human Services (DHHS), the North Carolina Department of Health,
and the Office for Human Research Protections.
 People designated by Vidant Medical Center and Vidant Health
 Additionally, the following people and/or organizations may be given access to your personal health
information and they are: Vidant Cardiovascular and Pulmonary Rehabilitation (Greenville, NC),
Vidant Cardiovascular and Pulmonary Rehabilitation (Washington, NC)

How will you keep the information you collect about me secure? How long will you keep it?
Your name will only be attached to this informed consent document and a list kept by the Principal
Investigator of the study participants. Surveys will be identified by an assigned number and kept in a
locked file cabinet. A list of study participants with contact information and your assigned number will
be listed in a password-protected file on a secure server at East Carolina University. If you are selected to
participate in an audio-recorded interview, the audio file will be password-protected and stored on a
secure server at East Carolina University. Hardcopies of your typed interview will be stored in a locked
file cabinet. Your name will not be attached to these materials. Audio files will be erased after the
interviews are typed and the member checking process is completed (if you are willing to be involved in
the process of double-checking the results, we will contact you over the phone or in person to read you a
summary of the results so you can provide feedback). Findings from this study may be used for other
professional presentations or publications (e.g., articles, book format). In all presentations and

208
publications, your identifying information will never be used. After this study is complete, documents
will be shredded and electronic files containing identifying information will be erased six years after the
project is completed.

What if I decide I do not want to continue in this research?

If you decide you no longer want to be in this research after it has already started, you may stop at any
time. You will not be penalized or criticized for stopping. You will not lose any benefits that you should
normally receive.

Who should I contact if I have questions?

The people conducting this study will be available to answer any questions concerning this research, now
or in the future. You may contact the Principal Investigator at (252) 737-1415 (Thursday and Fridays,
9AM-5PM) or the Principal Investigator’s Supervisor, Jennifer Hodgson, PhD, at (252) 328-1349
(Monday-Friday, 9AM-5PM).

If you have questions about your rights as someone taking part in research, you may call the Office for
Human Research Integrity (OHRI) at phone number 252-744-2914 (days, 8:00 am-5:00 pm). If you
would like to report a complaint or concern about this research study, you may call the Director of the
OHRI, at 252-744-1971 and the Vidant Medical Center Risk Management Office at 252-847-5246.

I have decided I want to take part in this research. What should I do now?
The person obtaining informed consent will ask you to read the following and if you agree, you should
sign this form:

 I have read (or had read to me) all of the above information.
 I have had an opportunity to ask questions about things in this research I did not understand and
have received satisfactory answers.
 I know that I can stop taking part in this study at any time.
 By signing this informed consent form, I am not giving up any of my rights.
 I have been given a copy of this consent document, and it is mine to keep.

_____________
Participant's Name (PRINT) Signature Date

Person Obtaining Informed Consent: I have conducted the initial informed consent process. I have
orally reviewed the contents of the consent document with the person who has signed above, and
answered all of the person’s questions about the research.

Person Obtaining Consent (PRINT) Signature Date

209
 UMCIRB HIPAA Privacy Authorization
East Carolina University (ECU)/Vidant Medical Center (VMC): Research Participant Authorization to
Use and Disclose Protected Health Information for Research
For use only with the research consent form for UMCIRB#:14-000159
Principal Investigator: Aubry N. Koehler, MA, LMFTA
Title: Cardiac Rehabilitation Referral and Participation for/among African American Patients

Location where research will be conducted

The members of the research team will conduct the research study at:
East Carolina University (ECU) VMC ECU & VMC Other: Vidant Cardiovascular and
Pulmonary Rehabilitation (Greenville, NC & Washington, NC),

When taking part in research, protected health information (PHI) is collected, used, and shared with
others who are involved in the research. Federal laws require that researchers and health care providers
protect your PHI. Also, federal laws require that we get your permission to use collected PHI for the
research. This permission is called authorization.

In order to complete the research project in which you have decided to take part, the research team needs
to collect and use some of your PHI as described below.

What types of protected health information (PHI) about me will be used or disclosed?
ECU Health Care Component: Vidant Health Entity:
[ ] ECU Physicians [ ] Entire Vidant Health system
[ ] School of Dental Medicine [ ] Vidant Medical Center
[ ] Speech, Language, and Hearing Clinic [ ] Other Vidant Health Entity
[ ] Human Performance Lab (please list):
[ ] Physical Therapy
[ ] Student Health
[ ] Other ECU Health Entity
(please list): Dept of Child Development & Family Relations

Type of ECU Records: Type of Vidant Records:

[ ] Medical/clinic records [ ] Medical/clinic records
[ ] Billing records [ ] Billing records
[ ] Lab, Pathology and/or Radiology results [ ] Lab, Pathology and/or Radiology results
[ ] Mental Health records [ ] Mental Health records
[ ] PHI previously collected for research [ ] PHI previously collected for research
[ ] Records generated during this study [ ] Records generated during this study
[ ] Other: [ ] Other:

Who will use or disclose my PHI?

[ ] Principal Investigator
[ ] Other members of the research team
[ ] Other providers involved in your care during research procedures, outpatient/inpatient stays during
which research is being performed, or physician office visits during which research is being performed.

Who will receive my PHI?

[ ] Sponsor or other funding source to provide oversight for entire research project
[ ] Research investigators to conduct and oversee the research project

210
[ ] Principal Investigator and research team members to participate in the various research activities
[ ] FDA or other regulatory agencies to provide regulatory oversight
[ ] UMCIRB to provide continuing review of the research project
[ ] Institutional officials in connection with duties for monitoring research activity
[ ] Other providers involved in your care during research procedures, outpatient/inpatient stays during
which research is being performed, or physician office visits during which research is being performed.
[ ] Researchers at other sites—List sites:
[ ] Data and Safety Monitoring Board and its staff
[ ] Contract Research Organization and its staff
[ ] Other: People designated by Vidant Medical Center and Vidant Health System

We will share only the PHI listed above with the individuals/agencies listed above. If we need to share
other PHI or if we need to send PHI to other individuals/agencies not listed above, we will ask for your
permission in writing again

How my PHI may be released to others:

ECU and VMC are required under law to protect your PHI. However, those individuals or agencies who
receive your PHI may not be required by the Federal privacy laws to protect it and may share your PHI
with others without your permission, if permitted by the laws governing them.

What if I do not sign this form?

You will not be eligible to participate in this study if you do not sign this Authorization form.

How may I revoke (take back) my authorization?

You have the right to stop sharing your PHI. To revoke (or take back) your authorization, you must give
the Principal Investigator your request to revoke (or take back) your authorization in writing. If you
request that we stop collecting your PHI for the study, you may be removed from the study. If you are
removed from the study, it will not affect your ability to receive standard medical care or affect payment,
health plan enrollment or benefit eligibility. PHI collected for the research study prior to revoking (or
taking back) your Authorization will continue to be used for the purposes of the research
study. Also, the FDA (if involved with your study) can look at your PHI related to the study even if you
withdraw this authorization.

Restrictions on access to my PHI:

You will not be able to see your PHI in your medical record related to this study until the study is
complete. If it is necessary for your care, your PHI will be provided to you or your physician.

How long may the PHI about me be used or disclosed for this study?
Research information continues to be looked at after the study is finished so it is difficult to say when use
of your PHI will stop. There is not an expiration date for this authorization to use and disclose your PHI
for this study.

If you have questions about the sharing of PHI related to this research study, call the Principal
Investigator, Aubry N. Koehler, at phone number (252) 737-1415 or the Principal Investigator’s
Supervisor, Jennifer Hodgson, PhD, at (252) 328-1349. Also, you may telephone the University and
Medical Center Institutional Review Board at 252-744-2914. In addition, if you have concerns about
confidentiality and privacy rights, you may phone the Privacy Officer at Vidant Medical Center at 252-
847-6545 or the Privacy Officer at East Carolina University at 252-744-5200.

211
Authorization
To authorize the use and disclosure of your PHI for this study in the way that has been described in this
form, please sign below and date when you signed this form. A signed copy of this Authorization will be
given to you for your records.

Name of Participant or Authorized Representative (print) Signature Date

If an Authorized Representative has signed on behalf of a Participant please print on the line above
the authority of the Legal Representative to do so (such as parent, court-appointed guardian, or
power of attorney).

Person Obtaining Authorization Signature Date

212
 Informed Consent for Qualitative-Only Participants

East Carolina University Informed Consent to Participate in Research

Information to consider before taking part in research that has no more
than minimal risk.

Title of Research Study: Cardiac Rehabilitation Referral and Participation for/among African American
Patients
Principal Investigator: Aubry N. Koehler, MA, LMFTA
Institution/Department or Division: Child Development & Family Relations
Address: 108 Rivers Building, Mail Stop 505, East Carolina University, Greenville, NC 27858
Telephone #: (252) 737-1415
Study Sponsor/Funding Source: N/A

Researchers at East Carolina University (ECU), Vidant Medical Center, and Vidant Medical Groups
study problems in society, health problems, environmental problems, behavior problems, and the human
condition. Our goal is to try to find ways to improve the lives of you and others. To do this, we need the
help of volunteers who are willing to take part in research.

Why is this research being done?

The purpose of this research is to better understand what medical services cardiac patients use while they
are recovering. The decision to take part in this research is yours to make. By doing this research, we
hope to learn what kind of factors affect the type of medical services cardiac patients with different
backgrounds use.

Why am I being invited to take part in this research?

You are being invited to take part in this research because you are an African American patient currently
recovering from a cardiac event or surgery. You are being asked to participate in the qualitative
(interview) portion of a larger study that also has a quantitative (survey) component. If you volunteer to
take part in this research (qualitative interviews), you will be one of about 12 people to do so.

Are there reasons I should not take part in this research?

I understand I should not volunteer for this study if I am: (a) a non-English speaker, (b) under 18 years of
age, (c) a non-Pitt County resident, (c) being discharged with a diagnosis of heart failure or following a
heart-lung transplant, and/or (d) cognitively impaired such that it may interfere with my ability to consent
to the study and participate in an interview.

What other choices do I have if I do not take part in this research?

Participation in this research project is voluntary. You may choose not to participate at any time.

Where is the research going to take place and how long will it last?
The research will occur at the following times and places: today at the Cardiac Rehabilitation facility,
when you will be guided through the informed consent paperwork (15 minutes) and then over the phone
for an interview, including a demographic questionnaire (about an hour). This will total about an hour
and 15 minutes. If you agree to participate in “member-checking” (a process of double-checking the
results; we will contact you over the phone to read you a summary of the results so you can provide
feedback), this will be an addition 15-30 minutes, for a total of one hour and 15 minutes to one hour and
30 minutes.

213
What will I be asked to do?
You are being asked to do the following:
 Allow us to view your electronic health record and paper records kept by Vidant Medical
Center/Health Groups to see what medical services you used for your recovery (for the next
six months only).
 Participate in an audio-recorded, over-the-phone interview. During this interview, we will
ask you about your personal experience recovering from a cardiac event or surgery. We will
also ask you some demographic questions about yourself and the follow-up care you have
received. We will type up your audio-recorded interview for analysis and keep it in a
password-protected file. Audio files will be password-protected and stored on a secure server
at East Carolina University.
 If you participate in an interview and are willing to be involved in the process of double-
checking the results (“member checking”), we will contact you over the phone and read you a
summary of the results. This will give you an opportunity to share any additional information
or help us make corrections. Audio files will be erased after they are typed and the member
checking process is completed. The typed interviews will be stored electronically on a secure
server at East Carolina University, accessed only by my computer, which is password-
protected. The typed interview documents will be kept in a locked filing cabinet in my
locked office. Documents will be shredded and electronic files containing identifying
information will be erased six years after the project is completed.

What possible harms or discomforts might I experience if I take part in the research?
There are possible risks (the chance of harm) when taking part in this research. This research will require
your time and energy to complete. Some participants may experience discomfort or negative feelings
(such as anger, fear, grief, or sadness) from being asked to recall and talk about their recovery experience..
Please know you may always ask to “skip” questions you are not comfortable answering. You can also
ask to stop an interview at any time. Additionally, you may choose to have a family member or friend
present during your interview if this makes you feel more comfortable. In the case that you experience
negative emotions during the interview and would like to seek professional support, we will help connect
you with behavioral health resources that you may choose to use. We will give you contact information
for resources over the phone.

What are the possible benefits I may experience from taking part in this research?
We do not know if you will get any benefits by taking part in this study. Hopefully, this research will
help us learn more about how to best serve cardiac patients from different backgrounds. There may be no
personal benefit from your participation but the information gained by doing this research may help
others in the future. However, other people who have participated in this type of research have
experienced benefit from being able to talk about their experience with researchers. By participating in
this research study, you may also experience these benefits.

Will I be paid for taking part in this research?

We will not be able pay you for the time you volunteer while being in this study. However, we do want to
thank you by offering you a $25 gas card for your participation. We will mail this to you after the
completion of your interview. If you are interested in receiving a gas card, please provide your mailing
address here:__________________________________________________________________________
_____________________________________________________________________________________.

We would also like to share the results of this study with you. If you are interested in receiving a
summary of the results from this study, we are more than happy to send you a copy. Please provide a
email address or mailing address here:______________________________________________________

214
_____________________________________________________________________________________.

What will it cost me to take part in this research? It will not cost you any money to be part of the
research. This research study is not for profit and is being completed as part of the Principal
Investigator’s degree requirements. All researchers are donating their time to the study.

Who will know that I took part in this research and learn personal information about me?
To do this research, ECU and the people and organizations listed below may know that you took part in this
research and may see information about you that is normally kept private. With your permission, these
people may use your private information to do this research:
 The University & Medical Center Institutional Review Board (UMCIRB) and its staff, who have
responsibility for overseeing your welfare during this research, and other ECU staff who oversee
this research.
 Any agency of the federal, state, or local government that regulates human research. This includes
the Department of Health and Human Services (DHHS), the North Carolina Department of Health,
and the Office for Human Research Protections.
 People designated by Vidant Medical Center and Vidant Health
 Additionally, the following people and/or organizations may be given access to your personal health
information and they are: Vidant Cardiovascular and Pulmonary Rehabilitation (Greenville, NC),
Vidant Cardiovascular and Pulmonary Rehabilitation (Washington, NC)

How will you keep the information you collect about me secure? How long will you keep it?
Your name will only be attached to this informed consent document and a list kept by the Principal
Investigator of the study participants. The audio file of your interview will be password-protected and
stored on a secure server at East Carolina University. Hardcopies of your typed interview will be stored
in a locked file cabinet. Your name will not be attached to these materials. Audio files will be erased
after the interviews are typed and the member checking process is completed (if you are willing to be
involved in the process of double-checking the results, we will contact you over the phone to read you a
summary of the results so you can provide feedback). Findings from this study may be used for other
professional presentations or publications (e.g., articles, book format). In all presentations and
publications, your identifying information will never be used. After this study is complete, documents
will be shredded and electronic files containing identifying information will be erased six years after the
project is completed.

What if I decide I do not want to continue in this research?

If you decide you no longer want to be in this research after it has already started, you may stop at any
time. You will not be penalized or criticized for stopping. You will not lose any benefits that you should
normally receive.

Who should I contact if I have questions?

The people conducting this study will be available to answer any questions concerning this research, now
or in the future. You may contact the Principal Investigator at (252) 737-1415 (Thursday and Fridays,
9AM-5PM) or the Principal Investigator’s Supervisor, Jennifer Hodgson, PhD, at (252) 328-1349
(Monday-Friday, 9AM-5PM).

If you have questions about your rights as someone taking part in research, you may call the Office for
Human Research Integrity (OHRI) at phone number 252-744-2914 (days, 8:00 am-5:00 pm). If you
would like to report a complaint or concern about this research study, you may call the Director of the
OHRI, at 252-744-1971 and the Vidant Medical Center Risk Management Office at 252-847-5246.

215
I have decided I want to take part in this research. What should I do now?
The person obtaining informed consent will ask you to read the following and if you agree, you should
sign this form:

 I have read (or had read to me) all of the above information.
 I have had an opportunity to ask questions about things in this research I did not understand and
have received satisfactory answers.
 I know that I can stop taking part in this study at any time.
 By signing this informed consent form, I am not giving up any of my rights.
 I have been given a copy of this consent document, and it is mine to keep.

_____________
Participant's Name (PRINT) Signature Date

Person Obtaining Informed Consent: I have conducted the initial informed consent process. I have
orally reviewed the contents of the consent document with the person who has signed above, and
answered all of the person’s questions about the research.

Person Obtaining Consent (PRINT) Signature Date

216
 UMCIRB HIPAA Privacy Authorization
East Carolina University (ECU)/Vidant Medical Center (VMC): Research Participant Authorization to
Use and Disclose Protected Health Information for Research
For use only with the research consent form for UMCIRB#:14-000159
Principal Investigator: Aubry N. Koehler, MA, LMFTA
Title: Cardiac Rehabilitation Referral and Participation for/among African American Patients

Location where research will be conducted

The members of the research team will conduct the research study at:
East Carolina University (ECU) VMC ECU & VMC Other: Vidant Cardiovascular and
Pulmonary Rehabilitation (Greenville, NC & Washington, NC),

When taking part in research, protected health information (PHI) is collected, used, and shared with
others who are involved in the research. Federal laws require that researchers and health care providers
protect your PHI. Also, federal laws require that we get your permission to use collected PHI for the
research. This permission is called authorization.

In order to complete the research project in which you have decided to take part, the research team needs
to collect and use some of your PHI as described below.

What types of protected health information (PHI) about me will be used or disclosed?
ECU Health Care Component: Vidant Health Entity:
[ ] ECU Physicians [ ] Entire Vidant Health system
[ ] School of Dental Medicine [ ] Vidant Medical Center
[ ] Speech, Language, and Hearing Clinic [ ] Other Vidant Health Entity
[ ] Human Performance Lab (please list):
[ ] Physical Therapy
[ ] Student Health
[ ] Other ECU Health Entity
(please list): Dept of Child Development & Family Relations

Type of ECU Records: Type of Vidant Records:

[ ] Medical/clinic records [ ] Medical/clinic records
[ ] Billing records [ ] Billing records
[ ] Lab, Pathology and/or Radiology results [ ] Lab, Pathology and/or Radiology results
[ ] Mental Health records [ ] Mental Health records
[ ] PHI previously collected for research [ ] PHI previously collected for research
[ ] Records generated during this study [ ] Records generated during this study
[ ] Other: [ ] Other:

Who will use or disclose my PHI?

[ ] Principal Investigator
[ ] Other members of the research team
[ ] Other providers involved in your care during research procedures, outpatient/inpatient stays during
which research is being performed, or physician office visits during which research is being performed.

Who will receive my PHI?

[ ] Sponsor or other funding source to provide oversight for entire research project
[ ] Research investigators to conduct and oversee the research project

217
[ ] Principal Investigator and research team members to participate in the various research activities
[ ] FDA or other regulatory agencies to provide regulatory oversight
[ ] UMCIRB to provide continuing review of the research project
[ ] Institutional officials in connection with duties for monitoring research activity
[ ] Other providers involved in your care during research procedures, outpatient/inpatient stays during
which research is being performed, or physician office visits during which research is being performed.
[ ] Researchers at other sites—List sites:
[ ] Data and Safety Monitoring Board and its staff
[ ] Contract Research Organization and its staff
[ ] Other: People designated by Vidant Medical Center and Vidant Health System

We will share only the PHI listed above with the individuals/agencies listed above. If we need to share
other PHI or if we need to send PHI to other individuals/agencies not listed above, we will ask for your
permission in writing again

How my PHI may be released to others:

ECU and VMC are required under law to protect your PHI. However, those individuals or agencies who
receive your PHI may not be required by the Federal privacy laws to protect it and may share your PHI
with others without your permission, if permitted by the laws governing them.

What if I do not sign this form?

You will not be eligible to participate in this study if you do not sign this Authorization form.

How may I revoke (take back) my authorization?

You have the right to stop sharing your PHI. To revoke (or take back) your authorization, you must give
the Principal Investigator your request to revoke (or take back) your authorization in writing. If you
request that we stop collecting your PHI for the study, you may be removed from the study. If you are
removed from the study, it will not affect your ability to receive standard medical care or affect payment,
health plan enrollment or benefit eligibility. PHI collected for the research study prior to revoking (or
taking back) your Authorization will continue to be used for the purposes of the research
study. Also, the FDA (if involved with your study) can look at your PHI related to the study even if you
withdraw this authorization.

Restrictions on access to my PHI:

You will not be able to see your PHI in your medical record related to this study until the study is
complete. If it is necessary for your care, your PHI will be provided to you or your physician.

How long may the PHI about me be used or disclosed for this study?
Research information continues to be looked at after the study is finished so it is difficult to say when use
of your PHI will stop. There is not an expiration date for this authorization to use and disclose your PHI
for this study.

If you have questions about the sharing of PHI related to this research study, call the Principal
Investigator, Aubry N. Koehler, at phone number (252) 737-1415 or the Principal Investigator’s
Supervisor, Jennifer Hodgson, PhD, at (252) 328-1349. Also, you may telephone the University and
Medical Center Institutional Review Board at 252-744-2914. In addition, if you have concerns about
confidentiality and privacy rights, you may phone the Privacy Officer at Vidant Medical Center at 252-
847-6545 or the Privacy Officer at East Carolina University at 252-744-5200.

218
Authorization
To authorize the use and disclosure of your PHI for this study in the way that has been described in this
form, please sign below and date when you signed this form. A signed copy of this Authorization will be
given to you for your records.

Name of Participant or Authorized Representative (print) Signature Date

If an Authorized Representative has signed on behalf of a Participant please print on the line above
the authority of the Legal Representative to do so (such as parent, court-appointed guardian, or
power of attorney).

Person Obtaining Authorization Signature Date

219
 APPENDIX E: SURVEYS

“TIME 1” (T1) SURVEY

To be administered at the time of study enrollment, pre-discharge.
Date:
ID #:

1. What was your recent hospitalization for?

☐Heart attack (MI)
☐Coronary artery bypass (CABG)
☐Coronary stenting (“stent,” PCTA/angioplasty, or other PCI)
☐Heart attack with revascularization (CABG, PCTA, or other PCI)
☐Angina
☐Heart valve repair/replacement
☐Heart transplant
☐Peripheral artery disease

DEMOGRAPHIC QUESTIONS

2. What is your sex/gender?

☐Female
☐Male
☐Other

3. What year were you born?

______________

4. How would you define your race/ethnicity:

☐American Indian or Alaskan Native
☐Asian or Asian American
☐Black or African American
☐Hawaiian or Other Pacific Islander
☐Hispanic or Latino/Latina
☐Non-Hispanic White

5. What is the highest level of education you have completed?

☐Did not complete High School
☐GED/High School graduate
☐Some college
☐College graduate
☐Graduate school
6. How would you describe your current employment?
☐Employed for wages – full time
☐Employed for wages – part time
☐Self-employed
☐Out of work for more than 1 year
☐Out of work for less than 1 year
☐A homemaker
☐A student
☐Retired
☐Unable to work

7. What is your total yearly household income?

☐Less than $10,000
☐$10,000 to $19,000
☐$20,000 to $29,000
☐$30,000 to $39,000
☐$40,000 to $49,000
☐$50,000 to $59,000
☐$60,000 to $69,000
☐$70,000 to $79,000
☐$80,000 to $89,000
☐$90,000 to $99,999
☐$100,000 to $149,000

8. What type of health insurance do you have?

☐None
☐Private insurance (i.e., Blue Cross Blue Shield)
☐Medicaid
☐Medicare
☐Other Public Assistance
☐Other (please indicate)

9. How would you describe your current relationship status?

☐Married
☐Divorced
☐Widowed
☐Separated
☐Never been married
☐In an unmarried relationship, living together
☐In an unmarried relationship, not living together

10. How many people are in your household?

__________________

221
 BEHAVIORAL HEALTH QUESTIONS
Please answer the following four questions (Question #11 - #14) according to this prompt:
Over the last 2 weeks, how often have you been bothered by any of the following problems?

11. Little interest or pleasure in doing things

☐Not at all
☐Several days
☐More than half the days
☐Nearly everyday

12. Feeling down, depressed, or hopeless

☐Not at all
☐Several days
☐More than half the days
☐Nearly everyday

13. Feeling nervous, anxious, or on edge

☐Not at all
☐Several days
☐More than half the days
☐Nearly everyday

14. Not being able to stop or control worry

☐Not at all
☐Several days
☐More than half the days
☐Nearly everyday

222
 SOCIAL SUPPORT QUESTIONS
Please answer the following questions (Question #15 - #33) according to this prompt: How
often is each of the following kinds of support available to you if you need it?

None of A little of Some of Most of All of

the time the time the time the time the time
15. Someone you can count
on to listen to you when you
need to talk 1 2 3 4 5
16. Someone to give you
information to help you
understand a situation 1 2 3 4 5
17. Someone to give you good
advice about a crisis 1 2 3 4 5
18. Someone to confide in or
talk to about yourself or your
problems 1 2 3 4 5
19. Someone whose advice
you really want 1 2 3 4 5
20. Someone to share your
most private worries and
fears with 1 2 3 4 5
21. Someone to turn to for
suggestions about how to deal
with a personal problem 1 2 3 4 5
22. Someone who
understands your problems 1 2 3 4 5
23. Someone to help you if
you were confined to bed 1 2 3 4 5
24. Someone to take you to
the doctor if you needed it 1 2 3 4 5
25. Someone to prepare your
meals if you were unable to
do it yourself 1 2 3 4 5
26. Someone to help with
daily chores if you were sick 1 2 3 4 5
27. Someone who shows you
love and affection 1 2 3 4 5
28. Someone to love and
make you feel wanted 1 2 3 4 5
29. Someone who hugs you 1 2 3 4 5
30. Someone to have a good
time with 1 2 3 4 5
31. Someone to get together
with for relaxation 1 2 3 4 5

223
32. Someone to do something
enjoyable with 1 2 3 4 5
33. Someone to do things with
to help you get your mind off
things 1 2 3 4 5

SPIRITUALITY QUESTIONS
Please answer the following two questions (Question #34 and #35):

34. I don’t need to improve my health because I know it is up to God.

☐Strongly Disagree
☐Disagree
☐Neither agree nor disagree
☐Agree
☐Strongly agree

35. I can control a small health issue, but only God can control a big health issue.
☐Strongly Disagree
☐Disagree
☐Neither agree nor disagree
☐Agree
☐Strongly agree

224
 “TIME 2” (T2) SURVEY
To be administered during the six-week post-discharge follow up call.

Date:
ID #:

MEDICAL/BIOLOGICAL QUESTIONS
1. Were you scheduled for a follow-up medical appointment after you were discharged
from the hospital?
☐Yes
☐No
☐Unsure

If you answered ‘Yes’ to the above question, please answer the following three questions
(Question #2 and #3).

2. Who was the appointment with?

☐Primary care provider
☐Cardiologist
☐Cardiac surgeon
☐Other

3. Did you go to this appointment?

☐Yes
☐No
☐Unsure

4. Have you had any rehospitalizations since you were first discharged?
☐Yes
☐No

5. If you answered ‘yes’ to Question #5, what was this rehospitalization for?
______________________________________________________________________________

225
 BEHAVIORAL HEALTH QUESTIONS
Please answer the following four questions (Question #6 - #9) according to this prompt:
Over the last 2 weeks, how often have you been bothered by any of the following problems?

6. Little interest or pleasure in doing things

☐Not at all
☐Several days
☐More than half the days
☐Nearly everyday
7. Feeling down, depressed, or hopeless
☐Not at all
☐Several days
☐More than half the days
☐Nearly everyday

8. Feeling nervous, anxious, or on edge

☐Not at all
☐Several days
☐More than half the days
☐Nearly everyday

9. Not being able to stop or control worry

☐Not at all
☐Several days
☐More than half the days
☐Nearly everyday

226
 SOCIAL SUPPORT QUESTIONS
Please answer the following questions (Question #10 - #28) according to this prompt: How
often is each of the following kinds of support available to you if you need it?

None of A little of Some of Most of All of

the time the time the time the time the time
10. Someone you can count
on to listen to you when you
need to talk 1 2 3 4 5
11. Someone to give you
information to help you
understand a situation 1 2 3 4 5
12. Someone to give you good
advice about a crisis 1 2 3 4 5
13. Someone to confide in or
talk to about yourself or your
problems 1 2 3 4 5
14. Someone whose advice
you really want 1 2 3 4 5
15. Someone to share your
most private worries and
fears with 1 2 3 4 5
16. Someone to turn to for
suggestions about how to deal
with a personal problem 1 2 3 4 5
17. Someone who
understands your problems 1 2 3 4 5
18. Someone to help you if
you were confined to bed 1 2 3 4 5
19. Someone to take you to
the doctor if you needed it 1 2 3 4 5
20. Someone to prepare your
meals if you were unable to
do it yourself 1 2 3 4 5
21. Someone to help with
daily chores if you were sick 1 2 3 4 5
22. Someone who shows you
love and affection 1 2 3 4 5
23. Someone to love and
make you feel wanted 1 2 3 4 5
24. Someone who hugs you 1 2 3 4 5
25. Someone to have a good
time with 1 2 3 4 5
26. Someone to get together
with for relaxation 1 2 3 4 5

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27. Someone to do something
enjoyable with 1 2 3 4 5
28. Someone to do things with
to help you get your mind off
things 1 2 3 4 5

SPIRITUALITY QUESTIONS
Please answer the following two questions (Question #29 and #30):

29. I don’t need to improve my health because I know it is up to God.

☐Strongly Disagree
☐Disagree
☐Neither agree nor disagree
☐Agree
☐Strongly agree

30. I can control a small health issue, but only God can control a big health issue.
☐Strongly Disagree
☐Disagree
☐Neither agree nor disagree
☐Agree
☐Strongly agree

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 DEMOGRAPHICS QUESTIONNAIRE
To be administered to qualitative-only participants at time of interview
Date:
ID #:

1. What was your recent hospitalization for?

☐Heart attack (MI)
☐Coronary artery bypass (CABG)
☐Coronary stenting (“stent,” PCTA/angioplasty, or other PCI)
☐Heart attack with revascularization (CABG, PCTA, or other PCI)
☐Angina
☐Heart valve repair/replacement
☐Heart transplant
☐Peripheral artery disease

2. What is your sex/gender?

☐Female
☐Male
☐Other

3. What year were you born?

______________

4. How would you define your race/ethnicity:

☐American Indian or Alaskan Native
☐Asian or Asian American
☐Black or African American
☐Hawaiian or Other Pacific Islander
☐Hispanic or Latino/Latina
☐Non-Hispanic White

5. What is the highest level of education you have completed?

☐Did not complete High School
☐GED/High School graduate
☐Some college
☐College graduate
☐Graduate school

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6. How would you describe your current employment?
☐Employed for wages – full time
☐Employed for wages – part time
☐Self-employed
☐Out of work for more than 1 year
☐Out of work for less than 1 year
☐A homemaker
☐A student
☐Retired
☐Unable to work

7. What is your total yearly household income?

☐Less than $10,000
☐$10,000 to $19,000
☐$20,000 to $29,000
☐$30,000 to $39,000
☐$40,000 to $49,000
☐$50,000 to $59,000
☐$60,000 to $69,000
☐$70,000 to $79,000
☐$80,000 to $89,000
☐$90,000 to $99,999
☐$100,000 to $149,000

8. What type of health insurance do you have?

☐None
☐Private insurance (i.e., Blue Cross Blue Shield)
☐Medicaid
☐Medicare
☐Other Public Assistance
☐Other (please indicate)

9. How would you describe your current relationship status?

☐Married
☐Divorced
☐Widowed
☐Separated
☐Never been married
☐In an unmarried relationship, living together
☐In an unmarried relationship, not living together

10. How many people are in your household?

__________________

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11. Were you scheduled for a follow-up medical appointment after you were discharged
from the hospital?
☐Yes
☐No
☐Unsure

If you answered ‘Yes’ to the above question, please answer the following three questions
(Question #2 and #3).

12. Who was the appointment with?

☐Primary care provider
☐Cardiologist
☐Cardiac surgeon
☐Other

13. Did you go to this appointment?

☐Yes
☐No
☐Unsure

14. Have you had any rehospitalizations since you were first discharged?
☐Yes
☐No

15. If you answered ‘yes’ to Question #5, what was this rehospitalization for?

______________________________________________________________________________

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 APPENDIX F: BEHAVIORAL HEALTH RESOURCES

Behavioral Health Resources (for participants pre-discharge)

Some patients who are recovering from a cardiac event or surgery (for example, a heart

attack, a bypass, or a stent) may have feelings of anxiety, depression, or emotional distress:

 Anxiety symptoms—Feeling worried, nervous, or on edge

 Depression symptoms—Feeling down, sad, “blue,” or hopeless

 Emotional distress—Feeling of angry, fearful or scared, frustrated, or grief-

stricken.

Today, when I asked you about how you are doing, some of your answers told me that

you may be experiencing anxiety or depression symptoms. What I am going to do is let your

care provider know that you are experiencing these symptoms. That way, he or she can help

connect you with behavioral resources in the hospital that you chose to use.

After you discharge, I encourage you to do the following to make sure you get the

support you need:

1) Let your primary care provider and/or cardiologist know that you are experiencing

feelings of anxiety, depression, or emotional distress.

2) Let your trusted family members and friends know that you are experiencing feelings of

anxiety, depression, or emotional distress.

3) Contact a behavioral health provider with whom you can meet and discuss your feelings.

Here are some local resources:

a. ECU Family Therapy Clinic, 612 East 10th St., Greenville, NC (252) 737-1415.

Provides therapy to individuals, couples, and families on a sliding-fee scale.

 b. ECU PASS Clinic, Rawl Building Room 311 (ECU Main Campus), East 5th St.,

Greenville, NC, (252) 737-4180. Provides therapy to individuals on a sliding-fee

scale.

c. PORT Human Services, 2602 Courtier Dr., Greenville, NC (252) 752-0483.

Provides individual, couple, family, and group therapy for those with a mental

health and/or substance abuse diagnosis. Accepts private insurance, Medicare,

and Medicaid. Non-insured individuals may be able to receive free services.

d. East Carolina Behavioral Health, (877) 685-2415. ECBH is Pitt County’s Local

Managed Care Entity (MCO). A MCO is a storehouse for behavioral health

resources. Call their access crisis line (above) for more information.

4) If you ever feel you are in crisis and need help immediately, here are some important

contacts:

a. REAL Crisis Intervention (252) 758-4357. 24/7 crisis line. Provides over-the-

phone counseling and referrals.

b. Call 911 or go to your nearest emergency room.

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 Behavioral Health Resources (for participants post-discharge)

Some patients who are recovering from a cardiac event or surgery (for example, a heart

attack, a bypass, or a stent) may have feelings of anxiety, depression, or emotional distress:

 Anxiety symptoms—Feeling worried, nervous, or on edge

 Depression symptoms—Feeling down, sad, “blue,” or hopeless

 Emotional distress—Feeling of angry, fearful or scared, frustrated, or grief-

stricken.

Today, when I asked you about how you are doing, some of your answers told me that

you may be experiencing anxiety or depression symptoms. I encourage you to do the following

to make sure you have the support that you need:

1) Let your primary care provider and/or cardiologist know that you are experiencing

feelings of anxiety, depression, or emotional distress.

2) Let your trusted family members and friends know that you are experiencing feelings of

anxiety, depression, or emotional distress.

3) Contact a behavioral health provider with whom you can meet and discuss your feelings.

Here are some local resources:

a. ECU Family Therapy Clinic, 612 East 10th St., Greenville, NC (252) 737-1415.

Provides therapy to individuals, couples, and families on a sliding-fee scale.

b. ECU PASS Clinic, Rawl Building Room 311 (ECU Main Campus), East 5th St.,

Greenville, NC, (252) 737-4180. Provides therapy to individuals on a sliding-fee

scale.

c. PORT Human Services, 2602 Courtier Dr., Greenville, NC (252) 752-0483.

Provides individual, couple, family, and group therapy for those with a mental

234
 health and/or substance abuse diagnosis. Accepts private insurance, Medicare,

and Medicaid. Non-insured individuals may be able to receive free services.

d. East Carolina Behavioral Health, (877) 685-2415. ECBH is Pitt County’s Local

Managed Care Entity (MCO). A MCO is a storehouse for behavioral health

resources. Call their access crisis line (above) for more information.

4) If you ever feel you are in crisis and need help immediately, here are some important

contacts:

a. REAL Crisis Intervention (252) 758-4357. 24/7 crisis line. Provides over-the-

phone counseling and referrals.

b. Call 911 or go to your nearest emergency room.

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 APPENDIX G: INTERVIEW GUIDE

Introduction

Thank you so much for meeting with me and my research assistant today. I am working

on this project because I want to better understand the experience of people recovering from a

cardiac event (e.g., heart attack, hospitalization for angina). This project is part of my

requirements for my doctoral program at East Carolina University. I am meeting with you

because I am particularly interested in the recovery experience of African American patients

with CVD after they are discharged from the hospital following a cardiac event.

There are no right or wrong answers; please share information as it comes to mind. What

you share with me today will be used only for this project. When I write about the results of my

project (in the form of an article, book, and or presentation), I will not use your name or

information that could be used to identify you. The consent form you signed when we first met

in the hospital is your written agreement for the interview today. Please know that you may

decide not to continue with the interview at anytime, or you may choose to “skip” a question if

you do not feel comfortable answering it. Just let me know and we will move on, or stop the

interview completely. This interview will take about an hour and will be audio recorded. Do

you have any questions about the process before we begin?

Grand Tour Question

How would you describe your experience recovering from your cardiac event or surgery after

being discharged from the hospital?

Probing Questions

 What has having a heart problem meant to you?

 What are some challenges you have faced in your recovery process?

o Have you experienced any physical challenges?

o Have you experienced any emotional challenges

o Have you experienced any social challenges?

o Have you experienced any spiritual/religious challenges?

 What successes have you experienced?

 How have you experienced the follow-up appointments with your cardiologist or primary

care provider after being discharged from the hospital?

o How would you describe how you have been treated?

o How were your questions/concerns addressed?

o What concerns do you continue to have?

 What is your understanding about how you can best recover from your heart problem?

o What messages or information have you gotten from your health care provider?

o What messages or information have your gotten from others?

 What messages or information have your gotten about diet?

 What messages or information have your gotten about exercise?

 Did any of your health care providers discuss cardiac rehabilitation (CR) with you?

Follow up probes: Which health care provider? When was it?

o What do you think is the importance of CR to your recovery?

o What were your intentions about participating in CR?

o Did you have any concerns about CR?

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 o Did you think about/engage in any alternatives to CR?

 What home remedies (non-medical strategies), if any, have been a part of your recovery

process?

 How have you been helped or supported by others in your process of recovering?

o How have health care providers like doctors, nurses supported you?

o How have other health people supported you?

o How have family members supported you?

o How have friends supported you?

o How has your community supported you?

o How has your church/faith community supported you?

 What services (or assistance) have you needed but have not received to help you with

recovery?

o What could health professionals like doctors and nurses have offered after

discharge to help you with your recovery?

 What else you would like to share about your recovery experience?

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 APPENDIX H: REFLEXIVE JOURNAL SELECTED ENTRIES
2/17/14

“A lot of my reflexivity, at this point, is about the process of getting my research started, rather

than about how I will interface with participants or the data. The photo-reflexivity project had

me writing more pointedly about participants and data, which I imagine I will do more of (and

will need to do more of) when I move along in my research. At this point, the bulk of my

reflexivity is about being aware of my own fears and the more objective limits of time, and

pushing forward in the most judicious way possible.”

7/18/14

“Just finished our first qualitative interview. So excited! As Sean would say, I am super stoked

on it! Right after we finished, I said to Michelle, “How about that black hole of cardiac rehab?”

People just don’t know. And the tragic thing is, this person would have been a great candidate

physically (Michelle says) and also in terms of compliance with medical recommendations. He

seems to have great rapport with his doctors, so I imagine if they recommended CR he would be

there in a second.”

9/27/14

“Tonight I called #037 to finish our interview. He has been difficult to reach and then, once I

reach him, his stamina has been low for the interview. A man answered the phone and I greeted

him by [the participant’s] name, but he corrected me, saying that my participant was back in the

hospital. Poor guy. It made me sad and also feel kind of hopeless about helping people. Here I

am talking to him and really offering no help. It’s a slap-in-the-face reminder of how sick these
people are, too, and how precious and short life is. I need to live while I do this dissertation

because it’s not going to keep me warm at night.”

11/20/14

“I went back through the significant statements I underlined in #009 and underlined more

inclusively. I had thought I was underlining only statements directly related to my research

question/phenomenon of study, but really it’s anything even peripherally related. It’s

overwhelming how much DATA there is to work with—I’m not sure how to begin coding it.

One step at a time. I am bogged down by the embarrassment of riches in my life—doing things I

love but often too much of them. SIMPLIFY.”

12/16/14

“I am juiced and eager to write. Last night, I dreamed I was an anthropologist collecting data on

a moped. That is my essence of researcher self! A freedom and excitement. I have lost that in

the mire of my dissertation, but I think I am regaining it when I visualize getting back on course

with the original purpose of my dissertation—to amplify marginalized voices. I can do that

through the qualitative. The qualitative is my vector.”

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 APPENDIX I: STATEMENTS OF BIAS
Lead Researcher

The lead researcher’s position both as a researcher and as a White, college-educated

female from the Northeastern United States are salient to the conceptualization and

implementation of this study. An important preliminary step in phenomenological research

process is “bracketing” or identifying and “stepping away” from one’s biases to increase the

likelihood that they will not interfere with data analysis (Bernard & Ryan, 2010, p. 259).

According to Colaizzi (1978), questioning of one’s presuppositions regarding the phenomenon of

study allows researchers to approach the study more objectively (Colaizzi, 1978). As Colaizzi

(1978) defines it, “objectivity is fidelity to phenomena. It is a refusal to tell the phenomenon

what it is, but a respectful listening to what the phenomenon speak of itself” (p. 52).

Throughout the conceptualization of this study, the lead researcher engaged in reflexivity

or “conscious self-reflection on the part of the researcher to make explicit their potential

influence on the research process” (Hennink, Hutter, & Bailey, 2011, p. 19). This process has

included (a) ongoing reflexive journaling, and (b) a photo-reflexivity project that assisted the

lead researcher in exploring her beliefs, assumptions, values, and biases associated with her

dissertation topic. These activities have elucidated the following insights into the lead

researcher’s perceptions: (a) a bias against health promotion interventions that are inaccessible to

socially disadvantaged patients; (b) an assumption that religion is important for many African

Americans living in the Southeastern United States; (c) a belief that most disparities in health

outcomes and health care can be explained by limited access to resources; and (d) a bias favoring

early intervention for the management of health problems and the need for integrated medical

and behavioral health care. The lead researcher challenged these biases and held an awareness to

them throughout study conceptualization to manage undue influence of these biases on the study.
 The lead researcher has also engaged in ongoing reflexivity and peer dialogue regarding

her position as a White researcher doing research with African American participants.

Considering the historical trauma experienced by African Americans in the context of medical

and scientific research (Washington, 2006), the lead researcher acknowledges the need for

particular sensitivity in approaching both this research topic and research participants. First and

foremost, she held an awareness of racial/ethnic disparities in power and privilege, and

specifically, how her own White privilege could inadvertently silence others (e.g., McGoldrick &

Hardy, 2008). She believed it was her charge to do everything possible to ensure that this

silencing did not take place. In taking a stance of cultural humility and curiosity, tentatively

offering ideas, asking questions to foster greater understandings, and including a methodological

component that explores participants’ experiences as they understand them (phenomenology),

she has endeavored to promote minority voices within this socially complex dynamic.

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 References

Bernard, H. R., & Ryan, G. W. (2010). Analyzing qualitative data: Systematic approaches.

Washington, D.C.: Sage.

Colaizzi, P. (1978). Psychological research as the phenomenologist views it. In R. Vaile & M.

King (Eds.), Existential phenomenological alternatives for psychology (pp. 48–71). New

York, N.Y.: Oxford University Press.

Hennink, M., Hutter, I., & Bailey, A. (2011). Qualitative Research Methods. Washington, D.C.:

SAGE Publications, Inc.

McGoldrick, M., & Hardy, K. (Eds.). (2008). Re-visioning family therapy: Race, culture, and

gender in clinical practice. New York, N.Y.: The Guilford Press. doi:10.1016/s0033-

3182(09)70864-3

Washington, H. A. (2006). Medical apartheid: The dark history of the medical

experimentation on Black Americans from colonial times to the present. Random House

Digital, Inc.
 Triangulated Researcher

When conducting research, it is important to examine and question biases that may

involve particular topics within the study at hand. Becoming more aware of personal beliefs and

values can help researchers recognize how their backgrounds may affect their perspective on

their research. The triangulated researcher’s position as a White, college-educated female in the

South affects her perspective on health and health disparities in several ways. First, she realizes

that her race inherently allows her opportunities and experiences that people of color may not

have. A degree in Anthropology has allowed her to become more aware of limitations and

restrictions that racial minorities may encounter in many environments, including healthcare

settings. This has led the triangulated researcher to believe that African Americans may have to

deal with implicit institutional oppression and inequality when trying to recover from a cardiac

event or surgery. Consequently, the triangulated researcher feels that there are more complex

issues for African Americans than for their White counterparts when considering how and why

rehabilitation services are used after discharging from the hospital.

Additionally, growing up in a small Southern town has reinforced the triangulated

researcher’s beliefs about the importance of religion in a healthy life and family system. Living

in the South for 23 years has contributed to her understanding that the majority of families in this

region value religion and the significance of prayer and reliance on God in the recovery process.

Because of this, the triangulated researcher feels that an emphasis needs to be placed on having

conversations about spirituality, perceptions about healthcare, and other factors that patients

believe influence their recovery.

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