1. Awareness of Heart Attack and Stroke Symptoms Among Hispanic Males Carlos Agüero, MD Department of Family and Community Medicine, University of Illinois-Chicago College of Medicine at Rockford STFM 41 st Annual Spring Conference - Baltimore, MD

2. Coauthors May Nawal Lutfiyya, PhD Ricardo Bardales, BS, M3 Robert Bales, MD, MPH, MS Michelle Brady, MS, FNP Michelle Brady, MS, FNP Adriana Tobar, MD Cynthia McGrath, MS, FNP Julia Zaiser, MS, FNP Martin Lipsky, MD, MS

3. Background Heart Disease and Stroke are respectively the first and third leading causes of mortality in men in the United States Hispanics constitute the fastest growing population in the U.S. and have surpassed all other racial or ethnic groups to become the largest minority in America There is little information on incidence and prevalence on this group as a whole Evidence suggests Hispanics may be at a higher risk for both Heart Disease and Stroke Heart Disease and Stroke are respectively the first and third leading causes of mortality in men in the United States Hispanics constitute the fastest growing population in the U.S. and have surpassed all other racial or ethnic groups to become the largest minority in America There is little information on incidence and prevalence on this group as a whole Evidence suggests Hispanics may be at a higher risk for both Heart Disease and Stroke

4. Percent of Hispanic adult men > 18 years of age with at least 1 MI and Stroke risk factor* 2005 Behavioral Risk Factor Surveillance Data *risk factors= Hypertension, Hyperlipidemia, Obesity, Diabetes

5. Knowledge and recognition of early warning signs of either heart attack or stroke are important for early appropriate response Hispanics (women and men combined) with acute heart attack or stroke have longer delay times, and are thus less likely to benefit from time-dependent reperfusion therapies. While a gap in heart attack and stroke symptom awareness for Hispanic women has been documented, knowledge of heart attack and stroke symptoms in Hispanic men remains largely unexamined Knowledge and recognition of early warning signs of either heart attack or stroke are important for early appropriate response Hispanics (women and men combined) with acute heart attack or stroke have longer delay times, and are thus less likely to benefit from time-dependent reperfusion therapies. While a gap in heart attack and stroke symptom awareness for Hispanic women has been documented, knowledge of heart attack and stroke symptoms in Hispanic men remains largely unexamined Background

6. Are there within-group disparities in Hispanic men’s knowledge of heart attack and stroke symptomology? We found no studies that looked at heart attack and stroke symptom awareness among adult U.S. Hispanic men exclusively Are there within-group disparities in Hispanic men’s knowledge of heart attack and stroke symptomology? We found no studies that looked at heart attack and stroke symptom awareness among adult U.S. Hispanic men exclusively The Research Question

7. Methodology Multivariate techniques were used to analyze a multi-year Heart and Stroke module from the Behavioral Risk Factor Surveillance System (BRFSS) database BRFSS uses a random-digit dial telephone survey targeting adults 18 years and older The data are cross-sectional and are focused on health risk factors and behaviors Three years of Behavioral Risk Factor Surveillance data (2003-2005) were amalgamated into a single dataset Multivariate techniques were used to analyze a multi-year Heart and Stroke module from the Behavioral Risk Factor Surveillance System (BRFSS) database BRFSS uses a random-digit dial telephone survey targeting adults 18 years and older The data are cross-sectional and are focused on health risk factors and behaviors Three years of Behavioral Risk Factor Surveillance data (2003-2005) were amalgamated into a single dataset

8. Methodology Only data from states using the Heart and Stroke module were selected for inclusion in the amalgamated database. Data from 23 states, 1 territory and the District of Columbia were included in the amalgamated 2003-2005 database The BRFSS Heart and Stroke module included 13 questions focused on ascertaining knowledge of early symptoms of heart attack and stroke Six of the questions focused on knowledge of stroke symptoms, six on knowledge of heart attack symptoms and one question on proper first response to either stroke or heart attack Only data from states using the Heart and Stroke module were selected for inclusion in the amalgamated database. Data from 23 states, 1 territory and the District of Columbia were included in the amalgamated 2003-2005 database The BRFSS Heart and Stroke module included 13 questions focused on ascertaining knowledge of early symptoms of heart attack and stroke Six of the questions focused on knowledge of stroke symptoms, six on knowledge of heart attack symptoms and one question on proper first response to either stroke or heart attack

9. Methodology Analytic Setup We examined Heart Attack and Stroke questions together (as cardiovascular events) and also separately for each condition For analysis we computed a Heart Attack and Stroke Knowledge Score for each respondent. A composite knowledge score (for both conditions) and an individual component score (heart attack and stroke separately) For the composite knowledge score the correct answers received 1 point and were categorized according to the following scale: low score 2-8 points, mid-range score 9- 10 points, and high score 11-13 points Analytic Setup We examined Heart Attack and Stroke questions together (as cardiovascular events) and also separately for each condition For analysis we computed a Heart Attack and Stroke Knowledge Score for each respondent. A composite knowledge score (for both conditions) and an individual component score (heart attack and stroke separately) For the composite knowledge score the correct answers received 1 point and were categorized according to the following scale: low score 2-8 points, mid-range score 9- 10 points, and high score 11-13 points

10. Methodology Analytic Setup For the individual knowledge score correct answers received 1 point. These scores were then categorized as either low or high scores according to the following scale: low scores 0-4 points and high scores 5-7 points Three original Behavioral Risk Factor Surveillance variables -education, annual household income and age- were re-coded for this analysis A logistic regression model was performed using low scores on the combined heart attack and stroke knowledge questions as the dependent variable Analytic Setup For the individual knowledge score correct answers received 1 point. These scores were then categorized as either low or high scores according to the following scale: low scores 0-4 points and high scores 5-7 points Three original Behavioral Risk Factor Surveillance variables -education, annual household income and age- were re-coded for this analysis A logistic regression model was performed using low scores on the combined heart attack and stroke knowledge questions as the dependent variable

11. Table 1. Variables & Factors% Age18-3448.0 35-5435.7 ≥5516.3 Education< High School30.7 ≥High School69.3 Health InsuranceYes59.5 No40.5 Household Income< $35,00060.2 ≥$35,00039.8 Medical Care Deferred Because of CostYes20.5 No79.5 Health Care ProviderYes54.5 No45.5 Selected Characteristics of Hispanic Men > 18 Years of Age Responding to the Heart and Stroke Module* 2003-2005 Behavioral Risk Factor Surveillance Data (weighted n=3,001,300)** * 25 states/territories were included in this analysis. By year of data collection these were: 2003: Arkansas, Georgia, Nebraska, North Carolina, North Dakota, South Carolina 2004: Colorado, Connecticut, Kentucky, Ohio 2005: Alabama, DC, Florida, Iowa, Louisiana, Maine, Minnesota, Mississippi, Missouri, Montana, Oklahoma, Tennessee, US Virgin Islands, Virginia, West Virginia** unweighted n=2023

12. Table 2. Heart Attack and Stroke Knowledge Questions with Correct ResponsesHispanic Men > 18 Years of Age 2003-2005 Behavioral Risk Factor Surveillance Data (weighted n=3,001,300)** Survey Questions % Correct Answers Heart Attack Do you think pain or discomfort in the jaw, neck, or back are symptoms of a heart attack?(Yes) 34.6 Do you think feeling weak, lightheaded, or faint are symptoms of a heart attack? (Yes) 62.3 Do you think chest pain or discomfort are symptoms for a heart attack? (Yes) 87.0 Do you think sudden trouble seeing in one or both eyes is a symptom of a heart attack? (No) 55.9 Do you think pain or discomfort in the arms or shoulders are symptoms of a heart attack? (Yes) 71.5 Do you think shortness of breath is a symptom of a heart attack? (Yes) 80.8 Stroke Do you think sudden confusion or trouble speaking are symptoms of a stroke? (Yes) 79.6 Do you think sudden numbness or weakness of face, arm, or leg, especially on one side are symptoms of a stroke? (Yes) 86.6 Do you think sudden trouble seeing in one or both eyes is a symptom of a stroke? (Yes) 72.8 Do you think sudden chest pain or discomfort are symptoms of a stroke? (No) 45.1 Do you think sudden trouble walking, dizziness, or loss of balance are symptoms of a stroke? (Yes) 82.2 Do you think severe headache with no known cause is a symptom of a stroke? (Yes) 52.6 First Response If you thought someone was having a heart attack or a stroke, what is the first thing you would do? (911) 80.4 ** unweighted n=2023

13. Table 3. Descriptive Statistics of Heart Attack and Stroke Knowledge Scores of Hispanic Men > 18 Years of Age 2003-2005 Behavioral Risk Factor Surveillance Data (weighted n=3,001,300)** Composite Heart Attack, Stroke and First Response Knowledge Score Heart Attack and First Response Knowledge Score Stroke and First Response Knowledge Score Score category Low33.240.032.6 Mid-Range32.0 High34.860.067.4 Range of Knowledge Scores1-130-7 Mean Knowledge Scores10.225.355.68 Std. Deviation2.051.241.22 ** unweighted n=2023

14. Table 4. Bivariate Analysis of Hispanic Men 18 Years of Age By Independent Variables and Heart Attack and Stroke Knowledge Score Level 2003-2005 Behavioral Risk Factor Surveillance Data Contingency Coefficient=.107, p<.00 Odds Ratio For Education ( High School): Low Scorers=1.619 (95% CI: 1.615, 1.624) Odds Ratio For Have Health Care Provider (Yes / No): High Scorers= 2.076 (95% CI: 2.054, 2.097) Odds Ratio for Annual Household Income ( $35,000): Low Scorers= 1.219 (95% CI: 1.214, 1.223) Odds Ratio For Was Medical Care Deferred Because Of Cost (Yes / No): Low Scorers= 1.245 (95% CI: 1.240, 1.249) Odds Ratio for Have Health Insurance (Yes / No): High Scorers=1.636 (95% CI: 1.620, 1.651) Variables Factors Contingency Coefficient and Unadjusted Odds Ratio (95% CI) High Score | Low Score Age 18-34 49.2 43.0 35-54 39.0 36.5 ≥55 11.8 20.5 Education < High School ≥High School Health Care Provider Yes No Household Income < $35,000 ≥$35,000 Medical Care Deferred Because of CostYes No Health Insurance Yes No

15. Table 5. Multivariate Logistic Regression Results forHeart Attack and Stroke Low Knowledge Score for Hispanic Men > 18 2003-2005 Behavioral Risk Factor Surveillance Data Variables FactorsAdjusted Odds Ratio (95% CI) Age Categories (vs. >55) 18-34.258 (.252,.264) 35-54.375 (.367,.384) Education (vs. >High School)< High School 16.266 (15.735, 16.815) Have Health Insurance (vs. Yes)No 1.543 (1.519, 1.569) Annual Household Income (vs. >$35,000)< $35,000.958 (.945,.972) Was Medical Care Deferred Because Of Cost (vs. Yes)No 2.098 (2.059, 2.138) Have Health Care Provider (vs. Yes)No 2.054 (2.019, 2.089)

16. Discussion One in three or 33.2% of U.S. Hispanic men scored in the low range on the composite heart attack and stroke knowledge questions There was an overall confusion when it came to correctly identifying symptoms for both stroke and heart attack There was a substantial difference between the levels of knowledge on stroke symptoms when compared to heart attack symptoms with 40.0% of U.S. Hispanic men earning low scores on heart attack and first response questions and 32.6% earning low scores on stroke and first response questions An astonishingly high percent of U.S. Hispanic men (almost 20.0%) failed to recognize that calling 911 was the appropriate first response to heart attack and stroke The analysis revealed a substantial gap in knowledge of heart attack and stroke symptom knowledge among U.S. Hispanic men One in three or 33.2% of U.S. Hispanic men scored in the low range on the composite heart attack and stroke knowledge questions There was an overall confusion when it came to correctly identifying symptoms for both stroke and heart attack There was a substantial difference between the levels of knowledge on stroke symptoms when compared to heart attack symptoms with 40.0% of U.S. Hispanic men earning low scores on heart attack and first response questions and 32.6% earning low scores on stroke and first response questions An astonishingly high percent of U.S. Hispanic men (almost 20.0%) failed to recognize that calling 911 was the appropriate first response to heart attack and stroke The analysis revealed a substantial gap in knowledge of heart attack and stroke symptom knowledge among U.S. Hispanic men

17. Limitations Survey is based on telephone derived data and may be skewed if persons of lower socioeconomic status were less likely to be included because of poorer phone access The survey consists of close ended questions and this may result in an overestimation of knowledge It is possible that the non-responders to the Behavioral Risk Factor Surveillance Survey might have scored differently on the questions skewing the results. After reviewing the source of the database, it was still unclear whether the survey for this module was available to participants who did not speak English Newly arrived immigrants may not be willing to participate in a phone survey if they feared their immigration status could be jeopardized Survey is based on telephone derived data and may be skewed if persons of lower socioeconomic status were less likely to be included because of poorer phone access The survey consists of close ended questions and this may result in an overestimation of knowledge It is possible that the non-responders to the Behavioral Risk Factor Surveillance Survey might have scored differently on the questions skewing the results. After reviewing the source of the database, it was still unclear whether the survey for this module was available to participants who did not speak English Newly arrived immigrants may not be willing to participate in a phone survey if they feared their immigration status could be jeopardized

18. Findings support the need to analyze the differences within a population group 69% of the sample had at least a high school education 59.5% had health insurance 55% of the sample had an identified health care provider Multivariate analysis of the group shows there were significant within- group differences Findings support the need to analyze the differences within a population group 69% of the sample had at least a high school education 59.5% had health insurance 55% of the sample had an identified health care provider Multivariate analysis of the group shows there were significant within- group differences Conclusions

19. Targeting educational efforts toward older (> 55 years) Hispanic men with less than high school education, those who don’t have an identified health care provider or health insurance, and who were deferring health care because of cost would perhaps be ways to improve the outcome of acute vascular events among the Hispanic adult male population By educating this group of U.S. Hispanic men on signs and symptoms of heart attack and stroke and knowing how to seek care, the public health status would be improved Early intervention can improve outcomes in morbidity and mortality leading to less public health care costs such as long term rehabilitation, Medicare and Medicaid support and social security disability costs Targeting educational efforts toward older (> 55 years) Hispanic men with less than high school education, those who don’t have an identified health care provider or health insurance, and who were deferring health care because of cost would perhaps be ways to improve the outcome of acute vascular events among the Hispanic adult male population By educating this group of U.S. Hispanic men on signs and symptoms of heart attack and stroke and knowing how to seek care, the public health status would be improved Early intervention can improve outcomes in morbidity and mortality leading to less public health care costs such as long term rehabilitation, Medicare and Medicaid support and social security disability costs Recommendations

20. This article is under review at: Ethnicity and Disease