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This is to certify that the ‘

thesis entitled

HORMONE REPLACEMENT THERAPY KNOWLEDGE,
‘ l

PERCEIVED RISK OF CORONARY HEART DISEASE, AND
LIKELIHOOD To TAKE AMONG LOW_INCOME AFRICAN
AMERICAN WOMEN presented by

Patricia A. Davis

 

has been accepted towards fulfillment
of the requirements for

MASTER Wgree in mm

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MSU IoAn Afflrmotlvo Action/Equal Opportunlty InotIMIon
Wm:

 

HORMONE REPLACEMENT THERAPY KNOWLEDGE, PERCEIVED RISK
RISK OF CORONARY HEART DISEASE, AND LIKELIHOOD TO
TAKE AMONG LOW-INCOME AFRICAN-AMERICAN WOMEN

BY

Patricia A. Davis

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE

College of Nursing

1997

ABSTRACT
HORMONE REPLACEMENT THERAPY KNOWLEDGE, PERCEIVED RISK

RISK OF CORONARY HEART DISEASE, AND LIKELIHOOD TO
TAKE AMONG LOW-INCOME AFRICAN-AMERICAN WOMEN

BY

Patricia A. Davis

This study is a secondary analysis examining African-
American women's knowledge of HRT, and it's risks,
cardioprotective benefits and likelihood to take HRT.
Research questions include: 1) What is the level of HRT
knowledge among low-income African-American women (LIAAW)?
2) What is the relationship between HRT knowledge and
likelihood to take HRT? And 3) What is the relationship
between HRT knowledge, perceived risk of CHD, and likelihood
to take HRT? The sample consisted of 197 LIAAW ages 40-70.
Findings include: 1) low level of knowledge (1.08 out of a‘
total of 5 (SD 1); 2) likelihood to take and knowledge had a
weak correlation (r=0.19); and 3) perceived CHD risk (0-208
risk out of 0% (no risk) to 100%). Both knowledge and
perceived risk indicated a predictive relationship (R5=.05)
for likelihood to take HRT. Implications for APN's of these
findings demonstrate the need for health education and

health promotion.

Copyright by
Patricia Ann Davis
1997

To my parents who gave me the ambition
to strive for great things.

To my loving husband and children who

supported me and helped me earn my MSN.

ACKNOWLEDGMENTS

This thesis would not be possible without the
assistance and support of my thesis committee. Great thanks
to Jackie Wright and Linda Beth Tiedje for their words of
wisdom and support during this writing process. Finally, I
would like to thank Georgia Padonu, chair of my thesis
committee. Without her time, persistence, positive
attitude, support and great ideas I would not be able to

contribute this thesis to Nursing.

REVIEW OF THE LITERATURE . .

METHODS O O O O O O 0

FINDINGS AND DISCUSSION . . . . . . . . . . .

TABLE OF CONTENTS

LIST OF TABLES O O O O O O O O O O O O O O O 0
LIST OF FIGURES . . . . . . . . . . . . . . . .

I NTRODUCT I ON C O O O O O O 0 O O O O O O O O 0

Conceptual Definitions .
Cardioprotection and HRT
Risks of HRT . . . . . .
Breast Cancer . . .
Endometrial Cancer
Perceived CHD Risk . .
Knowledge of HRT . . .
Likelihood to Take HRT
Summary . . . . . .
Purpose . . . . . .
Research Questions .
Conceptual Model . .

Original Study . . .
Present Study . . .
Sample . . . . . . . . . .
Procedure for Protection of Human Rights
Operational Definitions . . . . . . . .

RESULTS 0 I O O O O O O O O O O O I O O O O O 0

Mean Level of HRT Knowledge . . .
HRT Knowledge and Likelihood to take HRT
Perceived Risk . . . . . . . . . . . . .
Likelihood to take HRT . . . . . . . . .
Limitations . . . . . . . . . . . . . .
Implications for Advanced Practice Nurses
Recommendations for Future Research . . .

LIST OF REFERENCES 0 O O O O O O O O O O O O O

APPENDICES O O O O O O 0 O O O O O O O O O O O

Page
vii
viii

O O O O O O O O O O O O 0
g..-
0|

0 O O O O O
N
\I

30
3O
31
31

35
36
38

Table 1:

Table 2:

Table 3:

LIST OF TABLES

HRT Knowledge . . . . . . . . . . . . . .

Comparison of CHD Expectations to Actual
RiSKS O I O O O O O O O O O O O O O O 0

Regression of Knowledge of HRT, Perceived
Risk of CHD and Likelihood to take HRT .

vii

Page

. 32

. 32

Figure
Figure
Figure
Figure

Figure

LIST OF FIGURES

Lifetime Risks of CHD Not Treated with HRT

Women's Perceived Risk for CHD

Revised Pender Health Promotion Model .

Adapted Health Promotion Model

A Women's Perceived CHD Risk

viii

Page

INTRODUCTION

There is minimal research looking at risks and benefits
of hormone replacement therapy (HRT) and its use among
African-American women. This my be due to the fact that
African-Americans are not at risk for osteoporosis due to
their greater peak bone mass and therefore are not thought
to be candidates for long term HRT (Andrews, 1996).

However, there are other health and health care issues
that are significant in starting HRT in these women,
coronary heart disease (CHD) is the leading cause of death
among all women in the United States (Andrews, 1996).

Recent studies have correlated estrogen and estrogen
replacement with cardioprotection (Riggs, 1987).

The absence of CHD data among African-American women is
even more significant (LiaO & Cooper, 1992). However, one
of the few studies available is Grady, Rubin, Petitti, Fox,
Black, Ettinger, Ernster, & Cummings (1992). African-
Americans have a 46.5% lifetime chance of developing CHD
compared with 46.1% in whites (Grady et al., 1992) making
them equally eligible for the cardioprotection of HRT.

There is lack of knowledge on the natural history and

prognosis of CHD in all women due to the exclusion and/or

2
under-representation of women of all ages in past studies
and clinical trials.

Prevention of CHD is much more important and effective
than treatment. A statistically and clinically significant
reduction in all cause mortality was found with long-term
estrogen use in a cohort of aging women (Ettinger, Friedman,
Bush 8 Quesenberry, 1996). This was reflected primarily
through a reduction in mortality from coronary heart disease
and cardiovascular disease. Unfortunately, African-American
women were excluded from this study since it was originally
done to look at osteoporosis and African-American women were
not considered prone to osteoporetic fractures (Ettinger et
al., 1996). A 50% reduction in heart disease risk has been
documented in postmenopausal women taking estrogen (PEPI,
1995). Recent studies have shown the combined treatment of
progesterone and estrogen have a cardioprotective effective
similar to unopposed estrogen (PEPI, 1995).

The purpose of this study is to examine low-income
African-American women's (LIAAW) knowledge of hormone
replacement, CHD risks, and cardioprotective benefits. This
study will also analyze the predicted relationship between
perceived risk of CHD, HRT knowledge, and likelihood to take
HRT among low-income African-American women.

Women live approximately seven years longer than men
and spend nearly one third of their lifespan post-menopause,
therefore their later years may be filled with chronic

diseases. Furthermore, according to Grimes (1995) the

3
proportion of 0.8. women older than 45 years is predicted to
grow from 34% in 1995 to 43% in 2020, millions of baby
boomers are entering menopause increasing the numbers of
menopausal women from 15 to 18 million. During this time
period from 1995 to 2020 the 0.8. population will experience
an 81% increase in the number of elderly women (Grimes,
1995).

Health promotion and preventive health must be
emphasized since these activities may improve the quality of
life thereby decreasing morbidity and mortality. Health
care providers are experts in diagnosing and treating
diseases; however, it is time more providers expand their
focus to include a program of preventive health care,
specifically prevention of heart disease (Hammond, 1996).
Particularly advanced practice nurses (APN) in primary care
contribute to health promotion and disease prevention.

APN's provide education and incorporates self-care for women
regardless of race and educational level. Longitudinal
research on HRT is a necessity with so many women entering
menopause and living longer post-menopausal.

Hormone replacement therapy has been shown to reduce
menopausal vasomotor symptoms, genitourinary symptoms, and
decrease the risk for osteoporosis and CHD (Hammond, 1996).
This study will focus on the relationship between
cardioprotective effects of HRT, women's perceived risk of
CHD, and a woman's likelihood to take HRT. The use of

hormone replacement therapy for symptomatic treatment and

4
osteoporosis prevention will not be discussed within the
context of this paper.
REVIEW OF THE LITERATURE
Winning

Key concepts of this study are: knowledge of HRT,
perceived coronary heart disease (CHD) risk, and likelihood
to take HRT. These concepts will be defined and discussed
to briefly to preface the information embodied within the
review of literature.

Conceptual definition of knowledge of HRT in this study
will be defined as factual information about HRT risks and
benefits, including particular knowledge related to HRT's
cardioprotective effect. Gorsky, Koplan, Peterson, and
Thacker (1994) define HRT as non-contraceptive estrogen with
or without progesterone. Gillespie (1989) defines HRT as
various combinations of estrogen and progesterone and use of
testosterone in certain circumstances. In this study HRT is
defined as exogenous estrogen administration which may or
may not be in combination with progesterone. Polit and
Hungler (1995) discusses knowledge as having many roots;
stemming from inherited customs, tradition, and past
knowledge. There are a number of publications that address
naturally occurring estrogen (Freeman, 1995). Naturally
occurring estrogen will not be discussed within the context
of this study. Knowledge is defined as an individual's
interpretive framework which operates within oneself to

assign meaning to lived events (Hawthorn, 1994). Grady et

5
al. (1992) discussed knowledge of HRT as: 1) an
understanding of it's common side effects; 2) positive
benefits regarding decreased risks for various diseases; and
3) understanding improvement in life expectancy.

The conceptual definition of perceived CHD risk will be
defined in this study as an individual's estimated
probability that they will encounter coronary heart disease.
Perceptions is defined as any insight, intuition, or
knowledge gained by perceiving (American Heritage
Dictionary, 1985). Pender (1996) describes risk as an
estimate of health threats to which individuals may be
particularly vulnerable because of biologic makeup, family
history, and lifestyle. Logothitis (1988) defined perceived
risk as an individual's subjective susceptibility of
contracting a condition. People vary in their perceptions
of personal susceptibility, one may deny the possibility of
acquiring a condition while another may perceive a real
'danger of contracting the condition.

It should be noted that knowledge of HRT and perceived
CHD risk contain some of the same components within their
definition. However, they are treated as distinctly
separate variables. Knowledge is related to actual risk and
therefore different than perceived risk.

Likelihood to take HRT is conceptually defined as the
probability to use exogenous estrogen which may or may not
be combined with progesterone for treatment to reduce the

risk of coronary heart disease in menopausal women.

6

Rothert (1990) defines likelihood to use HRT as a
woman's use of information regarding cancer risk,
osteoporosis risk, and hot flashes to make the decision to
use HRT. Pender (1987) describes likelihood of action as
perceived benefits minus perceived barriers, the end result
determines the likelihood of taking recommended preventive
health actions. The American Heritage Dictionary (1985)
defines likelihood as probability.

The proceeding material discusses the current
literature surrounding: 1) cardioprotection associated with
HRT; 2) health risks associated with HRT use; 3) perceived
risk of CHD; 4) knowledge of HRT; and 5) likelihood of
taking HRT.

W

Heart disease is the leading cause of death in post-
menopausal women (Wild, 1996; Grady et al., 1992). Two main
long-term problems, atherosclerosis and osteoporosis exist
with estrogen deficiency (Hammand, 1996). HRT can be used
as prophylaxes verses therapy even if initial symptoms of
menopause; hot flashes or flushes, irritability, and/or
vaginal dryness, do not clinically manifest themselves
(Hammond, 1996). This emphasizes the significance of
informing asymptomatic women of potential health risks
associated with estrogen deficiency. Offering long term
hormone replacement therapy to decrease chances of
developing osteoporosis or cardiovascular disease is also

important (Hammond, 1996). The focus of this study is on

7
HRT and cardioprotection, therefore osteoporosis will not be
discussed within this study.

Coronary heart disease is at least twice as common as
any other disease in women of all races (Grady et al.,
1992). Death from CHD occurs at the median age of 74 years
old and death from stroke occurs at a median age of 83 years
old. There is a forty percent increase in mortality in
African-Americans and forty percent of the difference is due
to coronary artery disease (Andrews, 1996). Grady et al.
(1992) did a meta analysis determining relative risk of
developing coronary heart disease. African American women
untreated with HRT have a 46.5% lifetime chance of
developing coronary heart disease, similar to that of white
women at 46.1% (see Figure 1).

Reports from the 19705 suggested that African Americans
were naturally protected against coronary artery disease,
however had a higher incidence of stroke (Keil, Sutherland,
Knapp, Lackland, Gazes, & Tyroler, 1993). These reports
lead to further studies attempting to understand coronary
heart disease in African Americans. The Charleston Heart
Study, a longitudinal study (1960-1990), found no
statistically significant difference in age specific
mortality rates due to coronary events between white and
African-American women. However, the overall cause of death

rate in African-American women was significantly higher than

Lifetime Risk of CHD Not Treated with HRT

 

 

 

 

 

ICE!)

 

 

 

 

 

 

in white women (Keil et al., 1993). Inconsistently in the
literature exists. Keil et al. (1993) found no difference
in mortality rates in contrast Liao and Cooper (1995) found
a difference in mortality rates. Mortality rates did not
decline in AAW as in white women.

Grady et al. (1992) found that the expected benefit of
HRT in African-American women with coronary heart disease
was similar to the benefit in white women with coronary
heart disease. If treated with estrogen alone there was
reduction in the probability of recurrent coronary heart
disease and an increased life expectancy of 1.9 years. When

treated with combination of progesterone and estrogen there

9
was a reduction in probability of recurrent coronary heart
disease and an expected gain of 0.9 years.

Given the similarity of life time risk (Figure 1) it is
assumed the overall cardioprotective benefits of HRT among
African-American women are thought to be similar to white
women (Grady et al., 1992). Therefore, the direct
physiological effects of estrogen are also assumed to be
similar regardless of race. The individual effect of
estrogen is in the effect on lipid metabolism. Estrogen
increases high-density lipoprotein cholesterol (HDL-C) and
decreases low density lipoprotein cholesterol (LDL-C).
Estrogen deficiency related to menopause leads to increased
LDL-C and decreased HDL-C. Increased LDL-C transports more
cholesterol to the walls of the arteries and decreased HDL-C
compromises the ability to draw cholesterol away from the
arterial wall leading to arteriosclerosis and CAD (Wild,
1996; Lindheim, Notelovitz, Feldman, Larsen, Khan 8 Lobo,
1994; Nabulski, Folsom, White, Wolfgang, Heiss, Wu, & Szklo,
1993; Hammond, 1996).

Another effect of estrogen is on the arterial wall,
protecting the endothelial wall from injury due to stress.
Although the exact mechanism isn't known, this action may
decrease platelet aggregation and adhesion related to
atherosclerosis. Also estrogen has been found to alter
abnormal coronary vasoactivity, which is related to

myocardial ischemic. The direct effect of estrogen is on

10
the vascular smooth muscle, leading to arteriolar relaxation
in vessels, maintaining arterial tone (Wild, 1996).

Nabulsi et al. (1993) compared cardiovascular risk
factors in post-menopausal women (approximately 30% of these
women were African-American and 70% were white) who had
never used HRT, with those that had used HRT in the past,
and those women who currently used HRT. This study
demonstrated a significant reduction in LDL-C and an
increase in HDL-C only in those women who currently used
HRT. Women who had used HRT in the past but stopped had
similar cholesterol levels as those women who had never used
HRT. Based on these results the authors estimated a 42%
reduction in the risk of CHD associated with HRT use. This
study did not specify duration of HRT use in either group.

A fifty percent reduction in heart disease risk has
been documented in postmenopausal women currently taking
estrogen (PEPI, 1995). Recent studies have shown the
combined treatment of progesterone and estrogen have a
cardioprotective effect similar to unopposed estrogen (PEPI,
1995). Postmenopausal Estrogen/Progesterone Interventions
Trial (PEPI, 1995) compared the effect on heart disease risk
factors of estrogen alone or in combination with
progesterone. The results showed that the combined therapy
of progesterone and estrogen yielded an increase in HDL-C;
however, unopposed estrogen had a significantly greater
increase in HDL-C. Decrease in LDL-C was similar in all

groups. Fibrinogen levels remained stable in women with HRT

11
treatment (no difference between treatment groups) compared
to women in the placebo group who had a significant increase
in fibrinogen. The PEPI trial (1995) showed that unopposed
estrogen therapy had the greatest effect on HDL-C. However,
all hormone treatments were demonstrated to be significantly
better than none. The increment in HDL-C was associated
with 20-25% decrease in risk of CAD. The PEPI trial sample
was comprised of 80% whites and 4% African-Americans.

In a study comprised of white women, Gorsky, Koplan,
Peterson, and Thacker (1994) examined hypothetical health
outcomes among women usin HRT verses those not using HRT.
Two hypothetical cohorts of 10,000 women 50 years old was
extrapolated to age 75 years old. One cohort included HRT
users, the other cohort included non-HRT users. They found
women who used HRT for 25 years experienced 48% fewer fatal
CHD events, and 49% fewer nonfatal CHD events.

The direct effects of estrogen on the cardiovascular
system are well documented. However, data on the combined
effects of estrogen and progesterone are limited. The PEPI
(1995) trial evaluated the combined effects of estrogen and
progesterone in the reduction of CHD. This was a good
study, however, only 4% of the sample consisted with the
PEPi trial, however, this study did not specify duration of
HRT use in either group.

In summary, tremendous gaps exist in the literature.
Specifically, longitudinal studies on women, the effects of

combined estrogen/progesterone on CHD, and minorities were

12

not identified in most of the current literature. Further
longitudinal studies are needed to evaluate the lifetime
impact HRT has on all women. There is a significant deficit
in the literature surrounding African-American women and
HRT.
Risks_of_HBT

B:east_£angez. Grady et al. (1992), did a meta-
analysis and found that African-American women age 50 years
old have a lesser lifetime probability of developing breast
cancer compared to 50 year old white women. The median age
breast cancer develops in African-American women is 69
years. Grady et al's. (1992) study examined thirty-nine
epidemiological studies lookin at estrogen and its possible
relation to breast cancer, since 1970. Findings determined
an estimated relative risk for breast cancer among HRT ever-
users compared with those who never took estrogen equals
1.01, therefore demonstrating a slight increment in the risk
for breast cancer. In addition, there is no clear evidence
that the risk of breast cancer increases with increasing
doses of HRT or varied treatment regimes. Studies
evaluating long term effects of HRT also have conflicting
results, many show a small increase among women who took HRT
longer and others do not (Grady et al., 1996). Controversy
remains surrounding HRT use, length of use, and treatment
regimens and HRTs impact on breast cancer (Grady et al.,

1992).

l3

Stanford, Weiss, Voigt, Daling, Habel, and Rossing
(1995) studied 537 white women ages 50-64 that were
diagnosed with invasive or in situ breast cancer between
January 1988 and June 1990 and found women who had not taken
HRT. Women who had taken a combination of progesterone and
estrogen for greater than eight years had a relative risk of
0.4.

Colditz, Egan, and Stampfer (1993), conducted a meta-
analysis from 31 studies on HRT and its risk on breast
cancer. The results from this study showed no increased
risk of breast cancer in women who had ever used HRT.
However when looking at studies that examined 10-15 years of
use, there was a statistically significant 20-30% increase
in breast cancer.

Colditz, Hankinson, Hunter, willett, Manson, Stampfer,
Hennekens, Rosner, and Speizer (1995), did a longitudinal
study, The Nurses' Health Study from 1976-1992, and examined
the relationship between use of hormone replacement therapy
and the risk of breast cancer in postmenopausal primarily
white women. The results determined that the risk of breast
cancer was significantly incrased among women who were
currently using estrogen alone (relative risk, 1.32) or
estrogen combined with progestin (relative risk, 1.41).

In summary, inconsistency exists in the data
surrounding the associatin of breast cancer and HRT. Grady
et al. (1992) meta-analysis revealed a slight increment in

the risk for breast cancer not necessarily linked to length

14
of use or certain treatment regimes. Stanford et al. (1995)
found no increase in breast cancer risk associated with HRT
used for greater than 20 years. However, Colditz et al.
(1993) found a statistically significant increase in breast
cancer with HRT use of 10-15 years. Grady et al. (1992) and
others were unable to determine the relative risk of breast
cancer associated with combined estrogen/progesterone use,
related to inconsistent data. In addition to these
inconsistencies, a gap occurring in the literatures is the
lack of data on African-Americans, HRT use and the
association with breast cancer. In conclusion, the link
between HRT and breast cancer for African-American women
needs further study. AAW need to be included in studies
regarding breast cancer and HRT.

Endometzia1_gancez. Grady et al. (1992) found that
African-American women have a lower (1.5% versus 2.6%)
lifetime probability of endometrial cancer compared to white
women. The median age which endometrial cancer develops is
68 years old in both African-American and white women.
Thirty-five studies looking at estrogen therapy and
endometrial cancer were examined. A significant increase
was found in risk associated with exogenous estrogen. Grady
et al. (1992) assumed that the relative risk for endometrial
cancer and estrogen therapy is the same for black women as
white women. The link is not well established between
African-American women, estrogen therapy, and risk for

endometrial cancer due to lack of data. The relative risk

15
for endometrial cancer in a woman taking conjugated
unopposed estrogen is 2.31 and increases with increasing
doses and also increases with increased duration of use.
However, the risk from dying from this disease may not
equally increase, the increase in endometrial cancer in the
1970s did not increase the mortality rate from endometrial
cancer. This may be associated to the nonaggressive form of
endometrial cancers related to estrogen therapy, these forms
of endometrial cancers are less invasive compared to women
with endometrial cancers that have not been on estrogen
therapy.

Combining estrogen with a progestin for postmenopausal
women with an intact uterus has evolved as a way to prevent
endometrial cancer. Therefore, women who have an intact
uterus receiving HRT should be prescirbed a
estrogen/progestin combination to prevent the increased
cancer risk associated with estrogen therapy (Hammond, 1996;
Grady et al. 1992).

Grady et al's. (1992) meta analysis has documented
consistent results associating endometrial cancer and
unopposed estrogen. Equally consistent is the documentation
that adding progesterone reduces the endometrial cancer riks
to the same level as for women who do not take HRT.
Eeznsi!£d_£HD_Rifik

Very little is written about woman's perceived risk for
coronary heart disease, possibly due to the recent data

correlating estrogen with cardioprotection. Padonu et al.

16
(1996), found African-American women's perceptions of CHD
were associated with aging, certain risk factors, and family
history, not with menopausal status. Grady et al. (1992)
elaborates on perceived risk and proposes that women with
CHD are more likely to value prevention through use of HRT
to prevent recurrent CHD. However, no studies have been
done to substantiate this data.

Perlumutter, Smith, Slaughter, and Hanlon (1997)
published a national telephone survey regarding perceived
heart disease risk conducted in September, 1996. Fifty-
eight percent of women underestimated their heart disease
risk, thinking its threat is less than or equal to that of
breast cancer. Only thirty-three percent know that heart
disease is a greater threat than breast cancer, and nine
percent are not sure (Perlumutter et al., 1997) (see Figure
2).

There are gaps in the literature surrounding women's
perceived CHD risk. Perlumutter et al. (1997) was the only
study that specifically evaluated women's perceived risk of
CHD. Padonu et al. (1996) examined attitudes of women
toward CHD. The current study will contribute to the
literature surrounding women's perceived CHD risk.
Knowledgs_of_HET

Ransom, Guerin, Holmes-Rovner, Dodson, and Padonu
(1996) surveyed a group of African-American and white nurses
regarding perceived risks and benefits of estrogen

replacement therapy (ERT). In measures of knowledge

17
Women’s Perceived Risk for CHD

Know that
CHD Is a
greater threat
than breast
cancer
33%

 

Think Breast
Cancer to
more of a

threat than
heart disease
58%

Figure 2.

surrounding ERT and heart disease they found a significant
deficit, 60.8% of African-American nurses were unable to
identify an association of ERT's cardioprotective benefit,
compared with 27.5% of white nurses. The African-American
nurses were also less likely to believe that ERT was a good
idea for other women to take (43%), and even less likely as
a personal choice (30%), compared with white nurses (87%)
and (55%) consecutively. These two groups wre homogeneous
regarding health variables, age, and income.

Hunter and Liao (1994) sampled 101 London women; mean
age 45 years old, on the intentions to use HRT. The
majority were employed, 77% white, and the remaining were of
mixed ethnic group. They found very low knowledge of the
relationship of heart disease and menopause, and risks of
HRT related to breast cancer and long term use.

Padonu, Holmes-Rovner, Rothert, Schmitt, Kroll, Rovner,

Talarczyk, Breer, Ransom, and Gladney (1996) studied 55

18
African-American women and their perceptions of menopause
and HRT. These women expressed both positive and negative
perceptions about HRT. Value of HRT was expressed for the
relief of menopausal symptoms. Negative perceptions
included fear of cancer, resumption of menses, side effects,
and taking medication for a lifetime.

In a study of white, college educated women, Carlson
(1994) found that 69% of the women knew three is increased
risk of heart disease after menopause, however, only 50%
knew that estrogen replacement therapy reduces the risk.
Ninety percent of the women knew about the risk of
osteoporosis and 78% knew that HRT can prevent osteoporosis.
Lack of knowledge was identified in this study, 53% of the
women thought uterine cancer was a greater risk than
osteoporosis. Forty-six percent of these women believed
they should make the decision regarding HRT but strongly
considered the practitioner's opinion.

The data looking at knowledge level of HRT is
inconsistent. Ferguson et al. (1989) studied a group of
white women and found that 27% of the women not taking HRT
knew that estrogen was related to osteoporosis compared to
89% of women on HRT and premenopausal women. Factors
associated with HRT use was physician recommendations and
the elimination of hot flashes. An unfavorable factor, in
HRT use was vaginal bleeding. Knowing someone on HRT
regimen that was having difficulty was a negative factor of

all three groups of women. In this study of 227 women: 1)

19
37 were currently taking HRT; 2) 125 had never taken HRT;
and 3) 65 were premenopausal. The women that were currently
taking HRT viewed menopause as a medical condition,
advocated treatment, and were much likely to favor natural
approaches. However, the majority of the women currently
taking HRT in this study have had hysterectomies leading to
increase education and may be the reason these women viewed
menopause as a medical condition.

Ferguson et al. (1989) stated the following predictors
to HRT use: 1) perceived natural approaches less favorable;
2) knowing that estrogen can decrease osteoporosis; 3)
viewing menopause as a medical condition; 4) being under the
care of a gynecologist; 5) symptom control. These
predictors accounted for 51% of variance whether women take
HRT. The current study is similar to Ferguson's in that it
envisions the prediction of likelihood of HRT use.
Predictors for the proposed study include knowledge of HRT
and perceived risk of CHD.

Rothert, Rovner, Holmes, Schmitt, Talarczyk, Kroll, and
Gogate (1990) found that women are more concerned about hot
flashes and disruption of normal daily life than the
consideration for mortality and morbidity risk in deciding
about HRT. Also demonstrated in this study is that women
have different patterns in their use of information regardin
HRT. Most women felt they should be partners in the

decision making process.

20

Grady et al. (1992) found that women with coronary
heart disease are more likely to place increased value on
hormone replacement therapy, decreasing reoccurrence of
coronary heart disease events as compared to women with
increased risk for breast cancer.

Wardell and Engebretson (1995) found in a group of
forty, perimenopausal, early menopausal, middle class, ages
40-53; women skepticism in long term use of HRT.‘ These
women relayed lack of commitment, and concern of long term
side effects, specifically cancer. This group of women also
considered the risk/benefit of HRT inappropriate in healthy
women.

Only two studies in the literature address African-
American women's HRT knowledge level. Padonu's et al.
(1996) study is a qualitative study examining attitude
rather than level of knowledge. Therefore, the lack of
literature surrounding African-American women's HRT
knowledge level is not clear given the gaps in the
literature.

Likelih99d_tQ_TnK£_HRI

Very little is written about African-Americans
likelihood to take hormone replacement therapy. In Ransom's
et al. (1996) study of perceived risks and benefits of ERT
in a group of African-American nurses and white nurses, the
African-American nurses were less likely to believe that ERT
was a good idea for other women to take (43%), and even less

likely as a personal choice (30%), compared with white

21
nurses (87%) and (55%) consecutively. Padonu's et al.
(1996) study documented 24% of African-American women are
currently using HRT and 76% are not taking any form of HRT.

Jahnige and Fiebach (1997) compared the use of ERT in
African-American women and white women patients at a
hospitla based clinic at an urban medical center. Past ERT
use was similar betwen the two groups (13.6% vs. 15.1%)
however, current ERT use was higher among African-American
women (15.9% vs. 5.7%). Having two or more CHD risk factors
was significantly associated with ERT use among African-
American women. Altough, after controlling for age and high
CHD risk factors, African-American women and white women had
a similar likelihood of ERT use.

Only three studies documented HRT use among African-
American women (Jahnige & Fiebach, 1997; Ransom et al.,
1996; Padonu et al., 1996). One study documented equal use
of HRT between African-American and whites (Jahnige &
Fiebach, 1997), the other documented less use of HRT among
African-American women (Ransom et al., 1996) and one study
did not compare use between groups (Padonu et al., 1996).
SnmmAZX

Overall, gaps in the literature exist surroundign low-
income women and the relationship with HRT. Staning and
Glazer (1992) documented attitudes surrounding menopause in
low-income women, but did not explore HRT knowledge. The
literature is also deficient in studies surrounding African-

American women. Little is known regarding the extent of

22

their HRT knoweldge. Only recently has there been an
awareness surrounding decreased CHD risk and HRT use. Women
in general have been left out of the cardiovascular
longitudinal studies, which may be why there is little data
on women's perceived risk for CHD. As recent as 1991 the
National Institute of Health set forth the Women's Health
Initiative, raising the priority of women's health and
provide baseline data on understudied issues surrounding
death in women. The Women's Health Initiative has to date
focused on research surrounding CHD, cancers, and
osteoporosis (Rosser, 1994).
BRIDQSS

The purpose of this study is to examine low-income
African-American women's knowledge of hormone replacement,
CHD risks, and cardioprotective benefits. This study will
also analyze the predictive relationship between perceived
risk of CHD, HRT knowledge, and likelihood to take HRT among
low-income African-American women.
WW:
1. What is the level of HRT knowledge among low-income

African-American women?
2. What is the relationship between HRT knowledge and

likelihood to take HRT?
3. What is the relationship between HRT knowledge,

perceived risk of CHD, and likelihood to take HRT?

23
W

Health_2romotion_flgdel. Pender (1996) defines health
promotion as increasing the level of well being and self-
actualization of an individual. The Health Promotion Model
(HPM) was designed as a guide for exploring biopsychosocial
proceses that motivate persons to engage in behaviors that
promote healthy enhancement of health. The HPM focuses on
movement toward a positive state of health and well being,
the negative states of illness have little motivational
significance for health promoting behaviors. The motivation
for health promotion comes from the desire for growth
expression of human potential and quality of life promoting
behaviors, are a continuum of activities incorporated into
an individuals lifestyle. The HPM has been used as a
framework to determine/predict overall health promoting
lifestyles and specific behaviors (Pender, 1996) (see Figure
3).

Individual characteristics and experiences are unique
to each person that will affect subsequent actions. Prior
related behavior is any behavior that is the same or similar
behavior in the past. Prior behavior (previous HRT use and
prior knowledge) will have both a direct and indirect effect
on the likelihood of participating in health-promoting
behaviors. Personal factors are categorized as biologic
(age, race, menopausal status), psychological and
sociocultural (education and income) (Pender, 1996) (see

Figure 4).

Individual
Characteristics
and Experiences

 

 

Prior
Related

Behavior '

 

 

 

Personal

Factors:
Biological
Psychological
Sociocultural

 

 

 

 

24

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Situational Influences:

Options Demand
Characteristics
Aesthetics

 

 

 

 

 

 

 

 

 

 

Behavior-Specific Behavioral
Cognitions and Affect Outcome
Perceived
7" Benefits of _
Action
Perceived . .
— Barriers to —- Immediate
Action Competing
Demands (low
control) and
Perceived Preferences (high
— Self-Efficacy CODU'OI)
Activity- l
__ Related t... v
Affem Commitment Health
to a Plan of Promoting
Action Behavior
Interpersonal “
Influences
(family, peers, __
providers); Norms,
Support, Models

 

 

Eigurg 3. Pender (1996). Revised Health Promotion Model.

 

Individual
Characteristics

 

 

Prior Related
Behaviors
(previous HRT use)

(prior knowledge) '—>

 

 

 

Personal Factors
Biological/age, race,
menopausal status.
Sociocultural
(education and income)

~——>

 

 

 

25

Behavior-Specific
Cognitions and Affect

 

 

Perceived CHD Risk

1

 

 

 

 

 

Knowledge of HRT
Cardioprotection
Risk for. endometiral cancer,
breast cancer

Behavior
Outcome

 

 

Likelihood to
take HRT
CHD prevention
health promotion

 

 

 

 

Eigurg 4. Adapted Health Promotion Model.

 

26

Behavior-specific cognition and affect are considered
to be of major motivational significance within the HPM.
Variables within this category are considered crucial for
intervention since they can be modified through nursing
action (Pender, 1996). Variables cardioprotective benefits,
risk for endometrial cancer and breast cancer.

Commitment to carry out a specific plan of action leads
to a behavioral outcome. Likelihood to use HRT is the
outcome variable within this study. Health promoting
behavior is the action outcome in the HPM. These behaviors
are directed at attaining positive health outcomes, such as
the prevention of CHD (Pender, 1996).

As primary care health providers Advanced Practice
Nurse (APN) can provide risk assessment and educational
intervention to clarify beliefs and facilitate the
likelihood of action. Understanding menopause, HRT and
potential health outcomes allows women to make an informed
decision and take action towards prevention. Using HRT is
thought of as preventive behavior.

METHODS
Wild!

The original study consistsed of a survey to low-
income, menOpausal, African-American women to determine
their knowledge of menopuse and hormone replacement therapy.
Funded in part by the National Institute for Nursin Research
(Grant number NR01245). The purpose of the study was to

evaluate African-American judgments of estrogen replacement

27

therapy (ERT). A 92-item survey was used to collect data
which included; sociodemographic, health risks, and
perceptions of menopause, the alpha coefficient is .85.
W

Secondary analysis was done, this study design used a
descriptive correlational design utilizing data from all
participants (N-197). This study examined African-American
women's knowledge of HRT, and the relationship between HRT
knowledge and likelihood to take HRT. The relationship
between perceived CHD risk, HRT knowledge, and likelihood to
take HRT was also analyzed.
Sam

The convenient sample consisted of 197 predominantly
low-income, African-American, menopausal women, ages 40-70.
Participants were recruited from Saginaw, Michigan through
key informant strategies utilizing the Michigan State
University Department of Urban Development community
development projects, primarily from low-income housing
developments. Surveys were administered in a group settin
and required approximately 45 minutes to complete as part of
a longer study of judgment processes (total time, 2 hours
average). Participants were given $25 for the entire task.

Sixty-six percent of the sample were between the ages
of 40 and 50, 30% were between the ages of 51 and 55.
Twenty-four percent of the women were married, and 64.3% of
the women were either divorced, single, or separated.

Thirty-five percent were employed either part or full-time.

28

Sixty-two percent of the women had household incomes under

$15,000, and 18% earned between $15,000 nd $25,000. Thirty

percent had less than a high school education, 28% had a

high school education, and 34% had more than a high school

education or a technical/trade degree. Thirty-three percent
were still having regular periods, 15% had a period within
the last year, and 40% had not had a period for one year.

Twenty-seven percent of the women had hysterectomies.

E i E E l l' E H E' ii
Prior to beginning the original study, the subjects

each signed a consent form. Each participants was assigned

a code number to ensure confidentiality. Participants were

free to withdraw from the study at any time without penalty.

All data was to be released in aggregate form only. This

study was aprpoved by Michigan State University Committee on

Research Involving Human Subjects (UCRIHS) before the

research began.

: ll 1 D E' 'I'

These key concepts were operationalized through use of

Women's Menopause Information Instrument.

1. Knowledge of HRT is used to describe factual
information about HRT risks and benefits, including
particular knowledge related to HRT's cardioprotective
effect as it impacts an individuals' decision to use
HRT. As used here, knowledge is measured by questions
78, 80, 81, 82, and 88 (Appendix A) for a potential

score of 0 to 5 for overall knowledge. One point will

29
be given for each correct answer. These scores
correspond to the number of correct responses to
questions related to questions related to a basic
understanding of HRT.
Perceived risk of coronary heart disease (CHD) is an
individuals estimated probability that they will
encounter coronary heart disease. CHD is a number of
disease states involving the heart and the vascular
system, includes but is not limited to: myocardial
infarction, coronary spasm, embolism, arteriosclerosis,
and angina. A woman's perceived risk for CHD will be
measured from the participants response to one specific
question, number 28 (Appendix B) from the Health
Background section of the questionnaire. The question
is: How likely DO YOU THINK YOU are to get heart
disease? A perceived risk will be calculated by
compressing the answers into five categories, 1) 0-20%;
2) 21-40%; 3) 41-60%; 4) 61-80%; 5) 81-100%. Scoring
will be on a 1-5 scale with 5 indicating a higher
perceived risk.
Likelihood to take HRT is defined as the probability to
use exogeneous estrogen which may or may not be
combined with progesterone for treatment to reduce the
risk of coronary heart disease in menopausal women. A
woman's likelihood to take HRT was measured from
participants' responses to two specific questions from

the Health Background section of the questionnaire,

30

numbers 24 and 25 (Appendix C). These questions are:

Ho wlikely are you to take estrogen replacement therapy

(ERT)?; How likely are you to take

estrogen/progesterone combined therapy (PERT)?

Likelihood to take HRT was determined by the mean score

of both questions combined.

RESULTS

Analysis was done using descriptive statistics
determining: 1) the mean HRT knowledge score was 1.08 out of
a total of 5 (SD 1.0); 2) the mean likelihood to take HRT
(in the form of ERT or PERT) was 2.76, this falls between
the answers “Probably would not take this form of HRT” and
“May or may not take HRT”; 3) Perceived CHD risk most
frequent response was 0-20%; 4) Pearson r correlation was
r=0.13 between HRT konwledge and perceived CHD risk,
however, not statistically significant; 5) Stepwise multiple
regression determined a predictive relationship between
knowledge of HRT, perceived risk of CHD and the outcome
variable, likelihood to take HRT. The amount of variance
(adjusted Rfi=.05) is small however statistically significant
p$.003. The level of significance is set to p5 0.05.

FINDINGS AND DISCUSSION

nean_Le¥e1_of_HBT_Knowledss

Overall, the African-American women had a very low
level of HRT knowledge. Somewhat surprising, none of the
197 women answered question number 78 “HRT (estrogen)

decreases a women's risk of heart disease” correctly. This

31

exemplifies the lack of knowledge regarding HRT's
cardioprotective benefits. Not surprising, 50% of the
African-American women were able to answer number 8 “HRT can
relieve menopausal symptoms“ correctly (Table 1) . Clearly
the lack of knowledge demonstrated in this study speaks for
itself. Education is paramount to health promoting
activities such as taking HRT. The results are consistent
with the current literature on African-American women's
knowledge of HRT. Padonu et al. (1996) qualitative study
about perceptions of menopause and HRT demonstrated the
women's expresSed value of HRT for the relief of menopausal
symptoms. This is reflected in the current study where the
highest knowledge score obtained was on question number 81
HRT (estrogen) can be used to help relieve the symptoms of
menopause. The two other studies demonstrated an overall
low HRT knowledge.
HBT_KDQWl9dQS_And_L1K£lihOOd_LO_LAk§_HRT

There is a weak positive relationship between HRT
knowledge and likelihood to take HRT, indication educational
intervention is important. There are no studies in the
literature that correlate HRT knowledge and likelihood to
take HRT.
W

Most of the African-American women underestimated their
risk of CHD (Table 2). In actuality, African-American

women's lifetime probability for CHD is almost 50%. This

32
Table 1.

HBT_Knowledss_lnercent_of_correct_answeral_ln:1211

 

HRT Knowledge Question % of correct responses

 

HRT (estrogen) decreases a women's
risk of heart disease 0

The addition of a progestional
agent (Provera) to ERT increases
risk of cancer to the uterus 14 i

Estrogen therapy without progesterone
increases the risk of cancer of
the uterus .22

 

HRT (estrogen) after menopause
increases the risk of osteoporosis 22

HRT (estrogen) can be used to help
relieve the symptoms of menopause 50

 

HRT knowledge questions answered

 

correctly (0-5 scale) # of respondents (n-197)
0 correct responses 69 (35%)

1 correct response 65 (33%)

2 correct responses 42 (21%)

3 correct responses 20 (10%)

4 correct responses

__1_llil_
197 (100%)

 

mean-1.08; median-1; SD=1
Table 2.
Comnariaon_of_CHD_Exnectations.to_Actual_Bisks

African-American Women

 

 

Actual lifetime probability Sample population's most
for CHD in a 50 yr. old woman* frequently reported
response to perceived
CHD risk
46.5% 20% or less*
*Grady et al., 1992 *l=O-20%; 2821-4O%; 3=4l-GO%

4361-80%; and 5-81-100%

33
finding signifies the importance for educational
interventions.

In comparison, Perlumutter's et al. (1997) study also
demonstrated women underestimate their CHD risk as compared
with their subjective risk for breast cancer. Fifty-eight
percent thought breast cancer was more of a risk than heart
disease. Although the current study does not demonstrate
comparison between disease processes, over half of these
women believe they have equal to or less than 20% chance for
developing CHD (see Figure 5).

There is only one study in the literature on women's
perceived CHD risk, this is consistent with results from the
current study. Perlmutter's et al. (1997) study also
demonstrated women's underestimated risk for CHD when
comparing it to their risk for breast cancer. Padonu et al.
(1996) qualitative study mentioned that women believe their
risk for CHD is directly associated with family hisotry.

1.] 1.] i l l l HRT

HRT knowledge and perceived CHD risk demonstrated some
variance, however very low, in predicting likelihood to take
HRT. Therefore, HRT knowledge and a perceived CHD risk had
a small impact on African-American women's likelihood of
taking HRT (see Table 3).

Increasing a women's perceived CHD risk and HRT
knowledge through education may increase the likelihood of
taking HRT, thereby increasing CHD prevention and health

promotion. Although clearly distinct within this study and

 

34
AA Women’s Perceived CHD Risk

“-60% Risk 61-80% Risk
13% 5% iii-100% Risk

ILNMSRBK
16%

 

Figure 5.

Table 3.

W
W

 

Source of

 

Variation Beta Adjusted R2 F Statistic P
Knowledge .17 .03 6.70 .01
Perceived Risk .16 .05 5.88 .003

 

no significant correlation is present between CHD risk and
HRT knowledge, intuitively there is overlap between these
two variables. Although small, the statistically
significant variance HRT knowledge and CHD perceived risk
impact the likelihood to take HRT demonstrating the

importance of educational intervention.

35

Knowledge level and perceived risk only accounted for
5% of the variance. Within this study women scored highest
on the question related to symptom relief and HRT, inferring
some variance in relationship 0 symptom relief. One may
then speculate some impact on likelihood to take HRT if
these women had symptoms of menopause. Other things that
may impact taking HRT may be health care providers beliefs,
media, friends and family. Intuitively an overlap between
HRT knowledge level and perceived CHD risk may impact a
women's ability to make an “informed decision” to take HRT
rather than judge her “likelihood” to take HRT.

Ii 'l l'

The Health Promotion Model is a fairly good model for
predicting likelihood to take HRT, resulting in CHD
prevention and health promotion. The variable perceived CHD
risk fit within the major division Behavioral Specific
Cognitions and Affect, however, did not fit within any of
Penders individual variables. Likelihood to take HRT is
actually an “intent to a plan of action”, not an “outcome”.
To improve the fit of the model with the study and future
studies, the variable likelihood to take HRT should be
placed between Behavior-Specific Cognitions and Behavioral
Outcome. This variable is considered a “commitment to a
plan of action".

Another limitation was the use of secondary data.
Limitations existed within the survey, the answers were in a

likert scale which may have confused some of the subjects.

36
Further limitations in the study included the few (5)
questions evaluated to determine HRT knowledge.
Unfortunately, perceived CHD was determined by only one
question. The researcher found this question a little
confusing since there were up to 10 answers in which to
choose. To put this in better perspective, future studies
may want to compare disease risks, as in Perlumutter's et
al. (1997) study such as comparing CHD to breast cancer.
Answers to this question may prove more beneficial in
evaluating perceived risks, therefore leading to guided
educational process.

In conclusion, due to the limitations of the sample,
these findings are not generalizable to the African-American
population.

I 1' ll E El 1 E l' H

Results of this study have implications in at least
three areas of primary care: 1) assessment; 2) information
and health benefits; and 3) CHD prevention and HRT
education. The results from this study clearly demonstrate
the lack of knowledge surrounding HRT and CHD risk.
African-American women should know and understand their
lifetime risks for various diseases, specifically CHD. As
clinicians, advanced practice nurses (APN) are obligated to
assess each woman's individual disease risk and her group
risk. Increasing individual and group risk education will
allow each woman to make an informed decision regarding HRT

use .

37

Using a community approach targeting African-American
women will increase access to primary health care. APN's
must assess the community for culturally relevant issues,
such as styles of communication and possibly in focus
groups. Proposed strategies to initiate first contact
includes targetin malls, school programs, and beauty salons
for health promotion screening. Also providing menopause
and HRT educational materials. APN's can also educate other
health care providers within the community to counsel
African-American women about issues surrounding HRT and
menopause that is sensitive to the beliefs and values of the
community.

As educators, APN's should target pre-menopausal
African-American women educating them on risk factors,
preventive measures, and health promotion. Providing women
was precise information that is culturally relevant is also
very important in the educational process. An educational
approach should focus on multiple strategies to reduce
women's risk for heart disease. Preventive educational
strategies include, benefits of exercise, encourage healthy
diets low in fat, benefits of not smoking, and other health
risks related to CHD. African-American women are most
knowledgeable in HRT's symptomatic relief in menopausal
symptoms, therefore educating women on the importance of HRT
long term is essential to reducing long term risks for CHD.
Emphasize that not only women with menopausal symptoms

benefit from HRT but also those with no symptoms in regards

38
to long term prevention. Women that have a better
understnadin gof menopause and it's lon term risk factors
will be better prepared to make an informed choice regaridn
HRT use based on factual data. Provide patients with
culturally relevant educational materials such as books,
booklets, videos, and/or cassette tapes to clarify
information and abolish fears.

A providers own view of menopause and HRT may impact a
women's decision to take HRT, objectivity must be
maintained. Programs to educate health care providers may
be initiated, so they are able to provide African-American
women with the risks and benefits of taking HRT.

With the advnet of managed care and capitated health
care costs, the action of health promotion and disease
prevention should be forefront. Health care providers
should have a standard protocol for educating women about
menopause and their benefits/risks of using HRT, regardless
of their menopausal symptoms. Assisting African-American
women to make an informed decision of preventive therapy
with HRT increases a woman's lifetime expectancy, and
decreases her lifetime probability of CHD. Optimistically,
engaging in health promoting activities will not only impact
lifetime expectancy but improve qulaity of life.
WW

Clearly, future studies are needed evaluating African-
American women's HRT knowledge and perceptions and

incorporating educational interventions. This study

39
demonstrates African-American women's low level of
knowledge. However, those women with increased HRT
knowledge are more likely to take HRT. Studies surrounding
combined (estrogen and progesterone) therapy and the impact
on CHD is lacking. The lack of current literature surround
CHD in women is significant. Further research is crucial in
assessing all women regarding perceived CHD risk
incorporating an educational intervention.

Further studies are needed to evaluate what impact
African-American womens' decision to take HRT.
Specifically, evaluating African-American women's HRT
knowledge, perceptions of menopause and her ability to make
an informed decision. In conclusion, further research is
needed demonstrating improvement in the quality of life

associated with HRT.

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Principles_and_nethods (5th ed.). Lippincott: Philadelphia.

The Writing Group for the PEPI Trial. (1995). Effects
of estrogen or estrogen/progestin regimens on heart disease
risk factors in post menopausal women. The Postmenopausal
Estrogen/Progestin Interventions (PEPI) Trial. JAMAI
213(3), 199-208.

Ransom, S., Guerin, M., Holmes-Rovner, M., Dodson, M.,
& Padonu, G. (1996). The impact of ethnicity on attitudes
and beliefs about estrogen replacement therapy among
Michigan nurses. Journal_of_B1ack_Nurses_Association1_§(2).
38- 47. .

Rosser, S. (1994). Gender bias in clinical research:
The difference it makes. In A. Dan (Ed. ), Rofzonino_nonon;o
noaltn (pp. 253-65). Thousand Oaks, CA: SAGE Publications.

Rothert, M., Rovner, D., Holmes, M., Schmitt, N.,
Talarczyk, G., Kroll, J., & Gogate, J. (1990). Women's use
of information regarding hormone replacement therapy.

Eesearch_in_Nursins_i_Health(13). 355- 366.

Speroff, L. (1996). Postmenopausal hormone therapy and
breast cancer. obstetrics_£_G¥necolog¥1_81(2), 448-548.

Standing, T., & Glazer, G. (1992). Attitudes of low-
income clinic patients toward menopause. Health_Care_for
Women_1nternationali_11. 271- 280.

Wardell, D., & Engebretson, P. (1995). Women's
anticipations of hormonal replacement therapy. ungnzitool
22, 177-183.

Wild, R. (1996). Estrogen: Effects on the

cardiovascular tree. QhStetri£s_£_£¥nscolog¥1_81(2), 275-
355.

APPENDIX A

78.

79.

80.

81.

82.

88.

43

Hormone replacement therapy (estrogen):
1-Increases a woman's risk of heart disease
2=Decreases a woman's risk of heart disease

3=Has no effect on a woman's risk of heart disease
4=Don't know

Please answer Questions 79-90 using the following
scale:

1-True

2-False

3-Don't know

Hormone therapy (estrogen) after menopause increases
the risk of osteoporosis.

Hormonal therapy (estrogen) can be used to help relieve
the symptoms of menopause.

Estrogen therapy without progesterone increases the
risk of cancer of the uterus.

The addition of a progestational agent (Provera) to
estrogen replacement therapy increase risk of cancer to
the uterus.

APPENDIX B

44

NOTE: For item 25, if you already have the condition or
disease identified in a question, mark 91-100%, if you can't
get the condition or disease, mark 10% or less.

28. How likely DO YOU THINK YOU are to get heart disease?

1- 10% or less 5-41-50% 8-71-80%
2811-20% 6-51-60% 9881-90%
3-21-30% 7s61-70% 10-91-100%

4=31-40%

APPENDIX C

24.

25.

45

How likely are you to take hormone replacement therapy
(HRT) in the form of estrogen alone?
1- Very certain that you would not take this form of

23
33
4s
5:

HRT.

Probably would not take this form of HRT.
May or may not take HRT.

Probably would take HRT.

Very certain that you would take HRT.

How likely are you to take HRT in the form of
estrogen/progestogen combined?

1:

2::
3:
4s
5:

Very certain that you would not take this form of
HRT.

Probably would not take this form of HRT.

May or may not take HRT.

Probably would take HRT.

Very certain that you would take HRT.

APPENDIX D

 

OFFICE OF
RESEARCH
AND
GRADUATE
STUDIES

UnnennyCommuueon
Research Involving
Human Suble

wcmn

Mvcmgan Suze University
2‘6 Administration Building
East Lansing Michigan
QNMJME

SUBSSQISO
FAX 517/4324”!

he Men-cm Sm mum-r7
DEA 1: Uni-«1w Oman
(film an Amen

USU a an alum-me armr-
anuwunnnnmuar

   

46

MICHIGAN STATE

UNIVERSITY

 

March 20. 1997

TO: Marilyn Rothert
College Of Nursrng
A230 if: Soiences
RE: IRBI: 97-192
TITLE: HORMONE REPLACEMENT THERAPY KNOWLEDGE, PERCEIVED

RISK OF CORONARY HEART DISEASE. AND LIKELIHOOD
OF USE AMONG LOW INCOME AFRICAN AMERICAN WOMEN
REVISION REQUESTED: N/A
CATEGORY: l-E
APPROVAL DATE: 03/19/97

The University Committee on Research Involving Human Subjects'iUCRIHS) '“

review of this project is complete. I am pleased to adv1se that the
rights and welfare of the human subjects appear to be adequately
protected and methods to obra1n informed consent are appropriate.
Therefore, the UCRIHS approved this preject and any rev151ons listed
above.

RENEWAL: UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a project be ond one year must use the green renewal
form (enclosed with t e original approval letter or when a.
project is renewed) to seek u ate cert1f1cation. There 1s a
maximum of four_such expedite renewals ssible. Investigators
wishing to continue a prOject beyond tha time need to submit it
aga1n or complete rev1ew.

REVISIONS: UCRIHS must review any changes in rocedures involving human
subjects, rior to in1t1at1on of t e change. If this is done at
the t1me o renewal. please use the green renewal form. To
rev15e an approved protocol at any other time during the year,
send your written request to the. CRIHS Cha1r, requesting rev1sed
approval and referenc1ng the preject's IRE 8 and t1tle. Include
in your request a descr1ption of the change and any revised
instruments. consent forms or advertisements that are applicable.

Should either of the followin arise during the course of the
work. investigators must not1 UCRIHS promptly: (l) roblems
(unexpected s1de effects, comp aints. e c )_involving uman
subjects or (2)_changes 1n the research env1ronment or new
information 1nd1cat1ng greater r1sk to the human sub'ects than
existed when the protocol was previously reviewed an approved.

If we can be of any future hel , please do not hesitate to contact us
at (517)355-2180 or FAX ($17I4 2- 171.

W

avid E. Wright D.
UCRIHS Chair

Sincerely.

'DEWzbed

cc: Georgia Padonu
Patr1c1a A. Dayts

“‘IIIIIIIIIIIIII