Sexual Identity and Racial/Ethnic Differences in Awareness of Heart Attack and Stroke Symptoms: Findings From the National Health Interview Survey

Abstract

Purpose:

Investigate sexual identity and racial/ethnic differences in awareness of heart attack and stroke symptoms.

Design:

Cross-sectional.

Setting:

2014 and 2017 National Health Interview Survey.

Sample:

54 326 participants.

Measures:

Exposure measures were sexual identity (heterosexual, gay/lesbian, bisexual, “something else”) and race/ethnicity. Awareness of heart attack and stroke symptoms was assessed.

Analysis:

Sex-stratified logistic regression analyses to examine sexual identity and racial/ethnic differences in awareness of heart attack and stroke symptoms.

Results:

Gay men were more likely than heterosexual men to identify calling 911 as the correct action if someone is having a heart attack (adjusted odds ratio [AOR] = 2.16, 95% CI: 1.18-3.96). The majority of racial/ethnic minority heterosexuals reported lower rates of awareness of heart attack and stroke symptoms than White heterosexuals. Hispanic sexual minority women had lower awareness of heart attack symptoms than White heterosexual women (AOR = 0.43, 95% CI: 0.25-0.74), whereas Asian sexual minority women reported lower awareness of stroke symptoms (AOR = 0.25, 95% CI: 0.08-0.80). Hispanic (AOR = 0.52, 95% CI: 0.33-0.84) and Asian (AOR = 0.35, 95% CI: 0.14-0.84) sexual minority men reported lower awareness of stroke symptoms than White heterosexual men.

Conclusion:

Hispanic and Asian sexual minorities had lower rates of awareness of heart attack and stroke symptoms. Health information technology may be a platform for delivering health education and targeted health promotion for sexual minorities of color.

Keywords

sexual identity race/ethnicity heart attack stroke health promotion

Purpose

Improving the health of sexual minority (eg, gay/lesbian, bisexual, and nonheterosexual) individuals has been identified as a major public health objective in the United States.¹ A growing of body research has documented elevated cardiovascular disease (CVD) risk in sexual minority women (SMW) including higher rates of tobacco use,^2
-4 obesity,^5
-7 and hyperglycemia^5,8,9 compared to heterosexual women. Sexual minority men (SMM) report higher rates of mental distress and tobacco use relative to heterosexual men, which may predispose them to CVD.¹⁰ In addition, a recent analysis of population-based data found that bisexual men had 2 to 3 times higher odds of obesity, hypertension, and diabetes than heterosexual men.¹¹

Despite similar rates of health insurance coverage, sexual minorities (specifically bisexual individuals) are more likely than heterosexuals to delay care due to cost^12
-14 or for other reasons (eg, unable to schedule an appointment and transportation issues).¹⁴ In addition, bisexual women are less likely than heterosexual women to have a usual source of care^14,15 or to have had a routine checkup in the past year.¹² This is particularly concerning given their elevated risk of negative health outcomes, including CVD.

Advances in the prevention and treatment of CVD have led to decreased mortality rates over the past 5 decades.¹⁶ Approximately 47% of the reduction in CVD mortality observed from 1980 to 2000 was attributable to evidence-based medical and surgical treatments.¹⁷ However, CVD remains the leading cause of death worldwide.¹⁸ Despite the effectiveness of evidence-based guidelines for the treatment of CVD, receiving timely interventions is impaired by a lack of awareness of heart attack and/or stroke symptoms among Americans. In 2017, only 50.1% and 68.9% of adults aged 20 years or older in the United States were aware of early warning symptoms of heart attack and stroke, respectively.¹⁹ Following a heart attack, shorter time to treatment is associated with lower rates of short- ^20,21 and long-term mortality²² and recurrent heart attack.²⁰ Similar trends have been observed for ischemic stroke with lower rates of in-hospital²³ and post-hospitalization mortality²⁴ and disability²⁵ in individuals with shorter time to treatment. Therefore, increasing the proportion of patients with heart attack and stroke who receive timely evidence-based treatment was identified as a major public health objective of Healthy People 2020. ¹⁹

Further, racial/ethnic disparities in awareness of heart attack and stroke symptoms have been described. Although Black and Hispanic adults have higher CVD risk,²⁶ they report lower rates of awareness of heart attack and stroke symptoms than their White peers.^27

-31 Less research has focused on Asian Americans and individuals of other races/ethnicities.^32,33

An important aspect of awareness of health conditions is how individuals seek health information and engage with health information technology (HIT). In the general population, the majority of adults use the internet as their first source of health information.³⁴ Differences in health information seeking behavior have been observed in racial/ethnic minorities.^35,36 However, fewer studies have examined health information seeking behaviors in sexual minorities. Analyses of data from the Health Information National Trends Survey follow-up (2013-2017) have shown that, compared to heterosexuals, sexual minorities are more likely to view health videos on YouTube, have increased incidental exposure to health information online, and communicate with health care providers by email.^37,38 Sexual minorities were also more likely than heterosexual participants to report looking for information about health topics, but less likely to first seek health information from a physician.³⁸ These findings suggest that the patterns of health information seeking and engagement with HIT for sexual minorities may be different than for heterosexual individuals.

Despite established racial/ethnic differences in awareness of CVD symptoms, less is known about sexual identity differences or the intersection of race/ethnicity with sexual identity. No study has examined awareness of CVD symptoms in sexual minorities. Therefore, the purpose of this study, using data from the National Health Interview Survey (NHIS), was to (1) examine sexual identity differences in awareness of symptoms of heart attack and stroke and (2) investigate whether sexual minorities of color differ in rates of awareness of symptoms of heart attack and stroke from White heterosexual participants.

Methods

Design

The NHIS is a nationally representative health survey of the civilian, noninstitutionalized US population that is conducted annually.³⁹ Data are collected continuously and released every year. A complex survey design is used to achieve a representative sample. The NHIS is administered via computer-assisted personal interviewing collected by trained interviewers. The annual response rate for the NHIS is approximately 70% of eligible households.⁴⁰ We combined NHIS 2014 and 2017 data based on NHIS recommendations to maximize the sample size of sexual minority participants.⁴¹ These were the only years of NHIS in which data on both sexual identity and awareness of CVD symptoms were collected.

The 2014 and 2017 NHIS included 63 439 adult participants with complete data for sexual identity. We excluded any participant who responded “I don’t know the answer” (n = 376) or “refused” (n = 385) to the sexual identity item. An additional 8352 participants were excluded from this analysis because they responded “don’t know” or “refused” to other study variables.

Measures

Sexual identity

To assess sexual identity all participants were asked: “How do you think of yourself?” Responses included: gay or lesbian, straight/heterosexual, bisexual, or “something else.”

Demographic characteristics

The following demographic characteristics were assessed: age (continuous), sex (male, female), race/ethnicity (White, Black, Hispanic, Asian, other race), education (less than high school, high school or equivalency, some college/technical school, Bachelor’s degree, graduate school), family income to poverty ratio (continuous; range 0-19.5, higher scores indicate higher family income), and geographic region (Northeast, Midwest, South, West).

Health care access and utilization

We assessed current health care coverage (yes/no) and whether participants delayed receiving medical care due to cost in the past 12 months (yes/no). We also assessed whether participants had seen any health care provider in the past 12 months.

Use of HIT

Health information technology usage was assessed with 5 items that asked about internet use in the past 12 months, including (1) Have you ever looked up health information on the internet? 2) Have you ever used chat groups to learn about health topics? 3) Have you ever refilled a prescription on the internet? 4) Have you ever scheduled a medical appointment on the internet? and 5) Have you ever communicated with a health care provider by email? We created a count measure for HIT usage. Participants received a score of 1 for every HIT activity reported (range = 0-5).

Cardiovascular disease risk factors

Current tobacco use was based on participant report of current smoking (yes/no). Body mass index was calculated based on self-reported height and weight. Participants were categorized as obese if they had a body mass index ≥ 30 kg/m² (yes/no).⁴² Two items assessed whether participants had ever been diagnosed with hypertension or diabetes (yes/no).

Presence of CVD

Participants were asked if they had ever been diagnosed with heart attack, stroke, angina, coronary heart disease, or other types of heart disease (including circulatory problems and arrhythmias; yes/no). We created a dichotomous measure to categorize participants as either having a history of any CVD condition or no history of CVD.

Awareness of CVD symptoms

For heart attack symptoms, participants were asked: “Which of the following would you say are the symptoms that someone may be having a heart attack?” They were instructed to respond “yes” or “no” after each symptom was presented. These symptoms included (1) pain or discomfort in jaw, neck, or back; (2) feeling weak, lightheaded, or faint; (3) chest pain or discomfort; (4) pain or discomfort in the arms or shoulder; and (5) shortness of breath. Similarly, for stroke symptoms, participants were asked, “Which of the following would you say are the symptoms that someone may be having a stroke?” These symptoms included (1) sudden numbness or weakness of face, arm, or leg, especially on one side; (2) sudden confusion or trouble speaking; (3) sudden trouble seeing in one or both eyes; (4) sudden trouble walking, dizziness, or loss of balance; and (5) sudden severe headache with no known cause. We created separate count measures for heart attack and stroke symptoms (range 0-5).

Participants were also asked, “If you thought someone was having a heart attack, what is the BEST thing to do right away?” and “If you thought someone was having a stroke, what is the BEST thing to do right away?” Responses included (1) advise them to drive to the hospital, (2) advise them to call their physician, (3) call 911 (or another emergency number), (4) call spouse or family member, and (5) other (do something else). Participants that responded call 911 (or another emergency number) were categorized as correctly identifying the best action (yes/no).

Based on previous work by Ojike and colleagues,³³ we considered participants to be aware of heart attack symptoms if they correctly identified all 5 symptoms for heart attack and the correct action of calling 911 (yes/no). Similarly, participants that correctly identified all 5 stroke symptoms and the correct action of calling 911 were categorized as aware of stroke symptoms (yes/no).³³

Statistical Analysis

All analyses were sex-stratified with heterosexual participants (the largest group) as the reference group. We used Rao-Scott χ² and Student's t tests to examine sexual identity differences. The significance level for these analyses was set at P < .01 to account for multiple comparisons. Next, we used sex-stratified logistic regression models to examine sexual identity differences in awareness of CVD symptoms. For all regression analyses, model 1 was unadjusted, model 2 added demographic characteristics, and model 3 added health care access and utilization, HIT use, CVD risk factors, and presence of CVD.

We then examined the intersection of sexual identity and race/ethnicity on awareness of CVD symptoms. Because of sample size constraints, we were unable to compare sexual minorities to heterosexuals of the same race/ethnicity. Since there were no subgroup differences among sexual minority participants of the same sex, we combined all sexual minority participants of the same sex into one category. We compared all racial/ethnic minorities (Black, Hispanic, Asian, other race) to White heterosexual participants of the same sex by creating a variable to account for the intersection of sexual identity and race/ethnicity.

Results

The analytic sample consisted of 54 326 adult participants, of which 29 918 were women and 24 408 were men. As shown in Table 1, 28 955 (96.7%) women identified as heterosexual, 451 (1.6%) as lesbian, 405 (1.4%) as bisexual, and 107 (0.3%) as “something else.” All groups of SMW were significantly younger than heterosexual women and more likely to delay care due to cost. Compared to heterosexual women, lesbian and bisexual women were less likely to have health care coverage and more likely to report current use tobacco. Bisexual (P < .001) and “something else” women (P < .001) reported a lower family income to poverty ratio than heterosexual women. Bisexual women were more likely than heterosexual women to identify as White (P = .01) and to report higher rates of all forms of HIT use, except using HIT to fill a prescription (P = .67) and using chat groups to learn about health topics (P = .03).

Table 1.

Sample Characteristics in Women, National Health Interview Survey (2014 & 2017).^a,b

		Heterosexual(n = 28 955)	Lesbian(n = 451)		Bisexual(n = 405)		“Something else”(n = 107)
Demographic characteristics	N	(%)/Mean (SD)		P value	(%)/Mean (SD)	P value	(%)/Mean (SD)	P value
Age	29 918	18.0	14.8	<.001	13.9	<.001	18.5	<.001
Race	29 918			.46		.01		.34
White		65.6	63.0		71.4		69.1
Black		12.9	16.4		15.2		15.0
Hispanic		14.7	15.4		11.3		11.2
Asian		5.9	4.0		1.0		2.4
Other race		0.9	1.2		1.1		2.3
Education	29 918			.16		.67		.42
Less than high school		11.5	10.9		13.7		12.3
High school/GED		23.5	17.1		21.1		14.4
Some college/technical school		32.4	35.0		35.1		40.0
Bachelor’s degree		21.0	21.8		19.2		23.5
Graduate school		11.6	15.2		10.9		9.8
Family income to poverty ratio	25 169	3.1	3.2	.21	2.9	<.001	2.2	<.001
Employment	29 918			.03		<.001		.08
Employed		57.3	64.1		69.2		62.5
Unemployed, looking		3.4	4.8		7.9		8.0
Unemployed, not looking		39.3	31.1		22.9		29.5
Region	29 918			.76		.24		.88
Northeast		18.1	17.1		16.6		19.7
Midwest		22.1	19.7		22.2		19.4
South		38.0	39.7		33.9		35.8
West		21.8	23.5		27.3		25.1
Health care access and utilization
Health care coverage	29 918	89.8	84.3	<.01	80.9	<.001	90.3	.88
Delayed care due to cost	29 918	9.7	16.4	<.001	20.5	<.001	17.8	<.01
Seen health care provider in past year	29 918	22.4	21.3	.68	28.1	.03	21.7	.89
CVD risk factors
Current tobacco use	29 918	13.1	20.5	<.001	23.8	<.001	18.6	.16
Obese	29 918	32.9	38.8	.06	36.6	.24	30.1	.61
Hypertension	29 918	29.6	23.4	0.02	17.4	<.001	22.5	.17
Diabetes	29 601	8.5	7.3	.46	3.6	<.001	12.6	.25
Use of HIT
Looked up health information on internet	29 918	55.3	60.8	.10	74.4	<.001	64.4	.14
Filled prescription on internet	29 918	10.3	14.9	.02	9.6	.67	8.0	.59
Scheduled medical appointment on internet	29 918	12.4	17.1	.02	17.8	<.01	15.2	.50
Contacted health care provider by email	29 918	13.1	16.6	.12	18.7	.01	17.7	.25
Used chat group to learn about health topics	29,918	4.0	5.1	.40	7.8	.03	6.4	.20
HIT use in past 12 months	29 918			.03		<.001		.44
0		41.4	36.7		21.7		32.9
1		36.0	34.5		47.7		40.6
2		12.7	13.8		16.9		14.6
3		6.5	8.2		8.9		5.5
4		3.0	6.4		3.8		6.4
5		0.4	0.4		1.0		0
CVD conditions
Any CVD	29 918	11.9	12.8	.63	8.4	.07	12.0	.99

Abbreviations: CVD, cardiovascular disease; HIT, health information technology.

^a N = 29 918.

^b Boldface denotes statistical significance (P < .01); reference group = heterosexual women.

Among men, 23 655 (97.1%) identified as heterosexual, 517 (2.0%) as gay, 150 (0.6%) as bisexual, and 86 (0.3%) as “something else” (Table 2). Gay and bisexual were significantly more likely to have delayed care due to cost than heterosexual men. Compared to heterosexual men, gay and bisexual men were significantly younger (P < .001), more likely to have looked up health information on the internet (P < .001), and more likely to have scheduled a medical appointment on the internet (P < .001). Gay men were more likely than heterosexual men to have seen a health care provider in the past year (P < .001). Gay men (P < .001) and men who identified as “something else” (P < .001) were also more likely than heterosexual men to have contacted a health care provider by email.

Table 2.

Sample Characteristics in Men, National Health Interview Survey (2014 & 2017).^a,b

		Heterosexual(n = 23 655)	Gay(n = 517)	P value	Bisexual(n = 150)	P value	“Something else”(n = 86)	P value
Demographic characteristics	N	(%)/Mean (SD)		P value	(%)/Mean (SD)		(%)/Mean (SD)	P value
Age	24 408	17.6	16.4	<.001	17.4	<.001	18.8	.09
Race	24 408			.55		.13		.02
White		66.8	70.2		61.2		52.2
Black		11.3	11.9		7.9		23.4
Hispanic		15.6	13.9		20.4		11.3
Asian		5.4	3.3		10.5		11.7
Other race		0.9	0.7		0.0		1.4
Education	24 408			<.001		.35		.82
Less than high school		12.0	4.4		6.4		14.9
High school/GED		25.8	18.6		25.6		28.5
Some college/technical school		29.6	30.8		37.1		25.3
Bachelor’s degree		20.3	24.8		16.7		15.5
Graduate school		12.3	21.4		14.2		15.8
Family income to poverty ratio	21 030	3.2	3.8	<.01	3.4	.20	2.7	<.001
Employment	24 408			.89		.10		.90
Employed		69.0	70.5		73.7		66.4
Unemployed, looking		4.5	4.0		7.5		4.8
Unemployed, not looking		26.5	25.5		18.8		28.8
Region	24 408			.03		.18		.79
Northeast		17.2	18.8		16.5		18.2
Midwest		22.9	18.5		22.8		18.8
South		36.7	32.7		28.0		34.1
West		23.2	30.0		32.7		28.9
Health care access and utilization
Health care coverage	24 408	87.3	88.5	.56	89.7	.43	82.9	.48
Delayed care due to cost	24 408	7.7	11.3	.01	14.0	.01	16.2	.02
Seen health care provider in past year	24 408	16.8	24.7	<.001	21.2	.37	20.9	.46
CVD risk factors
Current tobacco use	24 408	17.1	22.1	.05	18.5	.69	21.2	.41
Obese	24 408	30.7	26.0	.11	22.3	.09	19.4	.06
Hypertension	24 408	31.4	31.6	.96	25.8	.30	25.7	.35
Diabetes	24 072	10.0	4.6	<.001	7.6	.49	6.6	.29
Use of HIT
Looked up health information on internet	24 408	44.6	61.8	<.001	62.4	<.001	54.6	.20
Filled prescription on internet	24 408	7.5	16.0	<.001	10.4	.41	10.6	.41
Scheduled medical appointment on internet	24 408	9.2	23.6	<.001	24.7	<.001	16.7	.06
Contacted health care provider by email	24 408	9.7	25.7	<.001	13.5	.20	25.3	<.001
Used chat group to learn about health topics	24 408	2.9	7.0	<.001	8.1	.03	9.6	.01
HIT use in past 12 months	24 408			<.001		.02		<.001
0		52.2	32.0		35.9		43.9
1		31.3	31.6		32.5		28.9
2		9.7	16.1		15.6		8.6
3		4.5	11.9		9.4		9.0
4		2.1	7.4		6.0		4.5
5		0.2	1.0		0.6		5.1
CVD conditions
Any CVD	24 408	13.7	14.8	.57	11.7	.55	15.6	.70

Abbreviations: CVD, cardiovascular disease; HIT, health information technology.

^a N = 24 408.

^b Boldface denotes statistical significance (P < .01); reference group = heterosexual men.

Table 3 shows the results of logistic regression analyses examining sexual identity differences in awareness of heart attack and stroke symptoms. Among women, there were no sexual identity differences in awareness of heart attack symptoms or correct action. Women who identified as “something else” were more likely than heterosexual women to identify all 5 stroke symptoms (adjusted odds ratio [AOR] = 1.89, 95% CI: 1.02-3.49). Among men, there were no significant sexual identity differences in awareness of heart attack or stroke symptoms. However, gay men were more likely to correctly identify calling 911 as the appropriate action if someone was having a heart attack (AOR = 2.16, 95% CI: 1.18-3.96).

Table 3.

Sexual Identity Differences in Awareness of Heart Attack and Stroke Symptoms, National Health Interview Survey (2014 & 2017).^a,b

	Women (n = 29 918)			Men (n = 24 408)
	Model 1OR (95% CI)	Model 2AOR (95% CI)	Model 3AOR (95% CI)	Model 1OR (95% CI)	Model 2AOR (95% CI)	Model 3AOR (95% CI)
Heart attack symptoms
Aware of all heart attack symptoms
Heterosexual	Ref	Ref	Ref	Ref	Ref	Ref
Gay/lesbian	1.09 (0.84-1.41)	1.15 (0.87-1.51)	1.14 (0.86-1.50)	0.93 (0.73-1.19)	0.92 (0.72-1.18)	0.89 (0.70-1.14)
Bisexual	0.77 (0.58-1.02)	0.94 (0.71-1.25)	0.91 (0.68-1.21)	0.70 (0.45-1.09)	0.84 (0.53-1.32)	0.80 (0.51-1.27)
“Something else”	0.86 (0.52-1.42)	0.95 (0.55-1.64)	0.95 (0.55-1.64)	0.62 (0.32-1.18)	0.73 (0.36-1.45)	0.71 (0.35-1.43)
Call 911 if heart attack symptoms
Heterosexual	Ref	Ref	Ref	Ref	Ref	Ref
Gay/lesbian	1.38 (0.72-2.64)	1.27 (0.66-2.45)	1.29 (0.67-2.46)	2.29 (1.26-4.15)	2.09 (1.14-3.82)	2.16 (1.18-3.96)
Bisexual	0.92 (0.57-1.49)	0.76 (0.46-1.24)	0.75 (0.46-1.23)	2.61 (0.83-8.23)	2.31 (0.74-7.16)	2.32 (0.75-7.24)
“Something else”	1.01 (0.37-2.75)	0.89 (0.32-2.43)	0.87 (0.32-2.41)	0.86 (0.32-2.32)	0.84 (0.31-2.28)	0.86 (0.32-2.33)
Aware of heart attack symptoms and correct action
Heterosexual	Ref	Ref	Ref	Ref	Ref	Ref
Gay/lesbian	1.09 (0.84-1.42)	1.14 (0.86-1.50)	1.13 (0.86-1.49)	0.99 (0.77-1.26)	0.97 (0.76-1.24)	0.95 (0.75-1.22)
Bisexual	0.78 (0.59-1.03)	0.92 (0.70-1.21)	0.89 (0.67-1.18)	0.72 (0.46-1.13)	0.84 (0.53-1.33)	0.81 (0.51-1.30)
“Something else”	0.92 (0.56-1.52)	1.00 (0.58-1.72)	1.00 (0.58-1.72)	0.64 (0.33-1.23)	0.74 (0.37-1.49)	0.73 (0.36-1.47)
Stroke symptoms
Aware of all stroke symptoms
Heterosexual	Ref	Ref	Ref	Ref	Ref	Ref
Gay/lesbian	1.19 (0.86-1.65)	1.21 (0.87-1.69)	1.22 (0.88-1.70)	0.95 (0.72-1.25)	0.90 (0.68-1.18)	0.86 (0.65-1.13)
Bisexual	1.22 (0.89-1.67)	1.35 (0.97-1.88)	1.33 (0.94-1.85)	0.63 (0.38-1.03)	0.68 (0.41-1.12)	0.65 (0.39-1.07)
“Something else”	1.76 (0.96-3.21)	1.88 (1.03-3.44)	1.89 (1.03-3.47)	0.75 (0.41-1.36)	0.84 (0.45-1.57)	0.81 (0.43-1.54)
Call 911 if stroke symptoms
Heterosexual	Ref	Ref	Ref	Ref	Ref	Ref
Gay/lesbian	2.11 (0.84-5.35)	1.98 (0.77-5.05)	2.03 (0.80-5.18)	1.49 (0.75-2.95)	1.34 (0.68-2.68)	1.41 (0.71-2.79)
Bisexual	1.71 (0.84-3.47)	1.51 (0.74-3.06)	1.49 (0.73-3.04)	0.84 (0.36-1.94)	0.74 (0.32-1.73)	0.76 (0.33-1.77)
“Something else”	0.78 (0.26-2.40)	0.70 (0.23-2.20)	0.69 (0.22-2.15)	0.73 (0.22-2.42)	0.72 (0.22-2.40)	0.77 (0.23-2.54)
Aware of stroke symptoms and correct action
Heterosexual	Ref	Ref	Ref	Ref	Ref	Ref
Gay/lesbian	1.21 (0.88-1.66)	1.22 (0.88-1.70)	1.23 (0.89-1.71)	0.98 (0.75-1.29)	0.92 (0.71-1.21)	0.90 (0.68-1.1.7)
Bisexual	1.23 (0.91-1.67)	1.34 (0.97-1.84)	1.31 (0.95-1.81)	0.65 (0.36-1.05)	0.69 (0.42-1.12)	0.66 (0.40-1.08)
“Something else”	1.67 (0.94-2.97)	1.76 (0.98-3.14)	1.76 (0.98-3.16)	0.79 (0.22-1.43)	0.88 (0.47-1.63)	0.85 (0.45-1.62)

Abbreviations: AOR, adjusted odds ratio; CVD, cardiovascular disease.

^a N = 54 326.

^b Boldface denotes statistical significance (P < .05); reference group = heterosexual same-sex participants. Model 1 was unadjusted; model 2 added demographic characteristics; model 3 added health care access and utilization, health information technology use, CVD risk factors, and CVD history.

As presented in Table 4, we examined the intersection of sexual identity and race/ethnicity on awareness of heart attack and stroke symptoms. Black, Hispanic, and Asian heterosexual men and women reported lower rates of awareness of heart attack and stroke symptoms than their same-sex White peers. Hispanic SMW reported lower rates of awareness of heart attack symptoms (AOR = 0.43, 95% CI: 0.25-0.74) than White heterosexual women. Asian SMW reported lower rates of stroke awareness than White heterosexual women (AOR = 0.25, 95% CI: 0.08-0.80). Hispanic (AOR = 0.52, 95% CI: 0.33-0.84) and Asian SMM (AOR = 0.35, 95% CI: 0.14-0.84) reported lower rates of stroke awareness than White heterosexual men.

Table 4.

Intersection of Sexual Identity and Race/Ethnicity on Awareness of Heart Attack and Stroke Symptoms, National Health Interview Survey (2014 & 2017).^a,b

Women(n=29,918)			Men(n=24,408)
	Aware of all heart attack symptoms and correct actionAOR (95% CI)	Aware of all stroke symptoms and correct actionAOR (95% CI)		Aware of all heart attack symptoms and correct actionAOR (95% CI)	Aware of all stroke symptoms and correct actionAOR (95% CI)
White HW	Ref	Ref	White HM	Ref	Ref
Black HW	0.63 (0.56-0.70)	0.66 (0.59-0.75)	Black HM	0.75 (0.68-0.86)	0.81 (0.71-0.92)
Hispanic HW	0.47 (0.41-0.52)	0.56 (0.50-0.63)	Hispanic HM	0.65 (0.58-0.73)	0.69 (0.61-0.78)
Asian HW	0.53 (0.45-0.62)	0.54 (0.46-0.63)	Asian HM	0.54 (0.46-0.63)	0.71 (0.61-0.83)
Other race HW	0.77 (0.58-1.02)	0.78 (0.56-1.09)	Other race HM	1.05 (0.74-1.49)	0.97 (0.69-1.36)
White SMW	0.96 (0.78-1.19)	1.14 (0.89-1.46)	White SMM	0.94 (0.74-1.19)	0.89 (0.68-1.18)
Black SMW	0.87 (0.55-1.39)	1.34 (0.73-2.44)	Black SMM	0.54 (0.27-1.07)	0.73 (0.38-1.41)
Hispanic SMW	0.43 (0.25-0.74)	0.99 (0.53-1.83)	Hispanic SMM	0.59 (0.33-1.05)	0.52 (0.33-0.84)
Asian SMW	0.39 (0.13-1.14)	0.25 (0.08-0.80)	Asian SMM	0.56 (0.22-1.47)	0.35 (0.14-0.84)
Other race SMW	0.62 (0.20-1.96)	0.93 (0.24-3.56)	Other race SMM	0.38 (0.06-2.28)	1.13 (0.24-5.45)

Abbreviations: AOR, adjusted odds ratio; CVD, cardiovascular disease; HM, heterosexual men; HW, heterosexual women; SMM, sexual minority men; SMW, sexual minority women.

^a N = 54 326.

^b Boldface denotes statistical significance (P < .05); models adjusted for demographic characteristics, health care access and utilization, health information technology use, CVD risk factors, and CVD history.

Discussion

This is the first nationally representative study to assess both sexual identity and racial/ethnic differences in the awareness of heart attack and stroke symptoms among Americans. We found that women who identified their sexual identity as “something else” had greater awareness of stroke symptoms relative to heterosexual women. Given that few studies have assessed CVD risk in individuals that identify their sexual identity as “something else,” it is unknown what factors contribute to these higher rates of stroke awareness. Previous studies have found that women who identify as “something else” are more likely to report poor health-related quality of life⁴³ and tobacco use⁴⁴ than heterosexual women, which may predispose them to higher CVD risk. It is possible that, because of higher risk of CVD, these women may receive more targeted education regarding CVD conditions and their symptoms during health care encounters. Also, gay men were more likely to correctly identify calling 911 as the appropriate action if someone was having a heart attack. Future work should examine potential explanations for these differences as they were unexplained by demographic characteristics, HIT usage, and CVD risk factors.

Certain groups of sexual minorities of color had lower rates of awareness of heart attack and stroke symptoms. Hispanic SMW had lower awareness of heart attack symptoms, and Asian SMW and Hispanic and Asian SMM had lower awareness of stroke symptoms compared to their White heterosexual counterparts. No differences were identified among Black sexual minorities. With the exception of Black participants, these disparities are consistent with those found among Hispanic^27,29
-31,33 and Asian adults.^32,33 Sociocultural factors (eg, lower health literacy) might potentially explain these differences.

Moreover, several studies suggest that SMW of color, particularly Black women, have higher rates of obesity, hypertension, and diabetes relative to their White SMW peers and heterosexual women.^45

-48 Fewer studies have examined racial/ethnic differences in CVD risk in SMM. Additional research is needed to understand factors that contribute to the lower rates of awareness of CVD symptoms we observed in Hispanic and Asian sexual minorities. Our analyses should be replicated to determine if they are consistent in other samples of sexual minorities.

This work has implications for health promotion initiatives to improve awareness of CVD symptoms in minority populations. Health care providers caring for sexual minorities should be aware of the lower rates of awareness of CVD symptoms observed in racial/ethnic minority men and women. Our data suggest that, in addition to continued efforts to increase awareness of CVD symptoms among racial/ethnic minorities, there needs to be increased attention to those at highest risk, which may include sexual minorities of color. Given the mixed results of public health campaigns to improve awareness of CVD symptoms,^49

-52 it is likely that a combination of public health and clinical efforts is needed to improve awareness of CVD symptoms and prevent delay in presentation to the emergency department in marginalized populations.

We also identified higher rates of HIT usage among sexual minorities, which is consistent with previous work.^37,38,53 Multiple studies have shown that sexual minorities are less likely than heterosexual individuals to receive preventive health care (eg, cancer screening, HIV/STI screening, and vaccinations).^54
-56 Although fear of disclosing their sexual identity to health care providers has been identified as a driver of delaying or not receiving necessary care,⁵⁷ the higher rates of HIT usage we observed among sexual minorities might also be driven by the desire for specialized health information related to sexual minority health (eg, information on HIV/AIDS among SMM).

Altogether these data suggest that HIT may be a strategic platform for increasing awareness of CVD symptoms and delivering targeted prevention efforts for sexual minorities. The recent literature demonstrates that the use of HIT to target individuals at high risk of heart attack⁵⁸ and stroke symptoms⁵⁹ is growing. The high use of various capabilities of HIT (eg, searching for information, filling prescriptions, and communications with health care providers) observed among sexual minorities in this study suggests that they may be amenable to using digital health technologies that not only raise disease awareness, but also promote prevention and behavior change. Designing HIT with end users is critical for fostering engagement and bolstering trust in the information provided. Websites and digital health tools designed for the general public are insufficient.⁶⁰ Tailored digital outreach for sexual minorities can be used to complement both broader public health campaigns and individual clinical encounters.

Limitations

Despite this study’s strengths, several limitations were identified. NHIS items that assessed awareness of heart attack and stroke symptoms were closed-ended. Therefore, it is possible that awareness of CVD symptoms is overestimated in this sample. Factors that can influence awareness of CVD symptoms, including health literacy and acculturation, were not examined. In addition, due to the limited number of bisexual men and “something else” men, we may have lacked statistical power to detect differences in these groups. Additional research is needed with larger samples of men with these sexual identities. Because of sample size constraints, we were unable to compare sexual minorities of color to White sexual minorities or heterosexuals of the same race/ethnicity. Similarly, we combined gay/lesbian, bisexual, and “something else” participants into 1 category in intersectional analyses. Future research should examine whether the observed differences among Hispanic and Asian sexual minorities are present in other samples. Although we examined several indicators of health care access and utilization, the purpose and content of these health care encounters is unknown. It is important to note that several factors may have changed between 2014 and 2017 that could influence the health and health care utilization of sexual minority adults. For instance, the availability and sources of health information on the internet may have changed. Also, although support for equal rights for sexual minorities remained strong among heterosexual adults (approximately 79%) between 2014 and 2017, significant increases in discrimination against sexual minorities were reported in 2017.⁶¹ Given these rapidly changing trends, analyses of future years of NHIS data are needed to determine whether our findings remain consistent over time.

Conclusion

This study is the first of its kind to examine sexual identity and racial/ethnic differences in awareness of heart attack and stroke symptoms among adults in the United States Our results indicate that Hispanic and Asian sexual minorities had the lowest rates of awareness. These findings have implications for future research, particularly in the areas of public health awareness and HIT development. Moreover, there is a need for additional public health, clinical, and digital health-related initiatives that address the low rates of heart attack and stroke awareness among sexual minorities and heterosexuals of color.

So What? (Implications for Health Promotion Practitioners and Researchers)

What is already known on this topic?

Despite evidence of higher cardiovascular disease risk, few studies have examined awareness of heart attack and stroke symptoms among sexual minorities.

What does this article add?

This study is the first to examine sexual identity differences in awareness of heart attack and stroke symptoms among adults. Women who identified their sexual identity as “something else” were more likely to have greater awareness of stroke symptoms than heterosexual women. Gay men were more likely than heterosexual men to correctly identify calling 911 if someone is having a heart attack. In addition to supporting evidence of decreased awareness of heart attack and stroke symptoms among Black, Hispanic, and Asian heterosexual individuals, this study provides evidence that Hispanic and Asian sexual minorities have lower awareness of these symptoms compared to White heterosexuals.

What are the implications for health promotion practices or research?

Health care providers and public health practitioners should develop health education initiatives tailored to improve awareness of heart attack and stroke symptoms among racial/ethnic minorities and consider health information technology as a platform for delivering educational content. Findings suggest these efforts should address the lower rates of heart attack and stroke awareness observed among certain groups of sexual minorities of color.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Robert Wood Johnson Foundation, (Grant / Award Number: ‘Future of Nursing Scholars Program’), National Institute of Nursing Research, (Grant / Award Number: K99NR017651',‘P30NR016587’,‘R00NR016275’), National Heart, Lung, and Blood Institute, (Grant / Award Number: ‘K01HL146965’).

ORCID iD

Billy A. Caceres

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