Challenging Dogma - Spring 2009

Thursday, May 7, 2009

Heart Disease is the Leading Killer of Women - The Go Red Campaign’s Contribution – Susan Palmer

What do you think of when you hear the term “heart disease”? Most admit to only thinking that it is the leading cause of death among men. Many do not know that heart disease is the leading cause of death among women as well. Heart disease includes any disorder affecting the heart’s ability to function properly. This term is defined by the International Classification of Diseases (ICD) and used by Center for Disease Control's (CDC) National Center for Health Statistics (NCHS), to include “acute rheumatic fever, chronic rheumatic heart disease, hypertensive heart disease, coronary heart disease, pulmonary heart disease, congestive heart failure, and any other heart condition or disease” (1). Heart disease is the leading cause of death for both men and women in the United States (US), and accounted for approximately 28% of the 1,244,123 deaths among women in 2002 (1-2). According to the CDC’s Division for Heart Disease and Stroke Prevention, “awareness of heart disease is the number one killer of women… only 13% of the women in [a] 2003 survey perceived heart disease as their greatest health problem” (1).
There is a surprising lack of public health campaigns currently in action for prevention of heart disease, especially considering the disease is the leading cause of death among women in the US. The American Heart Association (AHA), the largest voluntary health organization, has a mission to build healthier lives free of cardiovascular diseases and stroke (3). Their Go Red for women campaign launched as recently as February of 2004 and aimed to “educate women that heart disease is their leading cause of death” (4). Unfortunately, the campaign is not as recognizable as other public health intervention campaigns such as Lance Armstrong’s “LIVESTRONG” campaign for cance or Susan G. Komen’s “for the cure” for breast cancer campaign. The Go Red campaign incorporates a forgettable catch phrase and uses a red dress as their symbol, which is incidentally the same symbol for the National Heart, Lung, and Blood Institute (NHLBI) Heart Truth campaign. In a study of 81% of women reporting they had heard about heart disease within the past 12 months, only 23% of those women had “seen, heard, or read any information about the ‘red dress’ symbol” (5). Oddly, the AHA does not have the campaign advertised on their main webpage and it takes a bit of searching to find a link to the Go Red campaign. The Go Red campaign is seemingly just a slogan suggesting that women wear red to show their support for the fight against heart disease. But it is not clear how that “fight” is being employed. How is wearing red really going to get the word out there that heart disease is the number one killer of women? The failure of this public health campaign contributes to lack of awareness of heart disease among women.
A Flawed Foundation
One major flaw of the campaign is that it seems to have been designed upon the Health Behavior Model (HBM). Based on the HBM, the campaign assumes that a woman will rationally consider her susceptibility to heart disease and the severity of heart disease if action is not taken (6-8). The campaign attempts to educate the possible risks and severity of heart disease if left untreated by providing heart disease statistics and literature on their website. It is assumed that if a woman perceives a high risk and severity of heart disease, she will then contemplate the benefits and barriers to a proposed action. The campaign’s aim is to empower women to the benefits of talking to their doctor about heart disease. By providing a “Go Red Heart CheckUp” on their website, the AHA is providing a forum upon which women can check their heart disease risk online and then print the results to bring to their next visit to the doctor. The idea here was to show women that the costs of assessing heart disease are low and access to information is plentiful, and thus the barriers are low. Upon determining that the benefits are high and the barriers are low, the campaign assumes a woman will move forward with intent to lower her heart disease risk.
In theory, this campaign would educate and persuade a woman to take preventative action against heart disease. However, few studies have evaluated whether perceived susceptibility to heart disease is associated with action to lower that risk (5). The campaign does not account for the social and environmental factors that influence a woman’s decision, such as language barriers, and lack of access to a computer or internet to utilize their website (6-8). It also does not account for those who lack access to healthcare because they do not have health insurance or do not live within close proximity to a hospital or doctors office. Additionally, the campaign does not have motivational measures in place. For example, a woman may have heard of the Go Red campaign, accessed the website, decided to assess her risk of heart disease using the “Go Red Heart CheckUp,” and found that she was indeed at risk for heart disease. When prompted at the end of the “CheckUp” to print the information out to bring to her doctor, she did so intending to schedule a visit. However, as in most cases, her doctor could only schedule her for a visit 2-3 months later, and during that lapse in time between the intention and the action, the woman decides it is not as important as originally thought, or she has a scheduling conflict, and cancels her appointment. The woman is not motivated to see her doctor or address her risk of heart disease and six months later she has a heart attack. The campaign has failed its mission.
Undermining the Call to Action
The Go Red campaign encourages awareness through informational education, but lacks tools to promote self-efficacy. Self-efficacy in this case is a woman’s belief that she can perform a certain behavior (6-8). Specifically that would mean taking steps to preventing heart disease by lowering her risks. This campaign does not translate the message into real world action to prevent heart disease. The idea of “action” for this campaign is to wear red and be educated on heart disease risks. In reality, action should be promoted not only as a chat with your doctor about your risks, but by getting involved in exercise programs or smoking cessation classes to lower risks. A 2006 study reported that women who expressed self-efficacy believed their actions could impact their risk of heart disease (5). These women were more likely to take part in physical activity and to have lost weight in the previous year (5). The study also reports that the five most common motivators for taking action to lower their risk were 1) wanting to improve health, 2) wanting to feel better, 3) wanting to live longer, 4) wanting to avoid taking medications, and 5) did it for their family (5). So it seems that there is not a lack of “wanting” to be healthy, and that the real problem may be that women are not provided with the tools to help them take action.
The Go Red campaign’s attempt to advocate action includes long “to-do” lists of ways to decrease the risk of heart disease. Such lists include “make easy lifestyle changes,” “tips for women at work,” “tips for moms on the go,” “tips for traveling for work/play,” “love your heart: relaxation tips,” with each list containing at least five actions (4). While providing helpful tips for heart-friendly activities is a step in the right direction, long “to-do” lists may prove to be more overwhelming than anything else. Tools to promote self-efficacy by showing her how to take action are not provided.
In most cases, an individual who learns a behavior by observing others and builds the skills to do that behavior will be more likely to do that behavior, especially if they believe that the behavior will lead to a positive outcome. Simply providing lists of heart-healthy activities is not enough to promote self-efficacy. Women need to feel as if they can be successful and will receive positive reinforcement for engaging in these activities. Offering AHA sponsored activities such as free heart disease risk assessment, physical activity classes, and heart-healthy nutrition seminars may help build self-efficacy. By providing women with the skills and motivation, as well as interaction with others who have heart disease risks, it will motivate them into action. Without provision of self-efficacy tools, women will feel helpless despite their “want” to take action to reduce heart disease risks. The campaign has failed its mission.
Missing the Target
Despite the reality that heart disease is the leading cause of death among women in the US, a survey conducted by the AHA in 1997 indicated that 62% of women believe cancer is the greatest health threat for women (9). Since that survey was taken, and new public health interventions have been implemented, an increase in awareness of heart disease risk has been documented (2, 5, 9, 10, 11). However, it remains inconclusive whether greater awareness has led to increased preventative actions among women (5). The Go Red campaign may only be targeting women who already perceive themselves as having a high risk of heart disease, and not those that are unaware of their risk. A study run by the AHA found that awareness was significantly greater among those who perceive themselves as having a high to moderate risk compared to those at low risk (5).
The CDC reported in 2002 that age-adjusted death rates for heart disease were higher among African American women (169.7 per 100,000) than among Caucasian women (131.2 per 100,000) (12). A 2006 study reported that racial and ethnic minorities, such as African-American women, were less likely than whites to be aware of their heart disease risk (5). Of those who were aware of a risk, minorities were more likely than whites to underestimate their risk (5). The Go Red campaign uses television, print, radio, internet, and billboards to advertise the campaign. However, the number of advertisements is limited and they fail to target African American women, who are the highest risk group. Print advertisements in newspapers and magazines are most inclusive of African-Americans. In these ads, a picture of an African-American woman is used in tandem with the Go Red slogan and message to “Go Red in Your Own Fashion” (4). However, of women aware of heart disease information, more Caucasian women (46%) reported magazines as their source of information, compared to 28% of African-American women. The Go Red campaign does not use television, radio, or billboards to target the African-American group and only use Caucasian women in the advertisements (with a Hispanic radio version available dubbed in Spanish) (4). These forums should not be discounted by the Go Red campaign and may contribute to the lack of awareness among African-American women.
A 2000 study reported that less than 20% of African-American women mentioned that they were well informed about heart disease (10). When asked to list warning signs of heart attack, less African-American women than Caucasian women correctly identified chest pain, shortness of breath, pain in the arm, chest tightness, and nausea (10). For a public health campaign designed to raise heart disease awareness among all women, Go Red seems to mostly reach Caucasian women, and not the highest at risk group of African-American women. The campaign has failed its mission.
The AHA’s Go Red campaign’s mission to spread awareness that heart disease is the leading cause of death among women has failed. For one, the campaign’s foundation has cracked under the pressure of the HBM’s lack of consideration for irrational behavior. Social and environmental factors that influence a woman’s decision are not accounted for and contribute to the campaign’s failure to educate women. The campaign lacks the tools necessary to empower women to believe their actions could impact their risk of heart disease. Instead of only promoting the wardrobe choice of wearing red, the campaign should provide resources for women to join exercise programs or smoking cessation classes to lower heart disease risks. Additionally, the campaign contributes to the lack of awareness among African-American women by not targeting this high risk group in their campaign efforts. These awareness and preventive action gaps in the Go Red campaign contribute to preventable heart disease among women in the US and must be amended before more lives are lost.
Counter-Proposal to the Go Red Campaign for Heart Disease among Women
Improvements must be made to the current approach implemented by the Go Red campaign, whose mission to spread awareness and prevent heart disease among women is failing. An alternative campaign will attempt to remedy the major flaws of that approach and feature a new design to support a shift towards empowerment. The new design will remove the Health Behavior Model (HBM) from the foundation and instead consider social and environmental factors, implement tools empowering women into action, and target African-American women, the most at risk group affected by heart disease.
The new public health campaign proposed will promote heart disease awareness through organized walk/run/bike events in all major cities throughout the year, focusing on team participation and fundraising efforts. Participants will have the option of signing up individually or with a “team,” and to raise a minimum amount of money by the day of the event. The funds raised will go towards heart disease advocacy efforts. This campaign is modeled after two of the most renowned public health campaigns, the Susan G. Komen breast cancer Race for the Cure and the Lance Armstrong LIVESTRONG for cancer. Both campaigns heavily promote advocacy for cancer awareness through physical activity and fundraising events such as walk/run or bike races. The new campaign will frequently advertise the events using various media including television, radio, internet, billboards, and magazines. Paired with popular sponsor involvement (New Balance, Nike, Powerade, etc.), the cause will be able to reach a wide audience. In addition to promoting physical activity on the day of the event, the sponsors will provide free local heart disease risk assessments/screenings, heart healthy physical activities and nutritional seminars throughout the year in effort to provide women with the tools to live healthy lifestyles and stay motivated.
Building a Strong Foundation
The HBM is a weak foundation upon which to design a public health campaign because it does not take into account all factors that influence an individual’s decision on whether or not to do a behavior. Upon studying the HBM, researchers have reported that despite various preventative measures provided free or at low cost, people fail to take advantage of early detection (7). This new heart disease awareness campaign aims to take advantage of alternative health models which are based on the theory that behavior is irrational, people are influenced by expectations, have difficulty with self control, and place a high value on ownership.
The new campaign will be based upon the Social Network Theory (SNT), the main premise being that groups of people change together. The relationships that people have with each other, such as families, work groups, or other social groups, influence each others’ beliefs and behavior (6). People exist in social networks and change as social networks, not only as individuals. This campaign strives to work with this theory to provide women at risk for heart disease the tools to build a heart disease social network. This social network will be the forum upon which they become empowered by each other to address the disease in a proactive manner.
Specifically, a woman at risk or who already has heart disease will become a member of an event team working together to improve their physical, nutritional, and emotional health in tandem with promoting awareness. Team members involved in working towards the walk/run/bike event will recruit others into the team (or “network”). Whereas the SNT typically identifies small networks to disseminate information, the new campaign builds upon the theory to appeal to a larger population. An article assessing the dynamics of a large social network on smoking cessation, describes how people seemed to be under the “collective pressure” within networks to quit smoking (13). This can also be applied to promoting healthy behavior such as heart healthy physical activity.
While the campaign may start with one person deciding to join a heart disease awareness event, that one person can recruit others to become a member of their “team,” thus spreading awareness to others (6, 13). Where the Go Red campaign was hitting barriers, the new campaign’s efforts would not be negatively impacted by lack of access to a computer or internet, or lack of access to healthcare, since the events would be locally available to all participants. Motivational measures would be in place and awareness of heart disease among women would spread.
A Time to Act
The Go Red campaign failed to translate their message into action by only advocating education on heart disease risks and wearing the color red. The new campaign aims to provide women with the tools needed to promote self-efficacy. Women have reported the intent to participate in healthy behavior, but they need to believe they can lower their risk of heart disease, and be shown how to do that (5). The new campaign offers events to get people participating in heart disease awareness activities.
Sponsored activities such as free heart disease risk assessment, physical activity classes, and heart-healthy nutrition seminars will help raise awareness and build self-efficacy. Encouraging women and their teams to not only participate in a local walk/run/bike event, but also to participate in free health activities will motivate life-long healthy behavior. The most important factor in the decision to do a behavior is the idea of “self-efficacy” where the individual has self-confidence in the ability to do that behavior. This new campaign will encourage women to participate in an event that is heart healthy, offers encouragement through a team atmosphere, and aids in holding participants accountable through fundraising efforts.
The “team” factor will not only be the primary motivator on the day of the event, but will also be a source of continuous support during the time leading up to the event. Participants will be more likely to adhere to a physical and nutritional regime if they have others (their team) to report to (13). Raising money will also keep participants accountable to sticking with the event. By asking people to donate to their event, they are much less likely to drop out, and more likely to stay motivated. Involvement in this campaign creates a sense of community where everyone is working together to get healthy and raise awareness for heart disease. The belief that the campaign will lead to a positive outcome will reinforce life-long healthy behavior and participation in heart-disease awareness efforts.
Tailoring the Message
Many women report that they believe they are most at risk for breast cancer, which infers that the Go Red campaign has failed to deliver their message (9). Specifically, African-American women who are most at risk of heart disease have reported not being well informed about heart disease risks (10). The new campaign aims to reach a wider audience, particularly African-American women. Heart disease awareness walk/run/bike events will be held in or within close proximity to major cities, targeting the areas with a high African-American population. Additionally, free local heart disease risk assessments/screenings, heart healthy physical activities and nutritional seminars will be available throughout the year in effort to provide women with the tools to live healthy lifestyles and stay motivated at no cost to them. A 2006 study found that friends and/or relatives were more influential in motivating preventive action in nonwhites than whites (5). This finding is supported by the new campaign’s team participation design, predicting that team members, in particular African-Americans, will help support each other’s efforts towards heart healthy behavior.
All events will be heavily promoted using television, radio, internet, newspapers, magazines, and billboards. Advertisements will include versions specific to Caucasian, African-American, and Hispanic women so that the target audience(s) can personally identify with the message. In a 2003 study, 41% of African-American women reported television as the most common provider of healthcare information (2). Based on this information, a higher concentration of advertisements tailored towards African-American women should be broadcast on television. By simply increasing the frequency, circulation, and tailoring of advertisements to African-American women, the campaign should reach more people and increase awareness of heart disease.
The new public health campaign proposed will promote heart disease awareness through organized physical activity events in all major cities throughout the year, focusing on team participation and fundraising efforts. The new design will be supported by the SNT, concentrating on the relationships that people have with each other and the positive influence of social networks. Tools such as free local heart disease risk assessments, heart healthy physical activities, and nutritional seminars will be made available, empowering women into action. Advertisements tailored to African-American women will reach a larger number of those most at risk of heart disease. The combined effort of all three aspects of the new public health campaign will expand its reach more women at risk and hopefully motivate those women into action. REFERENCES
1. Department of Health and Human Services Centers for Disease Control and Prevention, Women and Heart Disease Fact Sheet. Atlanta, GA: Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, 2009.
2. Mosca L, Ferris A, Fabunmi R, Robertson RM. Tracking Women’s Awareness of Heart Disease. Circulation 2004; 109:573-579.
3. American Heart Association. Mission of the American Heart Association. Dallas, TX.
4. American Heart Association. Go Red for women Media Kit 2008 fact sheet. Dallas, TX: American Heart Association Heart Disease and Stroke Statistics – 2008 Update.
5. Mosca L, Mochari H, Christian A, Berra K, Taubert K, Mills T, Burdick KA, Simpson SL. National Study of Women’s Awareness, Preventive Action, and Barriers to Cardiovascular Health. Circulation 2006; 113:525-534.
6. Edberg M. Individual Health Behavior Theories. Essentials of Health Behav Soc and Behav Theory in Pub Health. 2007; 35-38.
7. Rosenstock IM. Historical Origins of the Health Belief Model. Health Education Monographs. 1974; 2:328-335.
8. Salazar MK. Comparison of Four Behavioral Theories. AAOHN Journal. 1991; 39:128-135.
9. Robertson RM. Women and Cardiovascular Disease – The Risks of Misperception and the Need for Action. Circulation 2001; 103:2318-2320.
10. Mosca L, Jones WK, King KB, Ouyang P, Redberg RF, Hill MN. Awareness, Perception, and Knowledge of Heart Disease Risk and Prevention Among Women in the United States. Arch Fam Med 2000; 9:506-515.
11. Christian AH, Rosamond W, White AR, Mosca L. Nine-Year Trends and Racial and Ethnic Disparities in Women's Awareness of Heart Disease and Stroke. Journal of Women's Health 2007; 16(1): 68-81.
12. Centers for Disease Control and Prevention. Public Health Action Plan to Prevent Heart Disease and Stroke. Atlanta, GA: Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, 2009.
13. Christakis, NA, Fowler JH. The Collective Dynamics of Smoking in a Large Social Network. The New England Journal of Medicine 2008; 358:2249-58.

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