- Email: [email protected]
Promoting Cardiovascular Health
Strategies for Action
Promoting Cardiovascular Health From Individual Goals to Social Environmental Change Elizabeth Barnett, PhD, Tracey Anderson, MA, John Blosnich, BA, Joel Halverson, MA, Janelle Novak, MA, MPH Abstract:
A conceptual model of the relationship between well-known individual-level behavioral and biomedical risk factors for heart disease and stroke and community-level social environmental risk factors, which may be less familiar to professionals working in cardiovascular health promotion, is presented. The social environment paradigm holds that programs and interventions should focus “upstream” and attempt to directly modify social environmental conditions in order to positively influence human behaviors, and consequently disability and disease. For each of the “big five” cardiovascular risk factors (poor diet, physical inactivity, cigarette smoking, high blood pressure, and high blood cholesterol), social environmental barriers and promoters are described. This conceptual model should be a useful tool in explaining and justifying the ways in which social environmental change can improve risk factor distributions for entire populations, and subsequently reduce disability and death from heart disease and stroke. (Am J Prev Med 2005;29(5S1):107–112) © 2005 American Journal of Preventive Medicine
Introduction
T
he purpose of this paper is to provide a conceptual model of the relationship between wellknown individual-level behavioral and biomedical risk factors for heart disease and stroke and community-level social environmental risk factors that may be less familiar to professionals working in cardiovascular health promotion. One limitation to designing and implementing health promotion activities focused on the social environment has been a lack of conceptual models that make explicit links among biology, behavior, and community.1,2 We have previously offered a comprehensive definition of social environment as it relates to population health.3 Human social environments encompass the immediate physical surroundings, social relationships, and cultural milieus within which defined groups of people function and interact. Components of the social environment include built infrastructure; industrial and occupational structure; labor markets; social and economic processes; wealth; social, human, and health services; power relations; government; race/ethnic relations; social inequality; cultural practices; the arts; religious institutions and practices; and beliefs about place and community.3 From the Departments of Epidemiology and Biostatistics (Barnett), and Anthropology (Novak), University of South Florida, Tampa, Florida; and Department of Community Medicine, West Virginia University (Anderson, Blosnich, Halverson), Morgantown, West Virginia Address correspondence and reprint requests to: Elizabeth Barnett, PhD, Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd. MDC 56, Tampa FL 33612. E-mail: [email protected].
Historically, heart disease and stroke prevention efforts have centered on health education and clinical interventions.4 –7 Programs and interventions that focused on modifying the social environment, with the exception of tobacco-control activities, were not widespread in the past. In recent years, growing awareness of the importance of social environmental and policy changes in promoting cardiovascular health has resulted in activities and interventions focused on community-level change at the Centers for Disease Control and Prevention (CDC)8 and the American Heart Association (AHA).9 The conceptual model presented here provides a tool for identifying social environmental barriers and promoters of specific risk factors for heart disease and stroke in both low-risk and high-risk populations.
Background Cardiovascular health promotion has traditionally employed a health education approach focused on the major biomedical and behavioral risk factors for development of heart disease and stroke. These risk factors include hypertension, elevated blood cholesterol, obesity, poor diet, physical inactivity, and cigarette smoking. Programs and interventions for these risk factors have been designed and implemented based on a health education paradigm. Under this model, population prevalences of adverse risk conditions are thought to be modifiable by providing education and behavior change tools to individuals to help them achieve lifestyle improvements. This model predicts that the cumulative effect of educating many individuals will result
Am J Prev Med 2005;29(5S1) © 2005 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/05/$–see front matter doi:10.1016/j.amepre.2005.07.036
107
in changes in population patterns of risk factors, and subsequently, disease incidence, prevalence, and mortality. A recent scientific statement from the American Heart Association on prevention of cardiovascular disease in children illustrates this paradigm.6 The guidelines focus solely on individual behaviors and biomedical risk factors, with recommendations only for health education and clinical assessment. Similarly, the National Heart, Lung, and Blood Institute Strategic Plan for 2002–2006 includes numerous goals for research, but none that focus on social environmental prevention or intervention initiatives.10 In contrast, the social environment paradigm of health promotion holds that programs and interventions should focus “upstream,” and attempt to directly modify social environmental conditions in order to positively influence human behaviors, and consequently, disability and disease.1 Increasing excise taxes on cigarettes and enacting local ordinances limiting smoking in restaurants are two examples of health promotion activities that fall under the social environment paradigm. While social environmental approaches to cardiovascular health promotion have not been widespread, two examples from the past exemplify how a multifaceted comprehensive approach with a high degree of support from policymakers and the public can be remarkably effective in improving population health.
The North Karelia Project In 1972, the World Health Organization collaborated with researchers and public health officials in Finland and initiated a major community-based intervention to combat very high rates of heart disease mortality in the rural agricultural province of North Karelia.11 Through a number of comprehensive and coordinated interventions focused on both population-level and individuallevel change, the North Karelia Project contributed to dramatic declines in several major risk factors for heart disease, including cigarette smoking, hypertension, and high blood cholesterol.12 A key component of the success of the North Karelia Project in changing nutrition practices was the recognition of the significant barrier that dairy farming, as the base of the local economy, created for dietary change. Health professionals moved well beyond traditional health promotion activities and worked to change agricultural policy, legislation, and pricing of dairy products and other foods.11 A berry farming project was initiated, which contributed to shifts in agricultural practices over time.11 As one recent assessment noted: North Karelians’ behavior changed in healthful ways, not solely by an increase in dietary knowledge, but also because their environments were 108
changed in ways that made healthy choices more available and acceptable.13
Tobacco Control Tobacco control activities of the past two decades have undergone a remarkable and effective shift away from a focus on educating individuals about the dangers of smoking, toward a goal of changing the social environment.10,14 Some of the specific strategies that have been successfully employed have included increases in excise taxes, changes to local and state ordinances pertaining to use of tobacco in public places including government workplaces and public schools, changes in private employer policies regarding tobacco use on the job, greater regulation of tobacco advertising, and greater focus on the economic implications of reduced tobacco consumption for farmers, manufacturers, and retailers.10,11,15 Research has shown that the social environmental approach to tobacco control has direct effects on health outcomes. In Helena, Montana, a public smoking ban resulted in reduced hospital admissions for myocardial infarction within a short time period.16 In California, the statewide tobacco control program implemented in 1988 resulted in declines in both heart disease mortality17 and incidence of lung cancer.18 Recognition that for tobacco use, as well as many other risk factors, production (in the economic sense) is an important influence on human behavior (i.e., consumption) has been a key achievement of the tobacco control movement in public health. Following on this insight, public health workers, advocates, and leaders have become more sophisticated in understanding that there are powerful organizations and groups within our society that will oppose health promotion activities because of their economic interests in maintaining production and consumption of specific commodities.
Leadership in Cardiovascular Health Promotion More recently, the lessons and insights gained from “the tobacco wars” have begun to be applied to other areas of cardiovascular health promotion. One example of this is the changing public dialogue around the growing epidemic of obesity in the United States.19 Whereas in the past, many public health and medical approaches to obesity focused exclusively on changing individual behavior— often in a rhetorical context that was demoralizing, victim blaming, and condemning20,21—today, phrases like “obesogenic environment” are much more widely used. In a recent issue of the American Journal of Public Health focused on obesity, the lead editorial stated22: The sad truth is that when it comes to helping individuals lose weight, public health professionals, health care providers, and the diet industry have all been woefully unsuccessful . . .. We need
American Journal of Preventive Medicine, Volume 29, Number 5S1
Lack of social support Lack of desire to quit Lack of knowledge of cessation strategies Mental depression Family tobacco use Psychosocial stress Peer pressure Lack of facilities Cost of clothes, equipment Cost of facilities Lack of social support Aversion to physical activity Mental depression Lack of social support Cost of healthy foods Restaurant portion sizes Food preferences Diabetes Obesity Psychosocial stress Lack of medical care No money for medication Lack of social support Physical inactivity Tobacco use Potential barriers to individual goal
Lack of medical care No money for medication Lack of social support Cost of healthy foods Restaurant portion sizes Food preferences Obesity Genetics
Social support Desire to quit Negative health effects Physical activity Aversion to tobacco Good overall health Time for physical activity Knowledge Enjoyment of physical activity Adequate income Healthy food availability Time for meal preparation Knowledge Food preferences Physical activity Healthy diet Good medical care Medication Physical activity Healthy diet Good medical care Medication Control of diabetes Potential promoters of individual goal
High-risk persons Cessation of tobacco use Low-risk persons Continuation of no tobacco use Participation in regular physical activity Consumption of heart healthy diet High-risk persons Reduction of blood cholesterol Low-risk persons Preservation of normal blood cholesterol
Blood cholesterol
We have outlined a conceptual model that connects individual goals for cardiovascular health promotion with population goals, and identified both barriers and promoters of each goal (Tables 1 and 2). We have highlighted “the big five” cardiovascular risk factors: diet, physical activity, cigarette smoking, blood pressure, and blood cholesterol. However, there are certainly a number of other well-known cardiovascular risk factors that could be added as specific examples to this conceptual model, including diabetes, depression, and psychosocial stress. The distinction between individual goals and population goals is not always recognized; however, it is a critical distinction because barriers and promoters of individual goals versus population goals are often different, and require different types of health promotion activities. For example, the first individual goal listed in the table is “consumption of a heart-healthy diet.” The corresponding population goal is “increase the percentage of people who consume a heart-healthy diet.” For an individual, an important barrier might be lack of money to purchase fresh fruits and vegetables. For a
Blood pressure
Conceptual Model: Individual Goals Versus Population Goals
Table 1. Promoters and barriers to cardiovascular health at the individual level
The CDC’s State Heart Disease and Stroke Prevention Program funds state health departments to conduct a wide range of cardiovascular health promotion activities, with an emphasis on developing and implementing heart-healthy policies and physical and social environmental changes.8 Currently, 21 states and the District of Columbia are funded through this program.
Nutrition
The major public health problems of our time will not be solved merely by individual actions and health choices, but by individuals coming together to make our society one in which healthy choices are easy, fun, and popular. Communities where policies and environments focus on the latter approach will be healthier and more satisfying places to live, work, and play.
High-risk persons Reduction of blood pressure Low-risk persons Preservation of normal blood pressure
Physical activity
In recognition of the ineffectiveness of a strictly individually oriented health education approach to reducing heart disease and stroke, the CDC’s Cardiovascular Health Branch is providing leadership for the widening of health promotion efforts to encompass policy and environmental change8:
Individual goal
Tobacco
to change both policies and the environment so that they support entire communities in eating healthy foods and enjoying regular physical activity. This means reducing “supermarket wastelands” and correcting food pricing structures in low-income communities. It means improving park safety and tackling traffic flow so that it is easier to exercise.
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110 American Journal of Preventive Medicine, Volume 29, Number 5S1
Table 2. Promoters and barriers to cardiovascular health at the population level Blood pressure
Blood cholesterol
Nutrition
Physical activity
Tobacco
Population goal
High-risk persons 1 % of people whose blood pressure is normalized Low-risk persons 2 % of people who develop high blood pressure
High-risk persons 1 % of people whose blood cholesterol is normalized Low-risk persons 2 % of people who develop high blood cholesterol
1 % of people who consume heart-healthy diet
1 % of people who participate in regular physical activity
High-risk persons 1 % of tobacco users who quit Low-risk persons 2 % of people who initiate tobacco use
Potential social environment promoters of population goal
Good family incomes Good working conditions Healthy food environment Healthy recreational environment Education/health promotion Stable employment Wellness programs at work/ school
Healthy food environment Healthy recreational environment Good family incomes Good working conditions Good working conditions Healthy food environment Nutrition/diet education Cultural programs ways Wellness programs at work/ school
Good family incomes Good family incomes Good working conditions Good working Healthy food environment conditions Nutrition/diet education Healthy recreational Cultural foodways environment Organized activities Recreational programs Pedestria-friendly development
No-smoking policies Tobacco cost and taxes Insurance costs Cessation classes/programs No tobacco sales to minors Wellness programs at work/ school Pedestrian-friendly development
Potential social environment barriers to population goal
Lack of access to medical care Lack of access to medications Unstable economies Social stressors (e.g., racism) Social conflict
Lack of access to medical care Lack of access to medications Lack of grocery stores Fast food restaurants Size of grocery stores Poor economic conditions Time pressure
Lack of grocery stores Fast food restaurants Size of grocery stores Poor economic conditions Time pressure
Location of tobacco vendors Lack of public policy Economic dependence on tobacco Advertising/marketing High smoking rates Tobacco vending machines Tobacco use in public places
Climate Lack of safety/hazards Social conflict Time for physical activity Economic constraints Familial constraints
population, a barrier might be low average family incomes, resulting in large numbers of people lacking money to purchase fresh fruits and vegetables. A health promotion activity focused on the individual might be provision of vouchers or food stamps (e.g., Anderson et al.23). In contrast, a health promotion activity focused on the social environment could concentrate on improving family incomes through economic development, job creation, and support of labor union efforts to increase wages. In the North Karelia Project, direct engagement with local agricultural practices and the economic concerns of dairy farmers was necessary before population-wide declines in consumption of high-fat dairy products could be achieved.11
Conceptual Model: Low-Risk Versus High-Risk Populations We also make an important distinction between low-risk and high-risk populations in relation to specific risk factors and their related individual and population goals. Using the example of blood pressure, the low-risk population consists of everyone whose blood pressure is currently normal, while the high-risk population consists of everyone who has elevated blood pressure or a medical diagnosis of hypertension. For the low-risk population, the individual goal is to maintain normal blood pressure throughout the life span, while the population goal is to reduce or eliminate the incidence of new cases of hypertension. For the high-risk population, the individual goal is lower blood pressure, while the population goal is to increase the percentage of persons whose blood pressure is normalized. For each of these four target goals related to blood pressure, the potential barriers and promoters are different to some degree (Tables 1 and 2). An important point about primary versus secondary prevention is that while we often think of high-risk populations only in terms of secondary prevention (i.e., medical treatment and intervention), these populations can also benefit from primary prevention of related factors that may worsen the principal risk factor—in this case primary prevention of obesity, stress, poor diet, and physical inactivity will help mitigate the impact of hypertension on health outcomes.
Conceptual Model: Promoters Versus Barriers of Social Environmental Change Designing, planning, and implementing social environmental interventions to improve cardiovascular health requires attention to both promoters of, and barriers to, change. For example, worksite wellness programs focused on reducing high blood pressure or maintaining normal blood pressure need to take into account local economic conditions that may result in employ-
ment instability and high job turnover. Similarly, efforts to create and strengthen social environmental promoters of normal blood cholesterol through healthy food and recreational environments will be more successful when coupled with efforts to reduce barriers such as lack of access to medical care/medications, time pressure, and inadequate family incomes. The inclusion of both barriers and promoters of social environmental change in our model improves on the vision of the AHA Guide for Cardiovascular Health at the Community Level.9 Although the AHA Guide does include some environmental change recommendations, there is no discussion of the barriers and challenges to implementing changes such as: “Work sites should provide employer-sponsored physical activity and fitness programs.” The economic disincentives for employers to improve employee benefits are many, particularly in an economic climate wherein it is often easier and more cost-efficient for employers to simply fire workers who become sick, rather than to make a long-term investment in employee health. Therefore, it is important for health professionals to recognize that some of the most serious social environmental barriers—such as racism, poor economic conditions, and advertising—arise from social conflicts among different interest groups in society. These barriers must be tackled; they are not insurmountable. However, successful approaches will require reaching out beyond the health promotion community to form broad coalitions of public agencies, nonprofit groups, concerned citizens, and policymakers.
Conclusion The pathways by which social environmental change can impact individuals, their behaviors, and their biology are not obvious to everyone. Advocates for cardiovascular health promotion are often required to explain and justify proposed public policies, environmental changes, regulations, and communitylevel interventions to organizational leaders in the public and private sector. The conceptual model presented here should be a useful tool in explaining and justifying the ways in which social environmental change can improve risk factor distributions for entire populations, and subsequently reduce disability and death from heart disease and stroke.14,15 This work was funded through a cooperative agreement from the Association of Teachers of Preventive Medicine and the Centers for Disease Control and Prevention (CDC). We are grateful to Michele Casper, PhD (CDC), for her important contributions to this work. No financial conflict of interest was reported by the authors of this paper.
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References 1. Marmot MG. Improvement of social environment to improve health. Lancet 1998;351:57– 60. 2. Levins R, Lopez C. Toward an ecosocial view of health. Int J Health Serv 1999;29:261–93. 3. Barnett E, Casper ML. A definition of the social environment. Am J Public Health 2001;91:465 (letter to editor). 4. Krauss RM, Eckel RH, Howard B, et al. AHA Dietary Guidelines: revision 2000: a statement for healthcare professionals from the Nutrition Committee of the American Heart Association. Circulation 2000 Oct 31;102:2284 –99. 5. Thompson PD, Buchner D, Pina IL, et al. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation 2003;107:3109 –16. 6. Kavey RE, Daniels SR, Lauer RM, Atkins DL, Hayman LL, Taubert K. American Heart Association guidelines for primary prevention of atherosclerotic cardiovascular disease beginning in childhood. Circulation 2003;107:1562– 6. 7. Balady GJ, Ades PA, Comoss P, et al. Core components of cardiac rehabilitation/secondary prevention programs: a statement for healthcare professionals from the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation Writing Group. Circulation 2000;102:1069 –73. 8. Centers for Disease Control and Prevention. Heart-healthy and stroke-free states: a communication guide for policy and environmental change. Atlanta GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2004. 9. Pearson TA, Bazzarre TL, Daniels SR, et al. American Heart Association guide for improving cardiovascular health at the community level: a statement for public health practitioners, healthcare providers, and health policy makers from the American Heart Association Expert Panel on Population and Prevention Science. Circulation 2003;107:645–51.
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10. National Heart, Lung, and Blood Institute. Strategic plan, FY 2002–2006. Available at: www.nhlbi.nih.gov/resources/docs/plan/index.html. Accessed January 2002. 11. Puska P, Pietinen P, Uusitalov U. Influencing public nutrition for noncommunicable disease prevention: from community intervention to national programme— experiences from Finland. Public Health Nutr 2002;5:245–51. 12. Vartiainen E, Jousilahti P, Alfthan G, Sundvall J, Pietinen P, Puska P. Cardiovascular risk factor changes in Finland, 1972–1997. Int J Epidemiol 2000;29:49 –56. 13. Roos G, Lean M, Anderson A. Dietary interventions in Finland, Norway and Sweden: nutrition policies and changes. J Hum Nutr Diet 2002;15:99 –110. 14. U.S. Department of Health and Human Services. The health consequences of smoking: a report of the Surgeon General. Atlanta GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. 15. Sklair L. The transnational capitalist class and global capitalism: the case of the tobacco industry. Political Power Soc Theory 1998;12:3– 43. 16. Sargent RP, Shepard RM, Glantz SA. Reduced incidence of admissions for myocardial infarction associated with public smoking ban: before and after study. BMJ 2004;328:977– 83. 17. Fichtenberg CM, Glantz SA. Association of the California Tobacco Control Program with declines in cigarette consumption and mortality from heart disease. N Engl J Med 2000;343:1772–7. 18. Barnoya J, Glantz SA. Association of the California tobacco control program with declines in lung cancer incidence. Cancer Causes Control 2004;15:689 –95. 19. Gerberding JL, Marks JS. Making America fit and trim—steps big and small. Am J Public Health 2004;94:1478 –9. 20. Cahman WJ. The stigma of obesity. Sociol Q 1968;9:283–99. 21. Hebl MR, Heatherton TF. The stigma of obesity in women: the difference is black and white. Personal Social Psychol Bull 1998;24:417–26. 22. Basset MT, Perl S. Obesity: the public health challenge of our time. Am J Public Health 2004;94:1477. 23. Anderson JV, Bybee DI, Brown RM, et al. 5 a day fruit and vegetable intervention improves consumption in a low income population. J Am Diet Assoc 2001;101:195–202.
American Journal of Preventive Medicine, Volume 29, Number 5S1
Promoting Cardiovascular Health From Individual Goals to Social Environmental Change Elizabeth Barnett, PhD, Tracey Anderson, MA, John Blosnich, BA, Joel Halverson, MA, Janelle Novak, MA, MPH Abstract:
A conceptual model of the relationship between well-known individual-level behavioral and biomedical risk factors for heart disease and stroke and community-level social environmental risk factors, which may be less familiar to professionals working in cardiovascular health promotion, is presented. The social environment paradigm holds that programs and interventions should focus “upstream” and attempt to directly modify social environmental conditions in order to positively influence human behaviors, and consequently disability and disease. For each of the “big five” cardiovascular risk factors (poor diet, physical inactivity, cigarette smoking, high blood pressure, and high blood cholesterol), social environmental barriers and promoters are described. This conceptual model should be a useful tool in explaining and justifying the ways in which social environmental change can improve risk factor distributions for entire populations, and subsequently reduce disability and death from heart disease and stroke. (Am J Prev Med 2005;29(5S1):107–112) © 2005 American Journal of Preventive Medicine
Introduction
T
he purpose of this paper is to provide a conceptual model of the relationship between wellknown individual-level behavioral and biomedical risk factors for heart disease and stroke and community-level social environmental risk factors that may be less familiar to professionals working in cardiovascular health promotion. One limitation to designing and implementing health promotion activities focused on the social environment has been a lack of conceptual models that make explicit links among biology, behavior, and community.1,2 We have previously offered a comprehensive definition of social environment as it relates to population health.3 Human social environments encompass the immediate physical surroundings, social relationships, and cultural milieus within which defined groups of people function and interact. Components of the social environment include built infrastructure; industrial and occupational structure; labor markets; social and economic processes; wealth; social, human, and health services; power relations; government; race/ethnic relations; social inequality; cultural practices; the arts; religious institutions and practices; and beliefs about place and community.3 From the Departments of Epidemiology and Biostatistics (Barnett), and Anthropology (Novak), University of South Florida, Tampa, Florida; and Department of Community Medicine, West Virginia University (Anderson, Blosnich, Halverson), Morgantown, West Virginia Address correspondence and reprint requests to: Elizabeth Barnett, PhD, Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd. MDC 56, Tampa FL 33612. E-mail: [email protected].
Historically, heart disease and stroke prevention efforts have centered on health education and clinical interventions.4 –7 Programs and interventions that focused on modifying the social environment, with the exception of tobacco-control activities, were not widespread in the past. In recent years, growing awareness of the importance of social environmental and policy changes in promoting cardiovascular health has resulted in activities and interventions focused on community-level change at the Centers for Disease Control and Prevention (CDC)8 and the American Heart Association (AHA).9 The conceptual model presented here provides a tool for identifying social environmental barriers and promoters of specific risk factors for heart disease and stroke in both low-risk and high-risk populations.
Background Cardiovascular health promotion has traditionally employed a health education approach focused on the major biomedical and behavioral risk factors for development of heart disease and stroke. These risk factors include hypertension, elevated blood cholesterol, obesity, poor diet, physical inactivity, and cigarette smoking. Programs and interventions for these risk factors have been designed and implemented based on a health education paradigm. Under this model, population prevalences of adverse risk conditions are thought to be modifiable by providing education and behavior change tools to individuals to help them achieve lifestyle improvements. This model predicts that the cumulative effect of educating many individuals will result
Am J Prev Med 2005;29(5S1) © 2005 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/05/$–see front matter doi:10.1016/j.amepre.2005.07.036
107
in changes in population patterns of risk factors, and subsequently, disease incidence, prevalence, and mortality. A recent scientific statement from the American Heart Association on prevention of cardiovascular disease in children illustrates this paradigm.6 The guidelines focus solely on individual behaviors and biomedical risk factors, with recommendations only for health education and clinical assessment. Similarly, the National Heart, Lung, and Blood Institute Strategic Plan for 2002–2006 includes numerous goals for research, but none that focus on social environmental prevention or intervention initiatives.10 In contrast, the social environment paradigm of health promotion holds that programs and interventions should focus “upstream,” and attempt to directly modify social environmental conditions in order to positively influence human behaviors, and consequently, disability and disease.1 Increasing excise taxes on cigarettes and enacting local ordinances limiting smoking in restaurants are two examples of health promotion activities that fall under the social environment paradigm. While social environmental approaches to cardiovascular health promotion have not been widespread, two examples from the past exemplify how a multifaceted comprehensive approach with a high degree of support from policymakers and the public can be remarkably effective in improving population health.
The North Karelia Project In 1972, the World Health Organization collaborated with researchers and public health officials in Finland and initiated a major community-based intervention to combat very high rates of heart disease mortality in the rural agricultural province of North Karelia.11 Through a number of comprehensive and coordinated interventions focused on both population-level and individuallevel change, the North Karelia Project contributed to dramatic declines in several major risk factors for heart disease, including cigarette smoking, hypertension, and high blood cholesterol.12 A key component of the success of the North Karelia Project in changing nutrition practices was the recognition of the significant barrier that dairy farming, as the base of the local economy, created for dietary change. Health professionals moved well beyond traditional health promotion activities and worked to change agricultural policy, legislation, and pricing of dairy products and other foods.11 A berry farming project was initiated, which contributed to shifts in agricultural practices over time.11 As one recent assessment noted: North Karelians’ behavior changed in healthful ways, not solely by an increase in dietary knowledge, but also because their environments were 108
changed in ways that made healthy choices more available and acceptable.13
Tobacco Control Tobacco control activities of the past two decades have undergone a remarkable and effective shift away from a focus on educating individuals about the dangers of smoking, toward a goal of changing the social environment.10,14 Some of the specific strategies that have been successfully employed have included increases in excise taxes, changes to local and state ordinances pertaining to use of tobacco in public places including government workplaces and public schools, changes in private employer policies regarding tobacco use on the job, greater regulation of tobacco advertising, and greater focus on the economic implications of reduced tobacco consumption for farmers, manufacturers, and retailers.10,11,15 Research has shown that the social environmental approach to tobacco control has direct effects on health outcomes. In Helena, Montana, a public smoking ban resulted in reduced hospital admissions for myocardial infarction within a short time period.16 In California, the statewide tobacco control program implemented in 1988 resulted in declines in both heart disease mortality17 and incidence of lung cancer.18 Recognition that for tobacco use, as well as many other risk factors, production (in the economic sense) is an important influence on human behavior (i.e., consumption) has been a key achievement of the tobacco control movement in public health. Following on this insight, public health workers, advocates, and leaders have become more sophisticated in understanding that there are powerful organizations and groups within our society that will oppose health promotion activities because of their economic interests in maintaining production and consumption of specific commodities.
Leadership in Cardiovascular Health Promotion More recently, the lessons and insights gained from “the tobacco wars” have begun to be applied to other areas of cardiovascular health promotion. One example of this is the changing public dialogue around the growing epidemic of obesity in the United States.19 Whereas in the past, many public health and medical approaches to obesity focused exclusively on changing individual behavior— often in a rhetorical context that was demoralizing, victim blaming, and condemning20,21—today, phrases like “obesogenic environment” are much more widely used. In a recent issue of the American Journal of Public Health focused on obesity, the lead editorial stated22: The sad truth is that when it comes to helping individuals lose weight, public health professionals, health care providers, and the diet industry have all been woefully unsuccessful . . .. We need
American Journal of Preventive Medicine, Volume 29, Number 5S1
Lack of social support Lack of desire to quit Lack of knowledge of cessation strategies Mental depression Family tobacco use Psychosocial stress Peer pressure Lack of facilities Cost of clothes, equipment Cost of facilities Lack of social support Aversion to physical activity Mental depression Lack of social support Cost of healthy foods Restaurant portion sizes Food preferences Diabetes Obesity Psychosocial stress Lack of medical care No money for medication Lack of social support Physical inactivity Tobacco use Potential barriers to individual goal
Lack of medical care No money for medication Lack of social support Cost of healthy foods Restaurant portion sizes Food preferences Obesity Genetics
Social support Desire to quit Negative health effects Physical activity Aversion to tobacco Good overall health Time for physical activity Knowledge Enjoyment of physical activity Adequate income Healthy food availability Time for meal preparation Knowledge Food preferences Physical activity Healthy diet Good medical care Medication Physical activity Healthy diet Good medical care Medication Control of diabetes Potential promoters of individual goal
High-risk persons Cessation of tobacco use Low-risk persons Continuation of no tobacco use Participation in regular physical activity Consumption of heart healthy diet High-risk persons Reduction of blood cholesterol Low-risk persons Preservation of normal blood cholesterol
Blood cholesterol
We have outlined a conceptual model that connects individual goals for cardiovascular health promotion with population goals, and identified both barriers and promoters of each goal (Tables 1 and 2). We have highlighted “the big five” cardiovascular risk factors: diet, physical activity, cigarette smoking, blood pressure, and blood cholesterol. However, there are certainly a number of other well-known cardiovascular risk factors that could be added as specific examples to this conceptual model, including diabetes, depression, and psychosocial stress. The distinction between individual goals and population goals is not always recognized; however, it is a critical distinction because barriers and promoters of individual goals versus population goals are often different, and require different types of health promotion activities. For example, the first individual goal listed in the table is “consumption of a heart-healthy diet.” The corresponding population goal is “increase the percentage of people who consume a heart-healthy diet.” For an individual, an important barrier might be lack of money to purchase fresh fruits and vegetables. For a
Blood pressure
Conceptual Model: Individual Goals Versus Population Goals
Table 1. Promoters and barriers to cardiovascular health at the individual level
The CDC’s State Heart Disease and Stroke Prevention Program funds state health departments to conduct a wide range of cardiovascular health promotion activities, with an emphasis on developing and implementing heart-healthy policies and physical and social environmental changes.8 Currently, 21 states and the District of Columbia are funded through this program.
Nutrition
The major public health problems of our time will not be solved merely by individual actions and health choices, but by individuals coming together to make our society one in which healthy choices are easy, fun, and popular. Communities where policies and environments focus on the latter approach will be healthier and more satisfying places to live, work, and play.
High-risk persons Reduction of blood pressure Low-risk persons Preservation of normal blood pressure
Physical activity
In recognition of the ineffectiveness of a strictly individually oriented health education approach to reducing heart disease and stroke, the CDC’s Cardiovascular Health Branch is providing leadership for the widening of health promotion efforts to encompass policy and environmental change8:
Individual goal
Tobacco
to change both policies and the environment so that they support entire communities in eating healthy foods and enjoying regular physical activity. This means reducing “supermarket wastelands” and correcting food pricing structures in low-income communities. It means improving park safety and tackling traffic flow so that it is easier to exercise.
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Table 2. Promoters and barriers to cardiovascular health at the population level Blood pressure
Blood cholesterol
Nutrition
Physical activity
Tobacco
Population goal
High-risk persons 1 % of people whose blood pressure is normalized Low-risk persons 2 % of people who develop high blood pressure
High-risk persons 1 % of people whose blood cholesterol is normalized Low-risk persons 2 % of people who develop high blood cholesterol
1 % of people who consume heart-healthy diet
1 % of people who participate in regular physical activity
High-risk persons 1 % of tobacco users who quit Low-risk persons 2 % of people who initiate tobacco use
Potential social environment promoters of population goal
Good family incomes Good working conditions Healthy food environment Healthy recreational environment Education/health promotion Stable employment Wellness programs at work/ school
Healthy food environment Healthy recreational environment Good family incomes Good working conditions Good working conditions Healthy food environment Nutrition/diet education Cultural programs ways Wellness programs at work/ school
Good family incomes Good family incomes Good working conditions Good working Healthy food environment conditions Nutrition/diet education Healthy recreational Cultural foodways environment Organized activities Recreational programs Pedestria-friendly development
No-smoking policies Tobacco cost and taxes Insurance costs Cessation classes/programs No tobacco sales to minors Wellness programs at work/ school Pedestrian-friendly development
Potential social environment barriers to population goal
Lack of access to medical care Lack of access to medications Unstable economies Social stressors (e.g., racism) Social conflict
Lack of access to medical care Lack of access to medications Lack of grocery stores Fast food restaurants Size of grocery stores Poor economic conditions Time pressure
Lack of grocery stores Fast food restaurants Size of grocery stores Poor economic conditions Time pressure
Location of tobacco vendors Lack of public policy Economic dependence on tobacco Advertising/marketing High smoking rates Tobacco vending machines Tobacco use in public places
Climate Lack of safety/hazards Social conflict Time for physical activity Economic constraints Familial constraints
population, a barrier might be low average family incomes, resulting in large numbers of people lacking money to purchase fresh fruits and vegetables. A health promotion activity focused on the individual might be provision of vouchers or food stamps (e.g., Anderson et al.23). In contrast, a health promotion activity focused on the social environment could concentrate on improving family incomes through economic development, job creation, and support of labor union efforts to increase wages. In the North Karelia Project, direct engagement with local agricultural practices and the economic concerns of dairy farmers was necessary before population-wide declines in consumption of high-fat dairy products could be achieved.11
Conceptual Model: Low-Risk Versus High-Risk Populations We also make an important distinction between low-risk and high-risk populations in relation to specific risk factors and their related individual and population goals. Using the example of blood pressure, the low-risk population consists of everyone whose blood pressure is currently normal, while the high-risk population consists of everyone who has elevated blood pressure or a medical diagnosis of hypertension. For the low-risk population, the individual goal is to maintain normal blood pressure throughout the life span, while the population goal is to reduce or eliminate the incidence of new cases of hypertension. For the high-risk population, the individual goal is lower blood pressure, while the population goal is to increase the percentage of persons whose blood pressure is normalized. For each of these four target goals related to blood pressure, the potential barriers and promoters are different to some degree (Tables 1 and 2). An important point about primary versus secondary prevention is that while we often think of high-risk populations only in terms of secondary prevention (i.e., medical treatment and intervention), these populations can also benefit from primary prevention of related factors that may worsen the principal risk factor—in this case primary prevention of obesity, stress, poor diet, and physical inactivity will help mitigate the impact of hypertension on health outcomes.
Conceptual Model: Promoters Versus Barriers of Social Environmental Change Designing, planning, and implementing social environmental interventions to improve cardiovascular health requires attention to both promoters of, and barriers to, change. For example, worksite wellness programs focused on reducing high blood pressure or maintaining normal blood pressure need to take into account local economic conditions that may result in employ-
ment instability and high job turnover. Similarly, efforts to create and strengthen social environmental promoters of normal blood cholesterol through healthy food and recreational environments will be more successful when coupled with efforts to reduce barriers such as lack of access to medical care/medications, time pressure, and inadequate family incomes. The inclusion of both barriers and promoters of social environmental change in our model improves on the vision of the AHA Guide for Cardiovascular Health at the Community Level.9 Although the AHA Guide does include some environmental change recommendations, there is no discussion of the barriers and challenges to implementing changes such as: “Work sites should provide employer-sponsored physical activity and fitness programs.” The economic disincentives for employers to improve employee benefits are many, particularly in an economic climate wherein it is often easier and more cost-efficient for employers to simply fire workers who become sick, rather than to make a long-term investment in employee health. Therefore, it is important for health professionals to recognize that some of the most serious social environmental barriers—such as racism, poor economic conditions, and advertising—arise from social conflicts among different interest groups in society. These barriers must be tackled; they are not insurmountable. However, successful approaches will require reaching out beyond the health promotion community to form broad coalitions of public agencies, nonprofit groups, concerned citizens, and policymakers.
Conclusion The pathways by which social environmental change can impact individuals, their behaviors, and their biology are not obvious to everyone. Advocates for cardiovascular health promotion are often required to explain and justify proposed public policies, environmental changes, regulations, and communitylevel interventions to organizational leaders in the public and private sector. The conceptual model presented here should be a useful tool in explaining and justifying the ways in which social environmental change can improve risk factor distributions for entire populations, and subsequently reduce disability and death from heart disease and stroke.14,15 This work was funded through a cooperative agreement from the Association of Teachers of Preventive Medicine and the Centers for Disease Control and Prevention (CDC). We are grateful to Michele Casper, PhD (CDC), for her important contributions to this work. No financial conflict of interest was reported by the authors of this paper.
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