Sunday, January 5, 2014

Million Hearts: Preventing Heart Attacks – Nazifa Abdul Rauf

Cardiovascular disease (CVD) is one of the leading causes of death in the United States, causing one of every three American deaths (resulting in approximately 800,000 deaths) (1). Some of the major risk factors for heart disease are hypertension, high cholesterol levels, and smoking; therefore addressing these factors may reduce the burden of CVD (1). And according to the National Health and Nutritional Examination Survey (NHANES) 49.7% of US adults above 20 have one of the three risk factors (nearly 107.3 millions people) Heart disease cost High blood pressures affects approximately 67 millions adults, costing the US government $51 billion in health care services and medications (1). Disparities by race and gender persist among those with hypertension – nearly 40% of African Americans suffer from high blood pressure in the United States, most of whom do not have it under control (2). They have a higher death rate from high blood pressure and heart disease and visit their physicians less frequently to receive preventative care than any other racial/ethnic or gender group (2). Additionally, 71 millions Americans suffer from high levels of cholesterol in the Unite States, with only 34 million people getting treated for it and 23 million have it under control (2). Taking high blood pressure and cholesterol medications is an essential step to controlling their blood pressure and cholesterol levels, respectively (2). Physicians often recommend adapting a healthier lifestyle to those with hypertension, but remembering to take their medications, exercising and following a strict diet can often be challenging for people (2). Furthermore, with the physician shortages our heath care system is currently facing physicians, too, are often frustrated that they have a very limited time to see their patients and work with patients to help them lower and track their levels of blood pressure and cholesterol (2). Cardiovascular disease has a significant impact on the health of our public and our economy – currently costing $444 billion in health services, medications and lost productivity (1). To reduce the prevalence of heart diseases in the United States, the U.S. Department of Health and Human Services in collaboration with key partners such as the American Heart Association (AHA) and the Center for Disease Control and Prevention launched an initiative  “Million Hearts” in 2011 with an aim to prevent 1 million heart attacks by 2017 (2). The initiative has two main goals to address this issue: improve care for those in need of treatment by focusing on “ABCS:”

A – Aspirin for people at risk
B – Blood pressure control
C – Cholesterol Management
S – Smoking Cessation

The second goal of Million Hearts is to encourage Americans to reduce or prevent tobacco use and reduce sodium and trans fat intake. Some of the strategies of the initiative to address the risk factors and ultimately reduce heart disease prevalence are:
·      Provide appropriate education and tools for patients to monitor and manage their health at home
·      Provide better access to nee health information technology
·      Improve access to providers for frequent physician consultations
The CDC released two 1-hour long and three short (~2 min) educational videos entitled “Million Hearts: Preventing Heart Disease and Stroke” as part of their initiative launch. Experienced national health policy leaders such as Kathleen Sebelius (21st Secretary of U.S. Department of Human Health Services), Dr. Thomas Freiden (Direction of CDC) and Nancy Brown (CEO of AHA) provide insightful, educational and statistical information about issues around CVD in our nation to the general public, in addition to sharing stories from Americans that survived heart attacks. The CDC and its partners also released multiple brochures providing accurate data and information on risk factors of heart disease and ways to prevent it. The brochures included statistical health data and visual images such as a graveyard to communicate their message that heart disease has a detrimental impact on our lives. This educational approach does provide the general public with the appropriate information/knowledge, but knowledge alone is not sufficient to produce behavioral changes in people (3). Although the intervention is still new and its outcomes are yet to be evaluated after 2017, I believe that their initial approach to launch the campaign and send their message to Americans would make “Million Heart” less effective from a social and behavioral sciences perspective. Thus it is imperative that appropriate social and behavioral sciences models are used to combat CVD and promote healthy behaviors. In this paper, I will explore three flaws with the CDC’s approach on reducing cases of heart attacks in the US and then present an intervention to address the current flaws with the “Million Hearts” campaign.

Flaw #1  - Framing Issue of CDC’s Primary Message
One of the major flaws of the campaign’s initial launch is that the CDC and its key partners did not frame their message effectively to invoke long-term healthy behaviors in Americans. The educational videos and brochures released by the CDC bombard the public or viewers with too many health statistics data and negative images such as a graveyard to communicate that heart disease is a leading cause in preventable death. The high health cost of heart disease overly emphasized in the videos, brochures and the campaign’s website also send people a negative message that they are costly and a burden to the government and that people should adopt the ABCS to improve their individual health and save the government costs on health care.
Framing in public health play a major role in campaign and policy formation (3). According to Menashe and Siegel, a frame is a way of presenting an issue such that it conveys a meaning and has an essential impact on the public’s and individual’s opinion and attitude toward the issue. An effective message frame impacts the public opinion poll but it also can change an individual’s behavior with the usage of strong and effect shared beliefs and values (3). A message frame consists of five major components: a core value, metaphor, catch phrases, images or symbols and a core position.

The overall message frame and its core value is health; the CDC casted to convey their primary message is that people should reduce their risk factors for heart diseases for a better and long-term health. The core position of the frame is that reducing risks of heart attack will reduce preventable deaths. Graveyard is one of the images used on the brochure, which conveys a negative message to the public. The major issue with CDC’s message framing is that health is used as a core value. Health as a core value does not frame a message powerfully enough to establish support for the change in people’s behavior and action. The public generally is generally are not driven by needs or values such as to health compared to other shared values such as freedom and happiness. According to the Maslow’s Hierarchy of Needs, people value and praise their self-actualization needs the most, yet are mainly driven by lower psychological and social needs such as food, freedom, sexual intimacy and family. The lower psychological and social needs should be met before reaching to the top of the hierarchy. An example of a message frame using family, as a frame would be to refer to heart disease as a “family destroyers.” This provides a symbol/image to the frame, it adds family/valuable relationships as a core value, and it is a catch phrase and a metaphor. This frame is more effective in my opinion because it implies that heart disease is coming not only you but it also threatens your family and destroys something very valuable and precious to us.

Flaw #2 – Initiative Makes Use of HBM
My second criticism of the campaign is that it follows the Health Belief Model (HBM) theory for an initiative that targets and is designed for the entire US population. The HBM is one of the oldest behavioral theories focused on the individual level behaviors; it originated in 1950 from the work of a US Public Health Service social psychologist Gofrey Hochbaum and colleagues. The CDC conducted their campaign using HBM and developed their information material based on the six constructs of HBM:

·      They developed brochures, educational videos, a very informative website that contains clear information and images informing the public about the risks factors of heart disease and how severely it can impact our overall health
·      The campaign in partner with other organizations then put together programs such as the ABCS that are relatively inexpensive and are covered by most insurances to show that obtaining a good CVD-free health is not costly and controlling for blood pressure, cholesterol, smoking and taking aspirin a day is what it takes to reach to the goal. In addition to the informative material, the CDC also included testimonials from heart attach survivors and two other short videos to show that the benefits of supporting the initiative are great.
·      The testimonials from family members of heart attack survivors are intended to inspire action from the people, which the CDC included as their cue for action
·      Booklets, brochures and information sheets listing simple and small steps people could take to reduce their chances of getting heart diseases were developed by the CDC for self-efficacy.

The HBM is an ineffective model to follow for a campaign such as the CDC’s Million Hearts for many reasons. It focuses largely on individual decisions and perceptions rather than on populations but does not place a great emphasis on external social and environmental factors (4). It assumes that the public values health, makes a rational cost-benefit analysis and will engage in health behaviors. Dan Ariely, in his book “Predictably Irrational: The Hidden Forces That Shape Our Decisions,” well illustrates that human behaviors and decision-making are largely influenced by internal and external factors around us rather than by intentions. Furthermore, he argues that humans do not behave in a fundamentally rational way as is described by the HBM model. Rather, our everyday experiences, “emotions, social norms, and other invisible, seemingly illogical forces skew our reasoning abilities (5).”

The model also discounts the fact that not everyone has equal access to the same information to make rational decisions about their behaviors (4). Additionally it assumes that an outcome always follows a behavior and if intervention touches upon the six constructs mentioned above, then the target will change their health behaviors.

The HBM model itself is a descriptive model rather than an explanatory. It provides individuals with information and knowledge, but does not propose a strategy to change health behaviors in the population at target. According to the contemporary health behavior theories, behavior is medicated by cognitions, which means that people’s knowledge and thinking affects their behavior or how they act (3). Secondly, knowledge is a necessary component but not sufficient enough to produce behavior changes (3). And lastly, health behavior theories also say that “perceptions, motivations, skills and the social environment are key influences on behavior (3).”

Flaw # 3 Optimism Bias and Ineffective Use of SCT
My third criticism on CDC’s approach to promoting healthy behaviors through the “Million Hearts” campaign is that it ineffectively uses the Social Cognitive/Learning Theory.  Social Cognitive Theory (SCT) is an interpersonal level health behavioral theory that says that individuals’ social environment (including family members, friends, health providers, coworkers) have a significant impact on them and their behaviors, “the opinions, thoughts, behavior, advice and support of the people surrounding an individual influence his or her feelings and behavior (3).” The CDC provides educational information to health care professionals and individuals on heart disease, but it does suggest providers and individuals work together and partner to inspire or promote behavioral changes in patients. Although, the information does provide knowledge to the patients and providers, many patients may not take action simply because they may not know how to proceed with the information they obtained. The brochure or the campaign’s website address the patients and physicians separately, which I believe sends a message that every individual is to themselves. Furthermore, SCT suggests that people learn not from their own experiences but from their observations of others. But based on the optimism bias, individuals believe that they are a less risk for developing a disease, “I was pretty healthy, I thought, obviously that proved not to be the case lately,” said a heart attack survivor during his testimonial. Thus individual interaction among individuals is essential to bring a health behavior or attitude change. 

Heart2Heart: A Path to Freedom
My alternative intervention to the “Million Hearts” campaign launched by CDC would be mainly based on Social Cognitive Theory and the Transtheoretical Models. The campaign would be named “Heart2Heart” to imply collaboration and partnership between individuals, communities, health professionals and organizations to help each other combat against heart disease. The focus of the campaign would be to reduce cases of heart disease but through a different “fun” and a more interactive approach. As I mentioned earlier in this paper, many studies have shown the positive association between heart disease, high blood pressure, high cholesterol levels, and smoking. Likewise, studies have well documented the significant impact exercising can have on the risk factors for heart disease. Therefore, my campaign would fight against heart disease and its risk factors by encouraging people to be more active in return for freedom – freedom from disease, pain, and suffering. In addition to exercising, I would also promote peer information sessions where people can share their experiences and ways they adopted healthier habits and behaviors to reduce their risks for heart disease as suggested by the SCT.

Recommended Message Framing:
Reframing the primary message of the “Million Hearts” campaign would inspire the public to modify their habits and adopt the desired behavior. The core value of the message frame should also associate with the shared belief and values Americans hold such as freedom, rebellion, and happiness. One potential way to reframe the message in the context of happiness is “if you take monitor your blood pressure, take your cholesterol medication and cease smoking you will likely have a longer and a happier life.” Alternatively, freedom is an even more powerful core value to use for effeicenitly framing a message. The tobacco industry has been successful at manipulating people’s behavior towards smoking by framing their message in the context of freedom. According to Menache and Siegel, “they shifted the opposition of smoking restriction to a broadly conceived argument equating smoking behavior with other personal liberties such as freedom of choice.”  Freedom as a core value is powerful because it is an Ameican value and is deeply embedded in our culture and law (3). The CDC used health as a core value for their campaign, which is an important core value mostly for public health activists. Like the tobacco industry, the CDC can deliver their message more effectively if they use a more compelling core value such as freedom and equality, for example, “everyone has equal rights to good heath , practicing the ABCS will increase your chances of equal health and give you the freedom – freedom from disease, pain , and suffering.” Earlier in the paper, I mentioned that a frame consists of a core value, a core position, metaphors, images/symbols. For the “Million Hearts” campaign, I would recommend the following:
Core value – Freedom
Core position – Adopt the ABCS
Metaphor – Fighting against heart disease
Catch Phrases – “Breaking free”
Images/Symbols – Statue of liberty, the American Flag

Recommended Solution to HBM
Because Million Heart is focused at decreasing rates at the population level, I would propose using a group-level behavioral model such as the Transtheoretical Model as opposed to the Health Belief Model. The TTM says that behavior change happens in stages: precontemplation, contemplation, preparation, action, and maintenance. As a first step, people should take a a survey to determine their the stage they are in. The following steps can be taken to change behavior using the TTM:

·      Provide clear and simply to read and understand information to inform people why change is needed
·      Peers, health professionals should encourage one another and set up plans on meeting their goals
·      Assist in preparing to change behavior by setting up gradual goals
·      Once they have taken action, provide support to continue maintaining behavior

Recommended Use of Social Cognitive Theory
As part of the intervention, I would recommend using the Social Cognitive Theory effectively given its proven success in changing health behavior in people. The CDC should encourage peer information sessions where heath professionals, patients and their families can interact with one another and share their experiences.
An effective use of SCT would be to address these integrate the 5 concepts of SCT in the following way (3):
·      Reciprocal Determinism
o   Develop multiple ways to promote behavioral change in the population (provide information, peer session, counseling)
·      Behavioral Capability
o   Train and teach population at risk ways to better monitor and manage their health (e.g. using blood pressure monitors)
·      Expectations
o   Set up positive expectations for everyone
·      Self-efficacy
o   Take one step at a time to change behavior so patients do not feel overwhelmed and do not give up.
·      Observational Learning
o   Peers teaching one another ways to manage their health
·      Reinforcement
o   Have small celebrations to acknowledge people’s achievement in meeting their goals.
Thaler in his paper “Nudge: Improving Decisions About Health, Wealth, and Happiness” illustrates that people are like lemmings and are “easily influenced by the statements and deeds of others (6).” He explains society can influence people’s behavior through, which means that people do what others do. Likewise, Defleur also suggest in his paper, “Socialization and Theories of Indirect Influence,” that based on the idea of behavioral imitation if a person sees someone successfully cope and resolve a problem, and then the observer will adopt that behavior for him/herself (7). Therefore, peer review session would be very effective in reducing heart disease cases in the US because health professional and patients can share their success stories with each other and pass it on.
In conclusion:
The Center for Control Disease implemented “Million Hearts” campaign to prevent 1 millions hearts by 2017. The campaign ineffectively used social and behavioral sciences models to deliver their message to the public. Their message frame did not use a strong compelling core value, which I recommended in this paper to change to freedom or equality. Additionally, the CDC mainly follows an individual level behavioral theory, the Health Belief Model, to promote change in behavior of its target population. I suggested using a group level model, the Transtheoretical Model, so promote behavioral changes in the population in different stages. Additionally, I suggested to use Social Cognitive Theory to promote interpersonal influence of peers on each other as a way to motivate people adopt healthy behaviors.

1.) Wright JS. Million Hearts™: preventing a million heart attacks and strokes through public-private collaboration. Interview by Caroline Telfer. Future Cardiol. 2013 May;9(3):305-7. doi: 10.2217/fca.13.15. PubMed PMID: 23668734.

2.) “New public-private sector initiative aims to prevent 1 million heart attacks and strokes in five years” US Department of Human and Health Services. Sep.2011

3.) Menashe CL, Siegel M. The power of a frame: an analysis of newspaper coverage of tobacco issues – United States, 1985—1996. Journal of Health Communication 1998; 3(4):307-325.

4.) Individual health behavior theories (chapter 4). In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007, pp. 35-49.

5.) Dan Ariely. Predictably Irrational: The Hidden Forces that Shape our Decisions. New York: HarperCollins Publishers, 2008.

6.) Following the herd (Chapter 3). In: Thaler RH, Sunstein CR. Nudge: Improving Decisions About Health, Wealth, and Happiness. New Haven, CT: Yale University Press, 2008, pp. 53-71.

7.) DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5th edition), Chapter 8 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plains, NY: Longman Inc., 1989.

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