Health promotion programs should be created to initially attack the above risk factors at the primary prevention level. The risk factors that are most associated with primary prevention include obesity, smoking, and alcohol consumption. These are the most reversible risk factors and the majority of funding should be directed at this level. In addition, health promotion strategies should involve improving physical activity levels in conjunction with diet modification (ex: low fat, low cholesterol, and low sodium). Furthermore, smoking cessation is an extremely important component of primary prevention and decreasing the consumption of alcohol would be beneficial. At the secondary level of prevention, screening for early detection of DM2, HTN, renal insufficiency, and dyslipidemia with routine outpatient clinic visits and serum lab tests are essential. If any of the screening tests are positive, then primary preventive measures should be the 1st line of defense against further disease progression. However, if the disease progresses further, than tertiary preventive measures should be instituted to control the complications of CVD. Tertiary care may consist of medications [aspirin, plavix, statins (Fievet & Staels, 2009), ACE-inhibitors, beta-blockers, metformin, sulfonylureas, insulin (Park & Wexler, 2009)], or procedural interventions (Percutaneous Transluminal Coronary Angioplasty, Coronary Artery Bypass Graft).
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CVD is an important condition for health promoters to intervene because it consists of multiple diseases. Health promotion and health education programs directed at decreasing the incidence of CVD is a very efficient and all-encompassing effort in controlling DM2, HTN, CVA, and dyslipidemia. In addition, health prevention programs must collaborate with multiple specialists (such as cardiologists, neurologists, vascular surgeons, and thoracic surgeons). CVD is the leading cause of death in developing countries. The statistics are alarming, with an incidence of 1.25 million heart attacks per year in last decade and a prevalence of 17 million individuals with a personal history of a heart attack. The mortality rates are extensive as well, with approximately 800,000 deaths per year which is equivalent to 35.3% of all deaths in the United States (relative mortality of other conditions compared to CVD: cancer 2/3 as many deaths, accidents 1/7, and HIV 1/40). Interventions begin early because cholesterol plaque deposits in blood vessels occur among most people over the age of 20. Even control of one CVD risk factor (like DM2, or smoking) has major implications on decreasing the incidence of CVD overall. Currently, there are multiple health promotion and health education programs directed at multiple diseases under the rubric of CVD with risk factors that overlap substantially. This method is very disorganized, ineffective, inefficient, and costly. If these programs were consolidated in a way to target the overlapping risk factors rather than the multiple CVD outcomes, then they would be more effective at preventing many diseases at lower cost. Health promotion and health education programs have the potential of being very successful in decreasing the incidence of CVD because the risk factors and complications are treatable and highly reversible (Gerr, 2009).
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Program: (Comprehensive CVD Health promotion Program Example), (Sitaker, Jernigan, Ladd, & Patanian, 2008), (CDC, 2009)
Model: Logic Model, (Goldman & Schmalz, 2006) , (McLaughlin & Jordan, 1999)
Outcomes — Impact
State program funding
Expertise of professional staff and infrastructure
Internal epidemiology partners and stakeholders
Internal epidemiology support for surveillance and evaluation
Programmatic guidance training
Educate Clinic Teams about Clinical Guidelines
Provide training to clinic teams in all 3 levels of prevention
Work with Media
CAD/CVA Stroke campaign
Worksite HP health programs
CAD Facilitation Project
CVA prevention meetings
Primary prevention service delivery
Adult/Pediatric populations at state and national levels
Federal/State/ and Local governments
Media and marketing representatives
Health professional organizations (AMA)
Collaboration: American Heart Association, American Diabetes Association
Increase in appropriate treatment of HTN, DM2, dyslipidemia
Skills of clinic teams developed to implement primary preventive strategies
Partnerships and collaborations are established and effective
Increased public awareness/knowledge of the signs and symptom of heart disease and stroke,
Increased public knowledge to call 9-1-1
Improved aspiration/motivation of target populations to decrease incidence of CVD
Improved learning of Basic Life Support protocols among the general public
Increase in number of patients with blood pressure, accuchecks, and serum lipids under control
Enhanced public health system structure
Improved quality of care
Improved emergency response to acute events
Better management of chronic conditions
Individual behavior change
Improved patient management of CVD co-morbidities
Decrease in CVD incidence
Decreased CDV morbidity/mortality
Reduce health disparities between privileged and underprivileged populations
Improved access to insurance
Improved legal representation of employees in worker’s compensation cases
Healthier food choices in public restaurants and fast food enterprises
Program: (Comprehensive CVD HP Program) (cont.), (Sitaker, Jernigan, Ladd, & Patanian, 2008), (CDC, 2009)
Situation: Logic Model, (Goldman & Schmalz), (McLaughlin & Jordan, 1999)
Outcomes – Impact
Conduct CVD workshops
Develop CVD resources
Produce surveillance analyses
Inventory of CVD epidemiologic data
Patient Counseling on CVD risk factors
Physical Activity Professionals
Department of Transportation (vouchers for patients in poverty)
Improved attitudes and opinions of CVD prevention through patient counseling
Improved management of CVD risk factors
Improved lifestyle behavior modification among patients
Dr. Campo provided five key lessons in her lecture to develop a successful health communication program to prevent CVD. The three lessons that will be discussed include human behavior is complex, do your homework/test/know your audience, and collaborate (Campo, 2008). While implementing these lessons, it is important to be reliable, accurate, and timely in order to have effective health communication (Sutter, 2009).
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Human behavior is complex and unpredictable and requires complex messages and communication strategies. In order to improve message sustainability, health communicators should utilize persuasive literature, improved message complexity, and edutainment. Sesame Street uses edutainment by providing entertaining health information at an early age (ex: the Cookie Monster eating apples) (Campo, 2008). These messages target childhood obesity, which is the greatest current barrier to improving CVD (Gerr, 2009). In addition, message complexity can be improved by increasing the number of channels utilized while considering the surroundings. Furthermore, interpersonal channels involve healthcare providers speaking to patients face to face about anti-CVD interventions. Moreover, guerilla marketing techniques utilize dramatic stunts to relay health messages (e.g., blow up a wall with TNT to display the effects of hypertension on blood vessels). Another cost-effective method is communicating CVD risk factor information through the internet (Campo, 2008).
Another lesson in Dr. Campo’s lecture involves doing your homework, and test/know your audience. It is best to know the target audience well in order to understand what is driving their behavior. Subsequently, the health communicator must adapt the message according to the target population (Campo, 2008). For example, health communication strategies can be applied to blood pressure and cholesterol screening. Before initiating a national campaign, audience testing must be directed towards the target community to see how people feel about it. In addition, different populations with CVD (such as white vs. black) must be separately tested because they have different decision-making processes secondary to substantial disparities in healthcare access (Mensah, Mokdad, Ford, Greenlund, & Croft, 2005).
The third lesson to be analyzed from Dr. Campo’s lecture involves collaboration and forming CVD partnerships with researchers, practitioners, and community members to implement the other four lessons. Working with patients with CVD in an interdisciplinary way provides the best health communication ideas, and maximizes involvement with target audiences (Campo, 2008). Collaboration is critical for any communication activity or endeavor, and is especially important when working with disenfranchised groups experiencing significant health disparities (Mensah, Mokdad, Ford, Greenlund, & Croft, 2005).
The CDC and AHA have collaborated with the National Heart Disease and Stroke Prevention Program to formulate a health campaign to decrease the incidence of CVD in the United States. The socio-cognitive theory is quite suitable for implementation of this health campaign. This theory primarily works at the interpersonal level and its foundation relies on social learning (Chrisman, 2009). Therefore, behavior changes between people are fostered by conducting surveillance of CVD related risk factors by health care providers and subsequently providing primary prevention counseling to high risk patients. In addition, population-based strategies focus on an identified population or area and include policy, environmental, and systems changes to alter social perceptions on CVD prevention (CDC, 2005).
Components of the socio-cognitive theory involve population approaches, considering the social context, dynamic processes, health behavior changes, and outcome expectancies (Rimer & Glanz, 2005). Current approaches need to utilize preventive strategies by analyzing the extent of CVD in the population (CDC, 2009). In addition, this campaign considers the social context by identifying culturally appropriate approaches to promote heart disease and stroke prevention among racial, ethnic, and other priority populations (CDC, 2005). Furthermore, dynamic processes analyze personal factors with environmental factors and human behaviors. This campaign implements this process by developing a plan for CVD prevention with an emphasis on policy development and environmental change. Health behavior changes are primarily dependent on self-efficacy and health campaign goals. Public health officials need to empower high risk populations (those with dysmetabolic syndrome) through education of lifestyle factors and smoking cessation. Moreover, outcome expectancies can be done by modulating educational campaigns about risk factor modification to control for dysmetabolic syndrome and reducing the overall risk of developing CVD (CDC, 2009).
The socio-cognitive theory also utilizes various constructs such as reciprocal determinism, behavioral capability, expectations, observational learning and reinforcements (Rimer & Glanz, 2005). Reciprocal determinism is the theory that a person’s behavior both influences and is influenced by personal factors and the social environment. This is reflected by implementing and evaluating policy, environmental, and educational CVD interventions in health care sites, work sites, and communities. Behavioral capability utilizes population-based public health strategies to increase public awareness of the signs and symptoms of heart disease and stroke, and the need to call 9-1-1. In addition, the expectations construct promotes health care systems to support increased adherence to guidelines for CVD prevention, by improving policy and environmental buffering of unhealthy lifestyles. Furthermore, observational learning is exemplified by encouraging training health care providers on health care systems. Finally, alliance need to be formed at all levels of the socio-economic model to enhance secondary prevention programs (such as early detection of CVD) and increase compliance with federal regulations (CDC, 2009).
CVD health education can be performed at all levels of the socio-ecologic model (individual, interpersonal, organizational, community, society/public policy, and supra-nation) (Beswick, 2009). Unfortunately, lack of training and education at the individual level (about CVD risk factors) is a major barrier that impedes the achievement of optimal health (Oprescu, 2009). When counseling patients to stop smoking, the health educator can utilize the trans-theoretical/stages of change model and stratify which level (pre-contemplation, contemplation, preparation, action, maintenance) their patient is and manage accordingly. Furthermore, health educators must understand different personality types and describe the effect of personality on health behaviors and disease development (Davidson, 2009). For example, type A personality has been associated with CVD and this relationship should be addressed by the healthcare provider (Archer, 2009).
At the interpersonal level, health educators should consider social networks and social support systems. Informational support can be provided by brochures explaining preventive strategies against CVD (Beswick, 2009). Furthermore, health educators must explain health messages in a way that is culturally sensitive and appropriate (Oprescu, 2009). This can be done by counseling African American patients about their increased risk of developing diabetes compared to other racial groups, the potential complications of diabetes (e.g., heart attacks, strokes, amputations, blindness), and how to improve their lifestyle and diet (Brown & Abdelhafiz, 2009). At the organizational level, health educators should focus on bottom up messages rather than top down (Oprescu, 2009). Worksite health education programs must strive to overcome challenges provided by disability and the subsequent loss of school and workdays from CVD. Effective solutions involve strategies originating from primary prevention methods (e.g., smoking cessation, lifestyle modifications) (Monahan, 2009). Organization based programs must utilize evidence based medicine to provide conditions supportive of health behavior changes, use several methods of intervention, and dynamically adapt to specific organization needs (Malenfant, 2009) (e.g., increase in prevalence of hypertension secondary to lead exposure) (Gerr, 2009).
Community level health educational strategies involve analyzing social relationships to reach large populations utilizing media and interpersonal strategies. The challenges that need to be overcome involve poor habits among health professionals (e.g., smoking), chronic illnesses (DM, HTN), population resistance, and health barriers involving health care systems. Similar to the organizational level, community level interventions should primarily focus on primary prevention. In addition, effective media utilization involves applying pressure to policy makers thereby empowering communities (Monahan, 2009). Furthermore, health educators must evaluate what is good for the community and subsequently transfer relevant information (via diffusion of innovation) (Oprescu, 2009). At the society/public policy level there exists the potential for making huge impacts on population health behaviors. In order to accomplish this, health educators need to educate policy makers to improve current CVD health regulations. This can be done by lobbying for CVD prevention strategies. In addition, advocation efforts must focus on decision makers to alleviate social inequity in our health care system (regarding CVD) (Oprescu, 2009). At the supra-nation level, cross cultural expansion is required to transmit universal CVD prevention themes internationally. Moreover, health educators must utilize the latest technology (via the internet) to transfer the latest CVD research information from developed countries to developing nations (e.g., benefits of aspirin prophylaxis for CVD).
The “Policy Creation Flowchart” includes 7 steps. Whenever there is a problem with any step, one must evaluate the previous steps to see where the process broke down (Pollack, 2009). Step 1 identifies, describes, and analyzes the problem (Pollack, 2009). Epidemiologically, CVD is the leading cause of death in the United States, and approximately eighty million Americans possess at least one of the subtypes of CVD (CDC, 2009). Step 2 assesses community capacity and readiness to determine if policy is an appropriate strategy and recognizes the need for a written policy. If it is not, then policy makers must improve awareness, education or environmental support strategies by referring back to step 1. However, if policy is an appropriate strategy, then it is ok to move to step 3 (Pollack, 2009). Capacity building for CVD is performed by empowering health care providers on prevention strategies and treatment options for multiple CVD co-morbidities that occur simultaneously (e.g., ACE inhibitors to prevent renal failure in patients with co-morbid hypertension and diabetes) (George, Matters, McGruder, Valderrama, & Xie, 2008).
Step 3 involves setting goals, objectives and policy options (Pollack, 2009). This can be done by utilizing population-based public health strategies to increase public awareness of the signs and symptoms of heart disease and stroke, and the need to call 9-1-1. Based on this, other policy options include increased detection and treatment of CVD risk factors and increased early detection and treatment of heart disease and stroke (Greenlund, Croft, & Mensah, 2004). Step 4 identifies decision makers and influencers. Any person who can influence lawmakers about an issue can help shape policy. These can include identifying individuals, communities, organizations, media, lobbyists, public health departments, and state legislators that can help with CVD policy implementation (Pollack, 2009). Step 5 builds support for policy among decision makers and determines if support for a particular policy is sufficient. If it is not sufficient, policy makers must develop an action plan to build support and refer back to steps 1-4. However, if support that is gathered is sufficient, then policy makers can move on to step 6 (Pollack, 2009). Regarding CVD, step 5 can be implemented by increasing public awareness, focusing on high-risk populations to eliminate disparities, and facilitating collaboration among public and private sector partners (through representational and facilitative advocacy) (Binger, 2009).
Step 6 involves writing and/or revising the policy and ascertaining if the policy been adopted. If it has not been adopted, then the policy maker should restrategize and go back to steps 1-5. However, if the policy has been adopted, then the policy maker may advance to step 7 (Pollack, 2009). For example, policy formation must involve CVD prevention strategies that focus on risk factor modification and reducing healthcare disparities (CDC, 2009). Step 7 involves implementation of the policy. CVD policy implementation should occur at all levels of the SEM by the formation of alliances to improve existing CVD prevention programs that are targeted to reduce CVD co-morbidities and increase compliance with CVD regulations (Pollack, 2009).
There are four steps to program planning (assessment, plan, intervention, evaluation) (Nothwer, 2009). In addition, there are nine principles to CBPR. These include: 1) recognizing the community as a unit of identity, 2) builds on strengths and resources within the community, 3) facilitates collaborative, equitable involvement of all partners in all phases of the research, 4) integrates knowledge and action for mutual benefit of all partners, 5) promotes a co-learning and empowering process that attends to social inequalities, 6) involves a cyclical and iterative process, 7) addresses health from both positive and ecological perspectives, 8) disseminates findings and knowledge gained to all partners, and 9) involves a long-term commitment by all partners (Hermann, 2009). During the assessment phase (assess needs, literature reviews, existing data) of program planning (Nothwer, 2009), the fourth CBPR principle of integrating knowledge with action for the mutual benefit of all partners is appropriate for this stage. CVD prevention programs must perform research targeted to provide for effective identification of problem areas and subsequent appropriate resource allocation. In addition, alliances must be formed at all SEM levels to effectively execute CDC prevention strategies targeted at all major co-morbidities (CDC, 2009).
The second step of program planning involves the actual plan (Nothwer, 2009). This involves the setting of goals and objectives, gathering information, analysis of logistics, and designing program activities. The second CBPR principle of building on strengths and resources of the community can be applied particularly at the point of setting goals and objectives. Economic and technologic incentives must be provided to CVD prevention programs in order to decrease healthcare disparities for effective modification of unhealthy lifestyles (CDC, 2009). The fourth and final step of program planning involves evaluating the results (Nothwer, 2009). When program evaluation is initiated from the very beginning, it reflects the sixth CBPR principle of involving a cyclical and iterative process (Hermann, 2009). In regards to CVD, these principles can be applied to surveillance and evaluation. Surveillance systems must utilize secondary prevention themes of early detection and identification of high risk patients and initiate primary prevention measures to reduce CVD incidence rates. In addition, CVD program evaluation must be cyclically implemented in order to make sure that all steps of the program planning process are running smoothly (CDC, 2009).
Potential benefits from CBPR for CVD campaign members and organizations include: heightened public profile, increased utilization of expertise or services (e.g., physician counseling for CVD risk factors), enhanced ability to address an important issue (through evidence-based CVD research), enhanced ability to affect public policy, development of valuable relationships with other groups, acquisition of useful knowledge about health issues, services, programs, or people in the community, achievement of organizational goals, enhanced ability to meet the needs of clients or constituency, ability to have greater impact by working collaboratively on goals, ability to make a contribution to the community, acquisition of additional financial support, and enhanced access to priority populations (by reducing CVD health disparities) (Butterfoss, 2006).
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