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Heart-Healthy and Stroke-Free: A Social Environment Handbook

Social Environmental Handbook cover image.

Introduction

This handbook is a tool for everyone working to create heart-healthy and stroke-free communities across America. Health advocates are recognizing that creating and sustaining healthy communities requires fundamental social change that goes far beyond the individual patient education approach of many traditional public health programs. However, changing the social environment has proved even more challenging than trying to modify individual lifestyle choices. The first step to improving the social environment is to accurately identify its health-promoting and health-damaging characteristics.

In this handbook, public health professionals, advocacy groups, and concerned community and state leaders will find specific ideas and strategies for identifying barriers and promoters for heart-healthy and stroke-free living in local environments. Although many public health tools are available for “community diagnosis,” this handbook is unique because of its particular focus on prevention and treatment of heart disease and stroke. All of the specific examples, tables, and worksheets relate directly to heart disease and stroke risk factors, prevention challenges, and treatment issues. We have attempted to present the information and ideas in the handbook in an accessible, straightforward fashion so that a wide range of users—from motivated school, church, and community leaders to highly trained local public health professionals—will find something useful in these pages.


A Paradigm Shift

Health promotion efforts for heart disease and stroke have traditionally employed a health education approach focused on the major biomedical and behavioral risk factors. These risk factors include hypertension, elevated blood cholesterol, obesity, diabetes, 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.

Social Environment

  • the arts
  • beliefs about community
  • built infrastructure
  • cultural practices
  • government
  • human services
  • industrial structure
  • labor markets
  • medical care
  • power relations
  • race relations
  • religious institutions
    social inequality
  • social processes
  • wealth

This model assumes that providing education and behavior change tools to individuals to help them achieve lifestyle improvements can lower the prevalence of adverse risk conditions at the population level. In other words, the cumulative effect of educating many individuals will result in changes in population patterns of risk factors, and subsequently, declines in heart disease and stroke incidence, prevalence, and deaths. 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. 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.


Importance of the Social Environment

In recent years, growing awareness of the importance of social environmental and policy changes in promoting heart-healthy and stroke-free communities has resulted in activities and interventions focused on community-level change at the Centers for Disease Control and Prevention (CDC) and the American Heart Association (AHA). These new activities require a conceptual model that links individual risk factors and behaviors for heart disease and stroke with their corresponding promoters and barriers in the social environment.

We have outlined a conceptual model that connects individual goals for heart and stroke health promotion with population goals and have identified both barriers and promoters for each goal (see the tables below). We have highlighted “the big five” heart disease and stroke risk factors: hypertension, dyslipidemia, tobacco use, poor nutrition, and physical inactivity. However, a number of other well-known risk factors certainly could be added to this conceptual model, including diabetes, depression, and stress.


Individual Versus Population Goals

The distinction between individual and population goals is not always recognized; however, it is a critical distinction, because barriers and promoters of individual goals are often different than those for population goals and require different types of health promotion activities.

For example, the first individual goal listed in the Nutrition Goals table below is "consume 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 population, a barrier might be low average family incomes, resulting in large numbers of people who lack money to purchase fresh fruits and vegetables.

A health promotion activity focused on the individual might be provision of vouchers or food stamps. In contrast, a health promotion activity focused on the social environment might concentrate on improving family incomes through economic development, job creation, and support of labor union efforts to increase wages. For example, in the North Karelia Project in Finland, the economic concerns of dairy farmers had to be addressed before population-wide declines in consumption of high-fat dairy products could be achieved.


Low-Risk Versus High-Risk Populations

We also make an important distinction between low-risk and high-risk populations in terms of specific risk factors and their related individual and population goals. Using the example of blood cholesterol in the table below, the low-risk population would consist of everyone whose blood cholesterol level falls within the normal range. The high-risk population would consist of everyone whose blood cholesterol is above the normal range.

For the low-risk population, the individual goal is to maintain normal blood cholesterol levels throughout the life span, while the population goal is to reduce or eliminate new cases of elevated blood cholesterol. For the high-risk population, the individual goal is to lower blood cholesterol through behavior modification and medical treatment. The high-risk population goal is to increase the percentage of people whose blood cholesterol levels are reduced to normal levels. For each of these four target goals related to blood cholesterol, the potential barriers and promoters are different.

We often think of high-risk populations only in terms of medical treatment and intervention for people who are already sick, but these populations can also benefit from prevention of related factors that may worsen the principal risk factor—in this example, primary prevention of diabetes, obesity, poor diet, and physical inactivity will help mitigate the impact of high blood cholesterol on risk for heart disease and stroke.


Promoters Versus Barriers to Change

Designing, planning, and implementing social environmental interventions to improve heart 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 employment instability and high job turnover. These negative life events can create psychosocial stress, which in turn can exacerbate high blood pressure.


How to Find Current Risk Factor Information and Guidelines

Source Description and Web Address
Centers for Disease Control and Prevention The Heart Disease Prevention: What You Can Do Web page provides fact sheets on many risk factors. Links to official guidelines and reports for blood pressure, cholesterol, obesity, physical activity, tobacco use, and diet.

http://www.cdc.gov/HeartDisease/prevention.htm

American Heart Association The Health Tools Web page provides links to information sheets on heart disease and stroke risk factors, treatments and tests, and disease conditions. There are several interactive features, including a risk assessment tool, family tree, cholesterol and blood pressure tracker, and an exercise diary.

http://www.americanheart.org/presenter.jhtml?identifier=3006028

American Stroke Association The How Cardiovascular and Stroke Risks Relate: Converging Risk Factors Web page provides an overview of many risk factors that are common to both stroke and heart disease, such as blood pressure, cholesterol, and physical activity. Links to additional detailed information are provided.

http://www.strokeassociation.org/presenter.jhtml?identifier=3027394

Furthermore, efforts to create and strengthen social environmental promoters of normal blood pressure 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 or medications, lack of time for healthy food preparation, and inadequate family incomes.

Health professionals must recognize that some of the most serious social environmental barriers to good health—such as racism, poor economic conditions, and advertising of harmful products—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 policy makers.


Conclusion

The pathways by which social environmental change can affect 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 community-level interventions to organizational leaders in the public and private sectors. 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.


Further Reading

  • Anderson JV, Bybee DI, Brown RM, McLean DF, Garcia EM, Breer ML, et al. 5 A Day fruit and vegetable intervention improves consumption in a low income population. Journal of the American Dietetic Association 2001;101:195–202.
  • Anderson LM, Fullilove, MT, Scrimshaw SC, Fielding JE, editors. Task Force on Community Preventive Services. Interventions in the social environment to improve community health: a systematic review. American Journal of Preventive Medicine 2003;24(3S).
  • Barnett E, Anderson T, Blosnich J, Halverson J, Novak J. Promoting cardiovascular health: from individual goals to social environmental change. American Journal of Preventive Medicine 2005;29(5S1):107–112.
  • Barnett E, Casper ML. A definition of the social environment. American Journal of Public Health 2001;91:465.
  • Brennan Ramirez LK, Baker EA, Metzler M. Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2007.
  • Centers for Disease Control and Prevention. Heart-Healthy and Stroke-Free States: A Communication Guide for Policy and Environmental Change. Atlanta: U.S. Department of Health and Human Services; 2004.
  • Centers for Disease Control and Prevention. Moving into Action: Promoting Heart-Healthy and Stroke-Free Communities (Employers). Atlanta: U.S. Department of Health and Human Services; 2005.
  • Centers for Disease Control and Prevention. Moving into Action: Promoting Heart-Healthy and Stroke-Free Communities (Health Care Leaders). Atlanta: U.S. Department of Health and Human Services; 2005.
  • Centers for Disease Control and Prevention. Moving into Action: Promoting Heart-Healthy and Stroke-Free Communities (Local Officials). Atlanta: U.S. Department of Health and Human Services; 2005.
  • Fichtenberg CM, Glantz SA. Association of the California Tobacco Control Program with declines in cigarette consumption and mortality from heart disease. New England Journal of Medicine 2000;343:1772–1777.
  • Ingham County Health Department. Hofrichter R, editor. Tackling Health Inequities Through Public Health Practice: A Handbook for Action. Washington DC: National Association of County and City Health Officials; 2006.
  • Marmot MG. Improvement of social environment to improve health. Lancet 1998;351:57–60.
  • U.S. Department of Health and Human Services. Healthy People 2010 Volume II, 2nd edition. Washington, DC: U.S. Government Printing Office; 2000.

Blood Cholesterol Goals

Individual Population and Social Environment
Goals High-risk individuals
Lower blood cholesterol.

Low-risk individuals
Preserve normal blood cholesterol.

High-risk population
Increase % of people whose blood cholesterol is normalized.

Low-risk population
Decrease % of people who develop high blood cholesterol.

Promoters Physical activity
Healthy diet
Good medical care
Medication
Adequate health insurance
Healthy food environments
Healthy recreational environments
Good family incomes
Good working conditions
Health promotion and education
Healthy cultural food practices
Wellness programs at work and school
Barriers Lack of medical care
Cost of medication
Lack of social support
Cost of healthy foods
Food preferences
Obesity
Genetics
Lack of access to medical care
Lack of access to medications
Lack of grocery stores
Grocery stores with limited selections
Large number of fast food restaurants
Poor economic conditions
Time pressure

Nutrition Goals

Individual Population and Social Environment
Goals Consume a heart-healthy diet.Increase % of population that consumes a heart-healthy diet.
Promoters Adequate income
Healthy food availability
Time for meal preparation
Knowledge
Preferences for healthy food
Healthy food environments
Good family incomes
Good working conditions
Nutrition and diet education
Healthy cultural food practices
Wellness programs at work and school
Barriers Lack of social support
Cost of healthy foods
Restaurant portion sizes
Preferences for unhealthy food
Lack of grocery stores
Grocery stores with limited selection
Large number of fast food restaurants
Poor economic conditions
Time pressure

Tobacco Goals

Individual Population and Social Environment
Goals High-risk individuals
Stop using tobacco.

Low-risk individuals
Don’t start using tobacco.

High-risk populations
Increase % of tobacco users who quit.

Low-risk populations
Decrease % of people who start using tobacco.

Promoters Social support
Desire to quit
Negative health effects
Physical activity
Aversion to tobacco
No-smoking policies
High tobacco cost and taxes
Higher insurance costs for smokers
Cessation classes/programs
No tobacco sales to minors
Wellness programs at work and school
Barriers Lack of social support
Lack of desire to quit
Lack of knowledge of cessation strategies
Depression
Family tobacco use
Psychosocial stress
Peer 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

Physical Activity Goals

Individual Population and Social Environment
Goals Participate in regular physical activity.Increase % of people who participate in regular physical activity.
Promoters Good overall health
Time for physical activity
Knowledge
Enjoyment of physical activity
Good family incomes
Good working conditions
Healthy recreational environment
Organized activities
Recreational programs
Pedestrian-friendly development
Barriers Lack of facilities
Cost of clothes and equipment
Cost of facilities
Lack of social support
Aversion to physical activity
Depression
Climate
Lack of safety/hazards
Social conflict
Time for physical activity
Economic constraints
Family constraints

Blood Pressure Goals

Individual Population and Social Environment
Goals High-risk individuals (including those with borderline high blood pressure)
Reduce blood pressure.

Low-risk individuals
Preserve normal blood pressure.

High-risk population (including those with borderline high blood pressure)
Increase % of population whose blood pressure is normalized.

Low-risk population
Decrease % of population that develops high blood pressure.

Promoters Physical activity
Healthy diet
Good medical care
Medication
Adequate health insurance
Control of diabetes
Weight loss
Good family incomes
Good working conditions
Stable employment
Healthy food environments
Healthy recreational environments
Health promotion and education
Wellness programs at work and school
Barriers Physical inactivity
High-salt, high-fat diet
Diabetes
Obesity
Psychosocial stress
Lack of medical care
Cost of medication
Lack of social support
Tobacco use
Lack of access to medical care
Lack of access to medications
Lack of access to recreational facilities
Unstable local economy
High rate of unemployment
Social stressors (e.g., racial discrimination)
Social conflict leading to stress

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