Challenging Dogma - Spring 2011

Monday, May 23, 2011

Why the WISEWOMAN Program Needs to Smarten Up: A Critique of a National Cardiovascular Risk Factor Reduction Program- Andrea Pinzon

Cardiovascular disease is the number one killer of women over the age of 25 in the United States, regardless of race or ethnicity. There are over 8 million women living with heart disease, and one in three women have some form cardiovascular disease (1,2) Since 1984, the number of cardiovascular deaths for women has surpassed that for men. Surprisingly, only 13% of women recognize cardiovascular disease as the greatest health issue facing women today (1). Most women believe that breast cancer is the leading cause of death among women, although cardiovascular disease has claimed more lives than all forms of cancer combined (1).
Despite recent advances in cardiovascular medicine that have led to significant reductions in cardiovascular deaths in men, case-fatality rates in women have not achieved as dramatic reductions (3). These gender differences are due in part to differences in clinical presentation of heart disease and differences in diagnosis and treatment of cardiovascular disease (3). Women at risk for cardiovascular disease aged 45-64 are less likely than similarly aged men to receive evidence-based aspirin therapy. Rates of counseling for nutrition, weight management, and exercise are low overall, however, an age disparity is seen, as younger patients are more likely to receive counseling than older patients. Also risk factor screening, like cholesterol screening, are more often offered to men than women, and this disparity worsens with issues of underinsurance or no insurance (4). Socioeconomic status, and the concomitant insurance status, is a fundamental determinant of health status. Low socioeconomic status is associated with worsened cardiovascular risk profile. Socioeconomic status in women has exhibited an inverse relationship with major cardiovascular risk factors, including hypertension, diabetes, high cholesterol, smoking, low physical activity, poor nutrition, and BMI (5-7). Uninsured women are more likely to postpone critical preventive services that insured women (10). In addition, low-income, less educated, uninsured minority women have limited access to health services, which increases the risk for cardiovascular disease morbidity and mortality (7).

Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN Program)
The WISEWOMAN program offers low-income, underinsured and uninsured women with aged 40-64 with chronic disease screening, lifestyle intervention and referral services at a low or cost, in an effort to prevent cardiovascular disease in this high-risk population (8). Through the WISEWOMAN program, qualified women receive testing and educational programs that are supposed to help women lower their risk for cardiovascular risk. If women in the screening program are considered to have a high cardiovascular risk factor profile, follow-up visits and interventions are set up for 6 months and 12-months after the initial screening. WISEWOMAN utilizes programs that they believe help women adopt healthy eating behaviors and encourage women to be more physically active. The WISEWOMAN program was initiated in 1995 and is administered through the Center for Disease Control Division for Heart Disease and Stroke Prevention. Currently only 21 WISEWOMAN programs are offered in the United States, including one in Boston, Massachusetts. These programs are only offered to women who are enrolled in the National Breast and Cervical Cancer Early Detection Program. WISEWOMAN programs use the same framework and tools for to measure behavior and behavior change, with minor changes as needed per region of country and ethnicity (and at times language). Despite the fundamental similarities across the programs, considerable inter-program differences in initial and follow-up screening rates of minorities and in efficacy or effectiveness of interventions on risk factors are still evident (9). These inconsistencies could be due to inherent underlying issues with programs and interventions offered by the WISEWOMAN framework. These underlying issues include use of the Transtheoretical model for behavior change, low commitment and transportation concerns for qualified women, and low reach of program for minority participants.

Use of the Transtheoretical model for behavior change
The health disparity in cardiovascular disease risk across high and low socioeconomic status and ethnicity is well recognized. Minority women of lower socioeconomic status are more likely to have higher rates modifiable risk factors like obesity and overweight and smoking (5,6). Among WISEWOMEN participants, a spatial clustering of high BMI and high smoking is observed in five of the participating states (12). Consequently, BMI is one of the individual characteristics explaining ethnic disparities in the baseline cardiovascular risk factor profiles of the WISEWOMAN programs (12). In order to address these issues and foster healthy behaviors, The WISEWOMAN projects focus on individual models of behavior change, specifically the Transtheoretical model (Stages of Change); In fact, WISEWOMAN is currently federally mandated to spend 60% of its funds on individually oriented interventions (7). WISEWOMAN utilizes the Transtheoretical model in hopes of assessing subjects’ readiness to change in physical activity, smoking, and dietary behaviors and individually tailoring programs to encourage healthy behavior adoption depending on the “stage” the subject is in. However, recent research has shown that the Transtheoretical model is not an optimal tool to use in smoking and physical activity changes. The WISEWOMAN intervention programs have not reported significant changes in BMI, smoking, or blood glucose (13). For the participants, the programs have achieved maintenance of BMI, with average weight loss across programs has been less than one pound, with some programs showing unfortunate weight gain (9, 12). The average reduction in smoking rate among participants across WISEWOMAN programs is 8%. Nonetheless, they rates of change across program are widely spread, ranging from 0% to 50% reduction in smoking (9,13), exhibiting a complete lack of consistency in the Transtheoretical Model across groups. There appears to be no convincing evidence that moving a person closer to action leads to an actual maintained behavior change; in fact, studies have shown the ability to change one’s attitude without affecting any positive change in behavior (14) In regards to smoking behavior, the most effective and successful way to quit smoking is to quit without any proper or previous planning; this holds true across gender, age, and socioeconomic status (15).

Low commitment and Transportation Concerns for qualified women
In congruence with low positive results in cardiovascular risk factor reduction, intervention programs can only be effective if subjects attend the designed intervention sessions. Transportation may play an important role in a subject’s decision about attending an intervention, especially if attendance requires evening travel (16). Utilization of health care tends to decrease as the distance traveled to care increases; transportation barriers to care are associated with reduced compliance to treatment and lower rates of preventive care (17). Transportation issues are more likely to affect vulnerable populations, such as rural residents, and racial and ethnic minorities (17). In a WISEWOMAN survey, many subjects regarded transportation as a major barrier to attending intervention programs. Other factors related to attendance were higher education level, small family size, and having health insurance. The transportation barrier was greater for women living in rural, especially since the 21 programs around the United States are located in major urban cities (16). Among women living in rural areas, younger women were less likely to attend an intervention than older women at any given travel distance. For middle-aged rural women, the probability of attendance falls sharply after the driving distance to the intervention site is greater than 15 miles. This age trend on distance traveled is also seen among women who live less than 10 miles from the intervention site (16).
The transportation barrier to attendance of cardiovascular risk factor reduction interventions was evident in a study conducted in a South Dakota. The WISEWOMAN program was implemented in a South Dakota Women’s Prison along with the general population WISEWOMAN population in the South Dakota. When comparing the two WISEWOMAN populations over a 16-month period, incarcerated women were more likely to attend intervention program sessions than non-incarcerated women in South Dakota. Incarcerated women were more likely to take up the intervention than non-incarcerated women (18). Incarcerated participants attended an average of 2 lifestyle intervention sessions, compared with an average of 0.4 sessions attended by non-incarcerated participants. Intervention completion rates were significantly different among groups, with 42.5% incarcerated women completing an intervention and 3.6% non-incarcerated women completing an intervention (18).

Low Reach for Minority Participants
Racial and ethnic variation in cardiovascular disease risk and cardiovascular disease morbidity and mortality are widely documented in the United States. Differences in cardiovascular risk factors are major sources of the racial disparities (5). Minorities are at higher risk of developing hypertension and diabetes; BMI and smoking are also strongly patterned by race. Black men and women, specifically, have a greater overall cardiovascular mortality compared to similarly aged White men and women (2,5). Not surprisingly, the baseline risk factor characteristics of WISEWOMAN participants mirror the national trends. After controlling for age in eight WISEWOMAN sites, minority participants showed greater rates of hypertension, known diabetes, and higher BMI (7). However, despite the increased cardiovascular risk among women, enrollment and participation rates among minorities were lower compared the rates of non-minority women. In states with a mixed racial population, minority participation rates ranged from 20-30% (19,20). Non-White women participants were also more likely to be lost to follow-up and less likely to return to the 12-month follow-up intervention session (19). A recent meta-analysis of minority participation rates in health research studies showed that minorities do not differ from non-Hispanic whites in consent rates (21), contrary to earlier studies that show a low willingness to participate in minority research subjects (22,23). Low participation rates among minorities may represent a lack of sensitivity in cultural and social norms (23). In WISEWOMAN-participating states with a high proportion of minorities in the source population, higher rates of participation and retention were observed among the eligible minority women compared to other states (10/24). These increased rates of participation can be explained by the incorporation of health service programs that targeted minorities, which involved community health workers (10). The success rates from these states show that in order to increase the reach of cardiovascular risk factor reduction, culturally sensitive programs must be integrated into interventions.

“WISE” Alternatives
WISEWOMAN is a nation wide program with several state sites that is aimed at reducing cardiac risk factors among low-income women. Despite the issues and concerns presented above regarding the WISEWOMAN programs, there may be alternative social science theories that can help address these inherent flaws. WISEWOMAN programs across the country have varying rates of cardiovascular risk factor reduction success among participants. The following theories provide potential options for alternative interventions in problem areas in certain WISEWOMAN sites.
Social Network Theory
As previously stated, five WISEWOMAN state program demonstrated spatial clustering of smoking and high BMI. This fact demonstrates the significance of an individual’s social network. A social network consists family, friends, and anyone with whom a person has close contact on regular basis. Connected persons may share exposures to common environmental factors, experience of simultaneous events, or other common features, like socio-demographic attributes, that may also cause them to share certain behaviors, albeit, unhealthy behaviors, like smoking and low physical activity (25). This suggests that group dynamics better explain adherence to certain behaviors than an individual-level theory like the Transtheoretical Theory.
The existence of social networks means that people and health are interdependent (26). Social networks can also influence the adherence to healthy behaviors. Person-to-Person spread of behavior is not bound by geographic distance; social norms may spread more easily over a distance than a behavioral effect. (25). This observation suggests that by simply changing a subject’s social norms about the acceptability of an unhealthy behavior, that healthy behavior change is more likely to occur. Previous research has shown that successful intervention in underserved ethnic minorities, independent of status, age, or place, should be built into philosophies and cultural practices that mold norms and values of the communities (9). Social norms can be changed by not allowing smoking in certain places, like one’s home, or suggesting to take the stairs versus the elevators when out in public places. For the WISEWOMAN program to exhibit improved behavior changes in the participants, a peer support network may be an important tool to incorporate in the interventions. One kind of peer group could connect participants who have been able to quit smoking or have increased their physical activity with other participants who live near them to influence them to adopt healthy behaviors. Another option would be to meet with one or two members of a participant’s social network to encourage behavior change and to help come up with ideas as a group to help positive behavior adoption.

Framing Theory
Some WISEWOMAN programs suffered from low participation and completion rates of the one-year intervention. The apparent issues with transportation among low socioeconomic status women and distance to the intervention site are unfortunate obstacles to continued commitment. However, an age disparity was observed even controlling for distance traveled. Younger women were less likely to attend or complete an intervention. Although not measured or studied, this lack of adherence to the intervention may be viewed as a lack of commitment to change. Younger women are more likely to be employed and may still have younger children to rear in the home compared to older women. In essence, they may view an outside intervention as a disruption in their daily or weekly flow, for which they may not have the time to spare, when they are trying to provide for themselves and their family. So in order for the WISEWOMAN programs to make the participants understand the importance of cardiovascular risk factor reduction, they would need to re-frame the issue.
Maslow’s Hierarchy of needs describes that people need to have their basic human/physiologic needs (food, shelter, clothing) fulfilled before fulfilling higher level needs, like health. (27) Most women, especially mothers, place the needs of their family and friends before their own needs (27), so employment is an essential part of being able to provide for them. Although healthy people are more likely to be employed, an increasing number of people in the employed population in the United States are either overweight or obese, and more likely to have accompanied cardiovascular risk factors like hypertension, diabetes, and high cholesterol (28). These are cardiovascular risk factors are more prevalent in the middle aged and older working population. These cardiovascular risk factors can cause limitations on work and productivity. The effect of the aforementioned cardiovascular risk factors on work limitations is similar to the magnitude of 20 years of aging (28). Therefore, The WISEWOMAN program should frame the importance of cardiovascular risk factor reduction in a way that helps participants fulfill lower order needs of themselves and their families. WISEWOMAN should frame the issue as the only way to be able to provide food and shelter for their families is if the women themselves are healthy. Cardiovascular health is not solely important for the individual, but plays a major role in their ability to provide basic needs for their family. Participants may then realize that by taking better care of themselves, they in essence, will be taking better are of their family.

Diffusion of Innovations
As previously stated, WISEWOMAN minority cardiovascular risk factor trends follow the trends seen in the general population. Unfortunately, eligible minority women are less likely to enroll in a risk factor reduction program like WISEWOMAN; notwithstanding, minority women who are enrolled in a program are less likely to complete a full intervention. Population groups experiencing disparities in chronic diseases have generally been considered ‘hard to reach’ by public health research because of their lack of responsiveness to health messages targeting younger, White, affluent audiences (29). As previously noted, this lack of participation may reflect a lack of culture sensitivity and inappropriate communication in the program’s enrollment and retainment protocols. Acceptance of any intervention is dependent on how the messages of behavior change are spread and seen by the community.
Diffusion is the process through which an idea is communicated through certain channels over time among members of a social system (30). Diffusion occurs through a combination of the need for individuals to reduce personal uncertainty when presented with new information, the need for individuals to respond to their perceptions about what credible people in the community are thinking and doing with the new information and general social pressure to do as others are doing (30). Any uncertainty about a new idea typically leads to search for information from a trusted and respected source, especially, if the idea is deemed important in terms of having significant consequences for the potential adopter (30). Minorities tend to be very collective societies, with strong traditions and high interdependence on its individual community members for support and survival of the community (29). Many community based health promotion programs using minority ‘community insiders’ have shown great strides in healthy behavior adoptions (29).
The success of this theoretical practice is evident in the Arizona WISEWOMAN program. The Arizona WISEWOMAN population is comprised of a large number of Hispanic women. Arizona’s WISEWOMAN interventions employed the use of Hispanic community health workers and lay health advisors called promotoras. (10) Promotoras act as liaisons between the community and health organizations, bringing information into the Latino communities and often playing the roles of educator, mentor and role model (31). Arizona shows slightly higher rates of intervention completion compared to other states, and the inclusion of promotoras in the intervention programs is associated with increased adoption of healthy behaviors, such as moderate to vigorous physical activity, as well as increased fruit and vegetable consumption among the participants (10). These important behavior changes can have significant effects on the reduction of overall cardiovascular risk and associated co-morbidities. This example reinforces the model that recruiting respected community members, as advocates and role models of healthy behavior changes, is an important facet to diffusing the main objectives of the WISEWOMAN program. Also, WISEWOMAN programs should be cognizant of their participants’ cultural and social backgrounds, (in a feasible manner) in an attempt to identify appropriate community advocates. Respect for the dignity and preferences of potential participants is key (29).

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