Challenging Dogma

...Using social sciences to improve the practice of public health

Sunday, April 22, 2007

Going Red is Not Enough: A Critique of the American Heart Association’s Go Red for Women Campaign’s Fight Against Heart Disease-Sarah Lesgold

Go Red For Women is the American Heart Association’s nationwide movement founded in 2004 to encourage women to band together and wipe out heart disease (1). One of the primary purposes of the campaign is to let women know that heart disease is the number one killer in America of both men AND women, as only 13 percent of women view heart disease as a health threat (2). Additionally, the campaign aims to “[empower] women with knowledge and tools so they can take positive action to reduce their risks of heart disease and stroke and protect their health” (1). While the American Heart Association’s Go Red for Women campaign has increased awareness of heart disease in many women and had fundraising success among wealthier, primarily Caucasian women, the use of the rigid health belief model in creating the campaign, and the campaign’s inability to properly take into account social and cultural aspects prevents the campaign from effective and significant reduction in America’s #1 killer.

Weakness of the Health Belief Model
The Go Red campaign appears to have been built on the Health Belief Model, as its main objective is to make women understand they are highly susceptible to heart disease and that contracting it will cause considerable harm. According to the health belief model, perceived susceptibility and its potential serious consequences (perceived severity) will induce one to take action that will be beneficial in either reducing severity or susceptibility to the health threat (perceived benefit) and that the costs associated with taking the proposed action (perceived barriers) are outweighed by the benefits , which leads to intention to modify one’s behavior, and then action (3). The first means by which the Go Red campaign will fail is the limited numbers it will reach in its use of the health belief model. I will go on to show how the Go Red campaign makes attempts to serve as a “cue to action” to initiate the desired health behavior, but the rigidity of the model weakens it on every step and does not provide women with the tools necessary to successfully improve their individual “heart healthiness.”

Perceived susceptibility and perceived severity are the first elements of the model on which the campaign is designed. The campaign makes attempts to be very straightforward; it tells women they are susceptible because they are women. While the goal is to raise awareness of heart disease as the number one killer of women, the problem lies in that 40% of women consider themselves “well informed” about heart disease, but only 13% of women perceive heart disease as their greatest health problem personally(4). This reflects an attitude that heart disease is "not my problem” demonstrating how the campaign fails to adequately provide women with information regarding their individual susceptibility.

The Health Belief Model sees women as a collective group without regard for their experiences (5). Thus one issue that will lead to failure is the campaign’s inability to personalize the message. This is particularly a problem with younger women. Most women (62%) still believe that cancer is the greatest health threat for women and the younger generation is even more convinced of this. Women age 25-34 are a key audience for prevention messages and nearly two-thirds of this age group believed cancer was their greatest health threat and just 4% regarded heart disease as a danger. These women are quite incorrect as epidemiological evidence suggests that as many as half of these women will die of cardiovascular disease (6). Simply being told that heart disease is the number one killer of women is clearly not enough for women to feel personally susceptible to the effects of heart disease. The campaign must take a multi-strategy approach and put time into understanding why women have these false perceptions and what approaches would be most successful in cueing women, particularly young women into their susceptibility.

Getting these women to feel susceptible is only the first step. In addition to the campaign’s inadequacy in making women aware of the problem by poorly demonstrating susceptibility, the second half of the health belief model states that a rational decision must be made between the perceived benefit and the perceived barriers of a health behavior. The campaign focuses on “5 simple ways to love your heart:” celebrate with a check-up, get off the couch, quit smoking, drop a pound or two, and be a heart detective (7). If you can do all of these, the campaign promises the benefit that you will reduce your risk for heart disease. However, the campaign unfortunately fails to acknowledge the barriers, other than a woman’s willingness and desire, that that may prevent women from taking the steps to modify and improve their heart health. In assuming that by educating women that heart disease is the number one killer, and giving them 5 “simple” steps, they will be able to make those changes, but not acknowledging that the “simple” steps are actually quite difficult for most women, is another means by which the campaign will fail. Quitting smoking, dropping weight, and getting a check-up are all things that could be extraordinary difficult for many women, none of which the campaign acknowledges. As a result of excluding barriers and calling these steps “simple”, the campaign minimizes the barriers to these actions, which can lead to two possibilities: 1) women may think the benefits greatly outweigh the barriers (because there are none implied) and then could be very discouraged if they are unable to perform these actions or 2) some women may perceive the barriers so high that they don’t think that they can succeed and therefore do not attempt any change – neither result of this cost-benefit scale is likely to lead to significant behavioral change, as this decision is not one that can be made on the rational basis that awareness will lead to action.

By failing to properly demonstrate susceptibility and acknowledge barriers, the Go Red campaign as it stands now is too rigid and not enough to successfully change the behavior of women to behaviors that show they “love their heart.” This, however, could be rectified by modifying the campaign to go beyond the health belief model and incorporating components of other health behavior models to personalize the message and further address the obstacles women face in changing their “heart health.

Failure to Include Sociocultural Concepts
The other main reason the Go Red campaign will fail is its failure to take into account social and cultural considerations. Even if women are exposed to the campaign, there are sociocultural concepts that may not apply or be accessible to the entire population. While heart disease does not discriminate and affects all, many minority women, particularly African American, Hispanic, and Native American women have a greater prevalence of risk factors or are at a higher risk of death from heart disease, stroke and other cardiovascular disease , but are less likely to recognize the risk (8).

Right from the start, the campaign does a poor job of taking into account sociocultural differences which may prevent certain populations from exposure to campaign information. In addition, by using one message, “love your heart” with only minimal attempts to include cultural variation, the campaign fails to address differences in cultural attitudes thereby failing to reach some of the most vulnerable audiences. The majority of the campaign information is accessed via the internet. Only 54% of Americans have internet access and of those who do, Caucasians are nearly twice as likely to have internet access at home as are African American or Hispanics. Additionally internet use is highly correlated with education and income level. Among households with income greater than $50,000, 77-92% have internet access, whereas only 31% of those with an income less than $25,000 have internet access. Education is also significant, with those who have at least some college education being 2-3 times more likely to have internet than those who only complete high school(9). Furthermore, after navigating through the entire campaign website, there were very few signs of targeting different cultures other than images of the campaign posters used – a Caucasian woman, an African American woman, and a Hispanic woman and PSAs in English and Spanish. These inclusions suggest that all women of a particular race or common language will respond in the same manner regardless of other factors such as income and education levels. However, there is more to it than race alone and we must look at acculturation and barriers that are unique to a particular race. One such example is that within the Hispanic culture, attitudes towards weight loss and smoking cessation, two of the “5 simple ways to love your heart,” vary considerably based on level of acculturation and national origin(10). For example, Puerto Rican women have significantly higher levels of smoking than both non Hispanic women and Central American women (11). Therefore, by targeting “Hispanics” as one group by including Spanish materials, Go Red is failing to recognize the unique trends and attitudes to women of different orgin and level of acculturation. Additionally, obesity among black or Hispanic women is associated with a lesser preoccupation with weight control and a lesser likelihood of perceiving oneself as overweight thereby limiting either the motivation for weight loss or the effectiveness of weight loss attempts (12). By referencing quitting smoking and losing weight as simple actions, Go Red will be unsuccessful in reaching these groups that may not see the need to drop a pound or two or where smoking may be a culturally acceptable activity.

In additional to racial disparities in health behaviors such as smoking cessation and weight loss, another problem lies one of the essential components of the campaign – to talk to your doctors. Failure to seek healthcare is a problem for both many races, as well as groups of lower socioeconomic status, which Go Red fails to acknowledge. There is a great distrust in the U.S. healthcare system among African Americans(13), influenced by the legacy of slavery, Jim Crow, and the Tuskegee syphilis study, (14) leading to a decreased participation and chance to discuss health risk among the most vulnerable group for heart disease. The cumulative effect of many negative clinical experiences, of which Tuskegee is only the best known, continues to foster distrust of health care providers and the health care system within the African American community. Many African Americans today, regardless of socioeconomic status, still carry lingering mistrust as the result of this legacy of mistreatment and lack of informed consent. This historical and cultural legacy of discrimination against African Americans affects their health care interactions and clinical outcomes. Understanding and inclusion of these cultural aspects is necessary in achieving the optimal cross-cultural clinical encounter between an African American patient and a physician (14,15,16). By failing to acknowledge these cultural distinctions, Go Red is failing those who perhaps need the campaign the most. Go Red must address these issues before women can be expected to form a strong relationship with their doctor, an essential component of successfully combating cardiovascular disease.

In addition to beliefs belonging to a particular race or cultural group that may be held regarding physicians, socioeconomic status is also crucial in regards to access to healthcare (as well as other issues) and ignored by the campaign. Many women face barriers, including lack of health insurance, that make the acquisition of basic health care services difficult. In 2003, 15.6 percent of Americans were uninsured (16). In addition to the millions of uninsured, more than 16 million Americans avoid care due to cost or have trouble affording their medications despite having health insurance. Individuals most likely to report financial barriers to health care services or medication were more likely to be younger than 65 years of age, female, and nonwhite (17). This is the primary group that Go Red should be targeting for prevention, however they are the ones that have the least access to care. Not only does Go Red fail to acknowledge racial and economical disparities but also fails to apply them to the campaign.

While race, culture and other socioeconomic considerations are of extreme importance, a large problem lies in the treatment disparities and information gap for women. Women are less likely to receive treatment for heart disease and stroke then men. While the American Heart Association recognizes these disparities and in many cases has published studies in their journal Circulation it has not chosen to include additional measures that take into account sociodemographic characteristics as a part of the campaign (8).

Perhaps one of the most drastic statements of the campaign is this: “By loving your own heart, you can save it. When women learn to love their hearts, they can appreciate their health, their life and their loved ones. If women make and keep a promise to be heart-healthy, we can wipe out heart disease (1).” This statement, directly from the Go Red website sums up why this campaign will fail if they do not provide the tools to reach the steps towards behavioral change. However, the campaign does have good foundations and if it finds ways to further personalize the message by taking into account sociodemographic characteristics then I believe it could make a significant impact on reducing the heart disease among women.

1. Go Red For Women. American Heart Association. Accessed March 23, 2007.
2. Go Red For Women. American Heart Association.
3. Waller, Cynthia. Understanding Prehospital Delay Behavior in Acute Myocardial Infarction in Women. Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine December 2006; 5(4):228-234.
4. Centers for Disease Control and Prevention, National Center for Health Statistics
5. Thomas LW. A critical feminist perspective of the health belief model: implications for nursing theory, practice and education. Journal of Professional Nursing .11:246-252, 1995.
6. Robertson, RM. Women and Cardiovascular Disease: The Risks of Misperception and the Need for Action. Circulation 2001; 103:2318-2320.
7. Go Red For Women. American Heart Association. Acccessed April 1, 2007.
8. Centers for Disease Control and Prevention. Observations from the CDC. Journal of Women’s Health and Gender-Based Medicine 2001; 10:717-724.
9. US Census Bureau. Computer and Internet Use in the United States: 2003. Available at: Accessed April 1, 2007.
10. Kerner JF, Breen N, Tefft MC, Silsby J. Tobacco use among multi-ethnic Latino populations. Ethnicity & Disease. 8(2):167-83, 1998
11. Pérez-Stable, Eliseo J. et al. Cigarette Smoking Behavior Among US Latino Men and Women From Different Countries of Origin. American Journal of Public Health. 91(9): 1424–1430, 2001 September
12. Boulware LE, Cooper LA, Ratner LE, LaVeist TA, Powe NR. Race and trust in the health care system. Public Health Reports 2003 Jul-Aug; 118(4):358-65 Kumanyika, Shiriki K. Special Issues Regarding Obesity in Minority populations methods for voluntary weight loss and control: National Institutes of Health Technology Assessment CONFERENCE. Annals of Internal Medicine. 119(7):650-654, October 1993
13. Eiser AR. Ellis G. Viewpoint: Cultural competence and the African American experience with health care: The case for specific content in cross-cultural education. Academic Medicine. 82(2):176-83, 2007 Feb.
14. Gamble VN. Under the shadow of Tuskegee: African Americans and health care. Am J Public Health. 1997;87:1773–1778
15. Eiser AR. Ellis G. Viewpoint: Cultural competence and the African American experience with health care: The case for specific content in cross-cultural education. Academic Medicine. Feb 2007;82(2):176-83.
16. U.S. Census Bureau. Health insurance coverage: 2003. Highlights; revised December 2004. Available at: Accessed April 12, 2007
17. Rahimi AR. Spertus JA. Reid KJ. Bernheim SM. Krumholz HM. Financial barriers to health care and outcomes after acute myocardial infarction. JAMA. 297(10):1063-72, 2007 Mar 14.

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