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Heart-Healthy and Stroke-Free: A Social Environment
Handbook
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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
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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*
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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*
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*Links to non–Federal organizations are provided solely as a service to our users. Links do not constitute an endorsement of any organization by CDC or the Federal Government, and none should be inferred. The CDC is not responsible for the content of the individual organization Web pages found at this link.
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 |
For Free Copies
To obtain free copies of the Heart-Healthy and Stroke-Free: A Social
Environment Handbook, please email
cdcinfo@cdc.gov, or write to:
National Center for Chronic Disease Prevention and Health Promotion
Division for Heart Disease and Stroke Prevention
4770 Buford Highway NE
MS K-47
Atlanta, GA 30341-3737
Back to Top
Date last reviewed:
08/29/2008
Content source: Division for Heart Disease and Stroke
Prevention,
National Center for Chronic Disease Prevention and
Health Promotion |
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