And Many "Miles to Go Before We Sleep"

Updated:May 27,2014

And Many "Miles to Go Before We Sleep”: Results of a 2012 American Heart Association National Survey

Disclosure: Dr. Piña has nothing to disclose.
Pub Date: Tuesday, February 19, 2013
Author: Ileana L. Piña, MD, MPH
Affiliation: Albert Einstein College of Medicine, Montefiore-Einstein Medical Center


Mosca L, Hammond G, Mochari-Greenberger H, Towfighi A, Albert MA; on behalf of the American Heart Association Cardiovascular Disease and Stroke in Women and Special Populations Committee of the Council on Clinical Cardiology, Council on Cardiovascular Nursing, Council on High Blood Pressure Research, and Council on Nutrition, Physical Activity and Metabolism. Fifteen-year trends in awareness of heart disease in women: results of a 2012 American Heart Association national survey. Circulation. 2013: published online before print February 19, 2013, 10.1161/CIR.0b013e318287cf2f.

Article Text

Each February, healthcare professionals and volunteers from all walks of life, including survivors of heart disease, blanket the country with messages about the heart-health of women in our nation. Red becomes the color of awareness, education, prevention and action.  The current rapid integration of internet-based communications and the ability to hold educational sessions online have all helped to improve the breadth of reach into the public.  The goals, however, have remained constant, i.e., education about the incidence and prevalence of CVD in women, prevention of CVD for women, recognizing the symptoms of CVD and responding appropriately, should symptoms occur.  If in fact, the goals of these campaigns were fulfilled, the rates of CVD in women would drop, earlier intervention would occur and heart muscle would be preserved.  However, public health campaigns often take decades to show the return on their human investment.  How then, to measure the intermediate outcomes of such an enormous effort?  As we turn our attention more to heart-health, how will we be reassured that the message has been received and incorporated into the thinking of women of all ages, races and ethnic groups?

The response to this question may be the administration of surveys that, if properly delivered, can test the awareness, knowledge, beliefs, and actions of specific groups on very specific subjects.  This approach has been used by the American Heart Association every 3 years for 15 years, starting in 1997 in order to examine the response to its public educational initiatives focused on women.  On the 10th anniversary of the Go Red Campaign, Mosca et al. report in Circulation the results of the 2012 survey, the most current survey, which the American Heart Association has conducted.  The study also compares the 2012 new findings with the original report of 1997.  Overall, the paper evaluates the trends in awareness of CVD risk among women by racial/ethnic and age groups, as well as collecting information about the knowledge of CVD symptoms and preventive behaviors/barriers. This survey follows a similar method of collection as in previous reports including random-digit dialing in 1205 women and Harris Poll Online survey of 1227 women.  Questions concerning awareness were standardized. Additional questions about preventive behaviors/barriers were given online.

The survey provides an interesting comparison among the characteristics of white, black and Hispanic women of various age groups.  The white women had higher incomes and were more likely than black women to have private insurance.  The Hispanic group of respondents were younger in the 25-34 and in the 35-44 age groups, whereas, there were more white women in the >65 year age group.  The population surveyed had a significant number of self-reported risk factors with over 50% of Black women reporting hypertension.  Hispanic women reported the highest rates of inactivity and white women, the highest rates of family history of CVD.

Impressively, the rate of awareness of CVD as the leading cause of death rose to 56% in 2012 from 30% in 1997.  It was disappointing to see, however, that although the rate of awareness among black and Hispanic women had risen in 2012 to 36% and 34%, respectively, those rates were at the level of white women in 1997. Thirty eight percent of blacks and 36% of Hispanic women responded that cancer was the leading cause of death.  These observations represent a significant racial and ethnic gap. Furthermore, this gap, which was already noted in 1997, persisted in all survey years. 

The public health campaigns targeted at women in the past few years have also focused on the atypical signs of a heart attack for women, in that the classic finding of chest pain may be absent but other symptoms present, such as shortness of breath or nausea and vomiting.  Perhaps due to these focused education efforts, awareness of atypical symptoms of CVD has improved. The number of women that identified chest pain as the warning sign dropped from 67% to 56% with more women identifying shortness of breath as a possible symptom as well.  In parallel with this observation has been an increase in women stating that they would call 911 for themselves, from 53% in 2009 to 65% in 2012.  However, 81% stated that they would notify 911 for someone else having symptoms.  Hispanic women were less confident about taking an aspirin themselves or recommending aspirin to someone else with symptoms.

On the aspect of prevention 35% of women (48% >65 years of age reported that they led a healthy lifestyle. Actions to prevent CVD were appropriate in the majority of women.  Some of these include hypertension management, weight loss, and healthier diets.  However, 73% of black women used meditation and prayer compared to 51% and 50% of white and Hispanic women.  Another 14% of all women used aromatherapy for prevention of CVD.  The survey also provided choices of 20 potential barriers to taking preventative action.  The most commonly reported barriers were financial/insurance issues, time to care for self, and inability to see themselves changing behavior.  The time issue was significantly more important for women in childbearing years.  Overall, the reasons given for prevention strategies were more often health improvement and not for living longer.

There are important lessons to be learned from Mosca et al.’s report of the 2012 survey.  First, we must celebrate the increase in awareness of the number one cause of death for women living in the United States and the rise in those who would make an emergency call for themselves, although more would call for others. We must also note differences in responses by age group that may help in crafting messages to different decades.   In addition, this survey shows a significant burden of risk factors that were self-reported. Hence, an appropriate population of women responded to the survey.  One could speculate that there are many more of these women who may be unaware of their own risk factors, such as blood pressure levels or serum cholesterol.

In contrast, however, we must be deeply concerned at the persistent race and ethnic gap in spite of large efforts, in particular, to deliver messages in Spanish to the Hispanic community. Why are we not reaching the Black and Hispanic women?  The American Heart Association and its partners in this effort must carefully evaluate the power of this report and engage fully in public health programs that are delivered in a culturally and racially sensitive manner. Hispanics must be reached acknowledging differences in cultures by country of origin or ancestry. Programs must also be constructed with variety of approaches understanding the aspects that are important for women of different ages and race.  The women represented in this survey with high penetration of risk factors are precisely those that can be shepherded into prevention and change in life-style.  We may be only skimming the top of a very deep glacier that will continue to manifest itself for many years to come.  Getting these numbers, is certainly a valiant continued effort that checks on our progress. Happy 10th Birthday to Go Red!  We have traveled some distance.  There are still many miles to go…

-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --


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