The Social Ecological Model Applied to the Prevention of Cardiac Disease in Women

There is a common misconception that the leading cause of death for women is breast cancer (Norris et al., 2020). However, cardiac disease is the number one killer of women worldwide and the leading cause of premature death in women in Canada (CWHHC, n.d.). Historically, most cardiovascular research, education and diagnostic testing have focused on men (Norris et al., 2020). While medical research has made significant advancements in understanding cardiac disease prevention in women, it remains understudied, under-diagnosed and under-supported (CWHHC, n. d.). Women are more likely to experience delays in diagnosis and to have worse outcomes than men (Norris et al., 2020). The discrepancy is further compounded by sociocultural, biological and environmental factors that affect women’s cardiac health (CWHHC, n.d.). There are also socioeconomic, demographic, cultural, racial and ethnicity factors that reduce women’s adherence to therapies and limit their participation in research and clinical trials (Norris et al., 2020). The social-ecological model, a framework for prevention, considers individual, relationship, community, and societal factors (CDC, 2022). The overlap in the model shows how these factors interconnect and influence behaviour change. To address and reduce cardiac disease in women in Canada, it is essential to consider the multiple levels of influence that affect cardiovascular health. The model provides a holistic approach to addressing the complex factors that affect women’s heart health and can help develop interventions to create positive change.

CDC, n.d. https://www.cdc.gov/violenceprevention/about/social-ecologicalmodel.html#:~:text=This%20model%20considers%20the%20complex,from%20experiencing%20or%20perpetrating%20violence.

Individual Level:

The first level identifies biological and personal factors that increase the likelihood of women developing cardiac disease (CDC, n.d). While some risk factors for heart disease are genetic and non-modifiable, others are deemed modifiable as they result from lifestyle choices (CWHHC, n.d.). Risk factors that are unique to women include menopause, pregnancy (gestational hypertension, gestational diabetes, preterm delivery intra-uterine growth restriction), birth control, and polycystic ovarian syndrome.

1-Non-modifiable: include race, genetics, age, and gender

2-Modifiable: include smoking, high cholesterol, physical inactivity, obesity, diabetes, hypertension, stress, anxiety and depression

A 2017 study found that lower cardiovascular disease risk awareness rates varied by age, race, ethnicity, and place of residence (Norris et al., 2020). Norris et al. (2020) also found that there are also demographic risk factors such as socioeconomic status, race and ethnicity, and disability. Women of lower socioeconomic status are more susceptible to cardiovascular disease than those with a higher socioeconomic status (Norris et al., 2020). Cardiovascular risk factors and rates are also higher among ethnic minority groups. The mortality rate for indigenous women in Canada is 53% higher than for non-indigenous women. Knowledge of cardiovascular risks is greater among urban women than non-urban women (Norris et al., 2020). Almost 80% of premature heart disease can be prevented through lifestyle choices (Heart & Stroke, 2023).

Prevention strategies at this level promote health education of health behaviours that decrease cardiovascular disease risk (UOHI, 2019). Educating individuals on heart-healthy behaviours at a personal level is essential in reducing the risk of cardiac disease development in women. Interventions should include promoting heart-healthy behaviours and focusing on modifiable risk factors such as diet, physical activity, and smoking cessation. Furthermore, providing education on recognizing cardiac symptoms is an essential intervention at the individual level (UOHI, 2019). Providing routine screening of cardiac disease risk factors such as hypertension, hypercholesteremia and diabetes for patients with a family history of cardiac disease can be an excellent start to cardiac disease prevention (CWHHC, n.d.).

Interpersonal Level:

This level of the model examines the role interpersonal relationships play in the risk of women developing cardiac disease (CDC, n.d.). A person’s family, friends, and others in their social network may influence their behaviour and contribute to their experience. Prevention strategies at this level may include encouraging family and friends to make heart-healthy choices to create a supportive environment for the individual. Interventions at an interpersonal level may also include the development of peer-to-peer support groups. Peer support is vital as it empowers women and provides them a place to increase awareness and connections for women with cardiovascular disease (UOHI, 2019). Peer support provides emotional and informational assistance and also enhances a sense of community. Interventions that support interpersonal relationships can help holistically address cardiac disease prevention.

Community Level:

At a community level, the socio-ecological model explores settings where social relationships occur, such as workplaces and neighbourhoods (CDC, n.d.). This helps identify the characteristics of these settings that may increase women’s risk of developing cardiac disease.

A range of interventions can be implemented to address cardiac disease risk factors at a community level. These may include initiatives to ensure community members have access to healthcare facilities, opportunities to be physically active, and healthy sources are essential (UOHI, 2019). Access to healthcare facilities is critical in remote areas where primary care and diagnostic testing are limited.

Furthermore, community-based programs and initiatives can be essential in educating people about heart health and promoting physical activity (UOHI, 2019). By providing access to information and resources, these initiatives can contribute to reducing cardiac risk factors within the community. These initiatives benefit urban areas but are even more essential for remote or underserved communities (Norris et al., 2020). It is vital to address cardiac disease at the community level using a comprehensive approach.

Organizational/Societal Level:

The fourth level examines societal and organizational factors influencing women's risk of developing cardiac disease (CDC, n.d.). These factors include social and cultural norms that may contribute to behaviours detrimental to heart health.

At an organization/societal level, public health campaigns are essential to raise awareness about heart health. There is a need for advocacy and educational campaigns at a national level to raise awareness about women’s cardiac health and prevention (CWHHC, n.d.). Advocating for policies at a national level can help challenge and reshape social and cultural norms that may affect unhealthy behaviours (CDC, n.d.). These policies may include campaigns to reduce smoking rates, subsidize healthy foods, and promote physical activity (Heart & Stroke, 2023). These are essential components in lowering the rates of cardiac disease in Canada.

Currently, there is also a lack of Canadian data on cardiovascular disease in women, which is part of the ongoing difficulty in increasing awareness and improving outcomes (Norris et al., 2020). Therefore, supporting research on cardiac disease can help inform future policies and interventions. Recent regulatory changes in Canada have taken positive steps by requiring the inclusion of women in clinical trials and requiring sex-specific analysis of clinical results. However, the gender balance in clinical studies remains unbalanced. Low enrolment is due to gender-based issues such as familial responsibilities and cultural and socioeconomic barriers (Norris et al., 2020). Promoting gender equity in clinical research is vital to advancing the understanding of cardiac disease in women and creating effective prevention and treatment interventions.

As a cardiac nurse, I am invested in reducing cardiac disease in women in Canada. Preventing cardiac disease in Canada requires a coordinated approach beyond interventions at the individual level. By addressing the interconnected levels of influence, we can create an environment that supports heart disease prevention in women in Canada. The socio-ecological model is an essential tool that helps address health inequities to ensure equitable access to healthcare resources.

References

Canadian Women’s Heart Health Centre (CWHHC). (n.d.). Why women’s heart health? Retrieved from https://wearredcanada.ca/why-womens-heart-health

Centers for Disease Control and Prevention (n.d.). The Social-Ecological Model: A Framework for Prevention. https://www.cdc.gov/violenceprevention/about/social- ecologicalmodel.html

Centers for Disease Control and Prevention (CDC). (January 18, 2022). The social-ecological model: a framework for prevention. Retrieved from https://www.cdc.gov/. violenceprevention/about/social- ecologicalmodel.html#:~:text=This%20model%20considers%20the%20complex,from%20experi.encing%20or%20perpetrating%20violence.

Heart & Stroke. (2023). Heart disease. Retrieved from https://www.heartandstroke.ca/heart-

disease\

Norris, C., Yip, C., Nerenberg, K., Clavel, M.-A., Pacheco, C., Foulds, H., Hardy, M., Gonsalves, C., Jaffer, S. (2020).State of the science in women’s cardiovascular disease: a Canadian perspective on the influence of sex and gender. Journal of American Heart Association. 9(4). https://doi.org/10.1161/JAHA.119.015634

University of Ottawa Heart Institute (UOHI). (2019). Coronary artery disease and recovery after a heart attack. Retrieved from https://www.ottawaheart.ca/document/coronary-artery- disease-guide-patients-and-families