Int. J. Environ. Res. Public Health 2009, 6 2482 for CHD. Three major sites of difference and ambiguity emerged: 1) place and access to health resources; 2) time and food culture; and 3) itineraries or travels through multiple locations. All participants reported difficulties in learning and adhering to new lifestyle patterns, but access to supportive health resources was different in the two regions. Even within regions, subgroups experienced different patterns of constraint and advantage. In each region, “fast” food and traditional foods were entrenched within different temporal and social meanings. Finally, different and shifting strategies for risk modification were required at various points during daily and seasonal travels through neighbourhoods, to workplaces, or on vacation. Thus health education for CHD risk modification should be place-specific and tailored to the needs and resources of specific communities. Keywords: cardiovascular disease; place; cardiovascular risk modification; qualitative methods; health behaviour 1. Introduction Cardiovascular diseases, which include coronary heart diseases (CHD), remain the leading cause of death in Canada and other industrialized countries, although mortality rates are declining [1]. Earlier diagnosis and improved medical management have contributed to longevity of people with CHD, and a corresponding decrease in major risk factors such as smoking has served to reduce its incidence [1,2]. International guidelines are based on the assumption that people at high risk for CHD benefit from healthy modifications to diet, tobacco use, exercise, and management of diabetes and hypertension [3-5]. A recent meta-analytic review noted that individually focused multiple risk reduction interventions result in small changes in target behaviours and have a low impact on morbidity and mortality [6]; nevertheless, the impact of these interventions is significant and independent of available medical therapy. Hence, the clinical importance of risk modification should not be underplayed. Two branches of research have explored the difficulties people face in making sense of and acting on risk reduction advice. One stream of inquiry is concerned with how people receive and act on risk reduction advice. This work indicates that understanding and personalizing the notion of cardiovascular risk involves “lay epidemiology”, which incorporates local meanings, familial experience, and known exceptions to the purported health effects of risk factors such as smoking [7-9]. The in-between, or liminal, state of being “at risk” is problematic for those who feel healthy but must interpret the meaning of diagnostic indicators such as elevated cholesterol levels [10]. Once identified as “at risk”, people may strive to minimize and normalize their risk status by contextualizing it as part of the life course [11]. Women and men may assign different meanings and attribute different causes to CHD—for example, women may perceive themselves as more susceptible to breast cancer and men as more prone to CHD [8,12,13]. Furthermore, it is difficult to change established routines and, over the longer term, many people struggle to adhere to healthy lifestyle recommendations [14-17]. Another research focus is on where people receive and act on risk reduction advice, because sociodemographic position and geographic location form circumstances that support or undermine