Promoting heart health in rural women.

Cardiovascular disease (CVD) is the number 1 cause of death in the world. Over one-third of Untied States (US) women aged 20 and older had some form of CVD in 20081;of these, 47.3% were black and 33.8% white. Prevalence rates of CVD specific for rural dwellers are outdated and difficult to extrapolate from national data.2 Rural Healthy People 2010 indicated rural populations have higher CVD morbidity, particularly in the South and Appalachian portions of the US.3 Although some note a higher prevalence of CVD risk factors in rural populations,4 very few studies have specifically identified the cardiovascular risk burden for rural US populations and these are usually small, descriptive, regional studies.5–8 One study conducted in New Mexico found that “rural patients, regardless of ethnicity received significantly fewer targeted CVD treatments and were less likely to reach blood pressure goals compared with urban patients.9(p420) Most agree there are limitations in access to health care, particularly specialty care, in rural areas. Cardiology services are often regionalized and may be less accessible to rural populations, who must deal with distance and transportation issues. One study found echocardiogram utilization among rural veterans was limited by distance.10 Another study found that transfer of Acute Myocardial Infarction (MI) patients from rural to more tertiary care facilities reduced inhospital mortality; however, women were transferred less frequently,11 possibly indicating another gap in cardiovascular care for rural women. Smoking, hypertension, hyperlipidemia and diabetes are known major risk factors associated with increased lifetime risk for CVD and decreased median survival rates.1 Elevated levels of C-reactive protein (CRP) may increase the risk of CVD in women.12 Other recognized modifiable risk factors for CVD include physical inactivity, obesity, and abdominal adiposity.13 Although rural often evokes visions of outdoor work with a physically fit population, this is not always the case. As rural America has become less agriculturally based and more mechanized, rural women have fewer opportunities for physical activity, which in turn increases their cardiovascular risk. Although current literature does not answer the question of whether US rural women have a higher CVD burden than their urban counterparts, it is clear that CVD, as the number 1 killer of women,1 is negatively affecting the health of all women including those living in rural areas, and thus intervention is warranted. Modifying diet, physical activity and smoking can reduce CVD risks and improve morbidity and mortality rates.14 Even modest behavioral changes have benefits, especially if sustained. However, making and sustaining lifestyle modifications is not easily accomplished. A major gap in the literature exists regarding study interventions lasting more than 6 months. Moreover, results are mixed on whether to approach lifestyle modification from sequential or combined interventions.14 The purpose of this study was to compare 2 strategies, Stage Matched Nursing and Community Intervention (SMN+CI), and Community Intervention (CI) alone, in reducing cardiovascular risk factors and improving risk markers among rural women. This study sought to reduce modifiable cardiovascular risk factors in up to 3 behavioral areas: diet, physical activity, and/or smoking. Theoretical underpinnings for this study included the Transtheoretical model (TM)15 as well as a social-ecological model to account for both environmental and personal systems in health-related behavior and status.16 Transtheoretical model included assessment of stage of change (SOC) at 5 levels (eg, pre-contemplation, contemplation, preparation, action and maintenance).15 The Moos model16 was chosen to help address environmental system limitations (eg, few sidewalks or safe places to exercise in rural communities) and the fact that many rural women drive long distances to work, thus limiting time for physical activity. Specific aims included determining whether rural women, ages 35 to 65 in the group that received SMN+CI, would have greater changes than those in the CI group on: 1) dietary intake, physical activity, and/or smoking; 2) forward movement through the SOC for behavioral action relative to dietary intake of fruits and vegetables, fats, fiber; intention for weight loss, and physical activity; and 3) improvement on selected modifiable cardiovascular risks as measured on the Framingham Coronary Disease Risk Prediction tool (Framingham), serum levels for CRP, lipids, and cotinine for those reporting smoking within the last 2 years, and anthropometric outcomes including blood pressure (BP), body mass index (BMI), and waist circumference.