A systematic review of the effectiveness of primary health education or intervention programs in improving rural women's knowledge of heart disease risk factors and changing lifestyle behaviours.

Abstract

Background Although there have been considerable advances in medical science, cardiovascular disease (CVD) continues to impose a financial burden on Australians.1 Cardiovascular disease remains a major public health problem in Australia and is a leading cause of mortality and disability. One Australian dies every ten minutes from cardiovascular disease and one in three families are directly affected by cardiovascular disease.2 CVD accounted for 46,134 deaths (35% of all deaths in Australia) in 2005. It is also one of the leading causes of disability, with around 1.4 million Australians (6.9% of the population) estimated to have disability associated with cardiovascular conditions.3 In the 2004-05 National Health Survey, about 19% of those surveyed reported one or more longterm diseases of the circulatory system, corresponding to 3.7 million Australians. Outside capital cities, the mortality rates for coronary heart disease are higher. The difference between rural and urban areas accounts for approximately 5000 excess deaths per year.4 Lifestyle is a major determinant of the risk of heart disease. Modifiable risk factors include diabetes, smoking, hypertension, nutrition, hyperlipidemia, physical activity, obesity and alcohol intake. These risk factors can be controlled or modified by lifestyle changes.5 As heart disease develops over many years, people need to be aware of the modifiable risk factors in order to follow healthy lifestyle practices and reduce their chance of a first or recurrent heart attack.6 Heart disease is not gender specific. Historically, coronary heart disease has been perceived as a man's disease and for many years, women were not included in cardiovascular research programs.7,8 Women diagnosed with coronary heart disease experience higher morbidity and mortality than men.9 One explanation for this less favourable outcome is that when women first experience a coronary event, they are older, and are more likely to have more co-morbidities, such as diabetes and hypertension, which in turn contribute to higher mortality rates.9 10 Coronary heart disease also accounts for the majority of cardiovascular deaths in women, disproportionately afflicts racial and ethnic minorities and is a prime target for prevention.11 For the reasons cited above and due to limited access and availability of healthcare in rural areas, women living in rural Australia are at greater risk of heart disease.12 Combining both the burden from premature death and the extent of its disability, CVD has been estimated to account for 18% of the overall disease burden in Australia in 2003, with coronary heart disease and stroke contributing over fourfifths of this burden. 13 Most of the cardiovascular burden was due to years of life lost (YLL) to premature death and they represented 29% of total YLL for Australia in 2003. Years of ‘healthy' life lost due to poor health or disability (YLD) arising from CVD accounted for 8% of Australia's total YLD in 2003. The cardiovascular burden increases markedly with age, particularly from 60 years onwards. In recent years there has been a shift in health service delivery from institutional to community-based care for chronic conditions, including cardiovascular disease.14 15 There is an increase in early hospital discharges and there have been moves to enhance shared care between acute care providers and general practitioners.16 Thus, there is an increasing prevalence of chronic illness within the community that requires ongoing, and increasingly complex, management. 14 Given that contemporary models of care are increasingly unable to meet the needs of those with major chronic illness, alternate models need to be explored in terms of both their cost to the health system and added value to consumers.17 The ageing population, improved survival from acute cardiac events and increasing incidence of lifestyle risk factors all impact upon cardiovascular disease incidence within the community. Interventions such as lifestyle and risk factor modification aimed at those at the ‘well' end of the illness trajectory can potentially improve health outcomes by slowing the development of symptomatic disease.18 This systematic review will generate new knowledge relating to the effectiveness of health education and intervention programs to improve the knowledge of risks associated with heart disease for women in rural communities. The objective of this review is to present the best available evidence related to the effectiveness of health education programs for cardiac risk factor reduction in healthy women living in rural areas that has been presented in the international literature. Review question/objective What is the effectiveness of primary health education or intervention programs on improving knowledge of risks associated with heart disease for rural women? More specifically, the research questions are: Do primary health education programs improve knowledge of risk factors for heart disease for rural women? Does this knowledge translate to lifestyle changes for rural women and reduce their risk of future heart disease? Types of participants The review will consider all studies reporting interventions that included women aged 18-65 years, living in rural areas, who participated in primary health care education programs. Studies that included children or interventions for cardiac rehabilitation will be excluded. Types of intervention(s)/phenomena of interest The interventions of interest for this review are studies that evaluate the effectiveness of primary health education or intervention programs aimed at improving rural women's knowledge of their risk of heart disease, eg group work, videos, telephone, workshops, educational material and counselling. Types of outcomes Primary outcomes of interest for this review include the following outcome measures: knowledge level of heart disease risk factors Lifestyle modification eg dietary improvements such as reduced daily salt intake, increased intake of fruit and vegetables and decreased intake of fat, increased frequency of exercise, decreased levels of smoking, alcohol intake within national guidelines, Health assessment measures eg blood pressure, body weight, cholesterol levels. Types of studies This review will consider any randomised controlled trials; in the absence of RCTs other research designs, such as non-randomised controlled trials and before and after studies, will be considered for inclusion to enable the identification of current best evidence regarding educational programs or interventions and their effectiveness in reducing the risk of heart disease. Exclusion criteria This review will exclude studies conducted in metropolitan areas or within tertiary health units. Studies that do not include women will also be excluded. Studies undertaken in children to promote healthy lifestyle will also be excluded. Studies with cardiac rehabilitation will also be excluded. Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilised in each component of this review. An initial limited search of MEDLINE, CINAHL and PsycINFO will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. The databases to be searched include: MEDLINE CINAHL Embase Academic Search Premier, Meditext Atsihealth and Rural (Rural & Remote Database) The search for unpublished studies will include: Mednar Conference Proceedings Dissertations abstracts, reports Initial keywords to be used will be: Rural Women Heart disease Cardiovascular disease Intervention studies Health education Chronic disease Health promotion Education program Primary health Assessment of methodological quality Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI, Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Quantitative papers will, where possible be pooled in statistical meta-analysis using the JBI-MAStARI. All results will be subject to double data entry. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form. Conflicts of interest None known