Underneath the Red Dress: How the ‘Heart Truth’ Campaign Fails through its Rigid Design & Disregard for Social Science Variables-Susan Helwig Svencer

Since 2003 the National Heart, Lung, and Blood Institute (NHLBI), a division of the U.S. Department of Health and Human Services, has promoted women’s cardiovascular health through a campaign entitled the Heart Truth, with a red dress as its symbol (www.hearttruth.gov ). The campaign focuses on increasing awareness that heart disease is the number one killer of women as a means of inspiring women to take action and lead healthier lives. Studies published on the Heart Truth website note that awareness of heart disease has increased among women since the program’s inception, but that women have not changed their cardiovascular-related health behavior (1). As a fundraising campaign among wealthier, Caucasian women, it appears to be effective, but as a true intervention among all women, it fails for a number of reasons. The campaign’s message will not have a broad reach due to its disregard for sociocultural and economic variables, as demonstrated through its narrow choice of communication channels and the promotional materials content. In addition, the environmental and economic variables that may significantly affect a woman’s receptivity to and ability to act on the recommended behavior changes were also ignored when the campaign materials were developed. And lastly, the theoretical basis on which the campaign is designed assumes awareness equates to action and does not capitalize on women’s stated drivers of and barriers to improved cardiovascular health.

The first means by which the Heart Truth scope is limited is through its prohibitive advertisement placement Women of lower socioeconomic status are considerably less likely to be exposed to the Heart Truth promotional materials as a result of the use of communication channels inaccessible to many women. While many of the campaign materials will reach middle-to-upper class women, others will not come into contact with them, confounding the campaign’s focus on all women.
The hallmark, annual promotional event for the Heart Truth takes place at New York’s Fashion Week, creating collaboration between the campaign and what the Heart Truth’s public relations firm deems “an industry intrinsically tied to the target audience” (2). However, fashion week’s target audience is a small subpopulation of women - mainly Caucasian and upper class – and focusing on fashion as a means of promoting the campaign reinforces the exclusion of the lower class. Furthermore, several high-end brands with upper class association are the primary fashion week sponsors, including Mercedes-Benz, IMG Models, Swarovski, Inc., and Olympus (2). A connection to fashion as well as these brands may reach wealthier women and generate favorable press for the campaign, but less advantaged women will certainly not be exposed to the Heart Truth messages through these fashion-related events.
In addition, large scale advertisements depicting women in red couture or former first ladies dressed in red were placed in 22 US airports. By displaying advertisements in airports rather than in more common locales, the Heart Truth circumvents women of lower socioeconomic status who are less likely to pass through an airport. Air travel frequency is significantly lower in households earning less than $25,000 per year than others, and in total, only 7% of long-distance trips within the US are by air (3, 4). Cost is the most-cited obstacle to increased air travel, meaning women without the expendable income to fly will not see the advertisements.
Public service announcements (PSAs) were also placed in numerous print magazines. While some of these (Essence, People En Español, BabyTalk) boast a relatively ethnically and financially diverse readership, several others do not. With a median household income between $80 and 90K, InStyle and Real Simple, two other magazine featuring Heart Truth PSAs, target affluent readers (5, 6). And arguably anyone reading Health and Balance magazines, where Heart Truth PSAs also appeared, are already proactive about their health and are not the population most in need of the Heart Truth’s messages.
The reach of the Heart Truth message is further restricted because the primary means of disseminating information to women is through the NHLBI’s website. Caucasians are nearly twice as likely to have internet access at home as are Blacks or Hispanics (7), and the same pattern emerges when overall use of the internet is examined. However, internet use is related to more than race: it is highly correlated to income level, education, and geographic region (8), rendering the Heart Truth health information less accessible or even unattainable to a large proportion of women. Moreover, even if women do have internet access, reading health information online has been shown to have little effect on the frequency of physician visits and even on the depth of overall health knowledge of the reader (9).

On top of the exclusionary dissemination of campaign information, the second way the Heart Truth message is constrained is by its disregard for the sociocultural context in which women receive their messages. Even if women are exposed to the Heart Truth materials, the content is not adaptable or even accessible to a diverse population.
Despite a stated focus on Latinas and African American women, the campaign information directed to each of these groups are only marginally different from the materials designed for the broader female population. The only changes made to the Latina and African American specific materials are images of women from each group and statistics specific to each population. Stating that “heart disease is more prevalent among black women than white women” (10) or that “nearly two out of every three Latinas are overweight or obese, increasing their risk of heart disease” (11) is not only uninspiring, it outright ignores the culture nuances that may significantly affect the health behaviors (i.e. level of physical activity and a healthy diet) that led to these statistics and an increased risk of heart disease. For example, Hispanic and Black women’s low level of physical activity has been shown to be influenced by factors different than that of white women, including family health, perceived social norms, access to neighborhood resources and facilities, as well as cost and time (12, 13). And while levels of smoking remain the same for Black and White women, Black women gain substantially more weight after smoking cessation than do white women (14) – a critical factor in getting women to quit smoking not addressed by the Heart Truth. By using race as an individual level, categorical variable, the NHLBI has overlooked the complexities of health disparities that arise when cultural factors are considered.
Intra-racial distinctions are another crucial determinant of health behavior that is overlooked by the Heart Truth. The campaign takes a one size fits all approach to its content, assuming, for example, that all Hispanic women respond and act in a similar way. However, attitudes towards smoking cessation and weight loss have each been shown to vary considerably within the broad Hispanic population, in some cases even by level of acculturation (15). In addition, a recent study among Black women suggests that those with strong religious beliefs have more interest in and higher actual consumption of fruits and vegetables than those with weaker religious beliefs and behaviors (16). Yet the Heart Truth communication materials do not even acknowledge intra-racial differences exist, much less allow their messages to be tailored to subgroups.
The advertisements placed in airports mentioned earlier in this article featured either mannequins dressed in red couture dresses designed for the Heart Truth by 21 prominent fashion designers or US First Ladies dressed in red suits. These images are concerning for several reasons. Rather than motivate women to better heart health, the former may serve to alienate those who cannot afford the glamorous dresses nor have an occasion to wear them. The First Ladies featured in the latter may not be recognizable to a large proportion of women. While these advertisements are no longer displayed in airports, First Lady Laura Bush remains the primary spokeswoman for the Heart Truth campaign, a polarizing figure even among those who can identify her. As purported through McGuire’s Communication / Persuasion Matrix, the source of information strongly affects its reception (17). In this case, women who can identify with Laura Bush and/or women who wear couture are more likely to be persuaded by the message being delivered through these print advertisements than are those who do not relate to the messengers, once again alienating women of lower socioeconomic status and non-white women.
The Heart Truth strongly suggests women develop a healthy relationship with their physician to determine their risk of heart disease and to set goals for achieving heart health. Yet in the general US population, distrust of the healthcare system is high and closely linked to a worse self-reported health, even after adjusting for socioeconomic status and access to health care (18). This distrust and resulting decreased participation in the healthcare system also varies considerably by race and culture – a fact conveniently disregarded by the Heart Truth. Significant racial differences (Caucasian vs. Black) in the level of trust in medical care have also been found to exist (19). Many have cited Tuskegee as a clear determinant of this mistrust among the Black population (20), but differences are also likely due to historical and personal experiences that are broader than that (21). Black and Hispanic residents in the south Bronx have expressed a “deep and pervasive distrust of the health care system, exasperated by difficulties that patients experience in communicating with their providers” (22). Specific to cardiac procedures, Black patients have also been shown to prefer they build a solid relationship with their physician before agreeing to undergo surgery, yet they consistently feel the trust they so desire is absent. These patients also report they are often confused by the cardiovascular health information they do receive, which could be unintentionally fostering these feelings of mistrust (23). Misgivings and suspicion toward organized medicine must be addressed before women can be expected to develop a strong relationship with their physicians, per the Heart Truth’s recommendations.

In addition to the economic and cultural oversights that limit the Heart Truth’s reach, many of the campaign’s lifestyle recommendations discount potential environmental and socioeconomic barriers. The Heart Truth fundamentally oversimplifies these issues by emphasizing, “Protecting your heart can be as simple as taking a brisk walk, whipping up a good vegetable soup, or getting the support you need to maintain a health weight” (24). Women are told to “choose a diet low in saturated fat, trans fat, cholesterol, and moderate in total fat” (25) without being informed how to do so. The Heart Truth website does provide women with recipes for heart healthy food, yet many of these recipes contain ingredients that may be difficult for women of low income and in disadvantaged neighborhoods to obtain, much less afford (i.e. Dijon salmon, zucchini lasagna, and peach cobbler (26). Strong links between socioeconomic status and food purchasing decisions have been found, with those of lower socioeconomic status being less likely to buy high fiber, low fat, salt and sugar foods, as well as fruits and vegetables (27). When low income women are provided financial supplements for the purchase of produce, they come closer to meeting dietary guidelines, as one of the key impediments (cost) to their purchasing is eliminated (28). For all women to adopt heart healthy eating habits, an understanding of the obstacles preventing such lifestyle changes is paramount. Unfortunately, the Heart Truth does not acknowledge that any barriers other than a patient’s willingness to change play a role in health behavior.
Lastly, the Heart Truth campaign was developed under the assumption that all health behaviors are rational, such that basic awareness of women’s heart disease risk will inspire action. Coupling this erroneous postulation, seemingly derived from the Health Belief Model (HBM), with the Heart Truth’s disregard for women’s stated influences of their health behavior has rendered the intervention ineffective at improving women’s overall cardiovascular health.
The Heart Truth campaign appears to have been built on the (HBM), as its primary aim is to make women understand they are highly susceptible to heart disease and that contracting it will cause considerable harm. According to the HBM, internalizing this susceptibility and potential severity should cause women to see the benefit in a behavior (in this case eating healthier, exercising, and visiting their physician regularly to prevent heart disease) and therefore cause them to intend to adopt the behavior (29). Yet this model assumes that obstacles to performing a given health behavior are minimal. It also does not take into account how attitudes and beliefs may affect uptake of a behavior, and assumes that all health behaviors are rational. Because these factors – most notably the existence and impact of obstacles as well as variable attitudes towards health – are excluded from the Heart Truth’s design, its reach is significantly constrained. This, however, could be rectified by incorporating components of other health behavior models (Bandura’s notion of self-efficacy or the social factors and attitudes that comprise part of Azjen and Fishbein’s theory of reasoned action) (30) to address the obstacles women face in adopting behaviors beneficial to their cardiovascular health.
NHBLI surveys suggest awareness that heart disease is the number one killer of women has risen from 34% to 55% since 2000 (1), as well as that women do recognize the red dress as a national symbol of heart health (31). However, data also show that few behavior modifications have been made as a result of this increased awareness (32). Through several studies, women have cited numerous barriers to their taking preventive health measures. First among these is confusion in the media (1, 33). With conflicting information regarding the benefits of various diet changes and exercise regimens, are women supposed to accept the Heart Truth’s recommendations at face value? It is unfair and unrealistic to assume that they will. Caretaking responsibilities and family obligations are also commonly noted impediments to behavior change. And interestingly, women who do take action note that they do so for their family as opposed to for themselves. These attitudes reveal an important driver of health behavior that should be used as a motivator and as a means of helping women address many of the barriers they face. Unfortunately, the Heart Truth has ignored these data points because they are inhibited by the rigid, illogical structure of the HBM.

Through the Heart Truth campaign, the NHBLI has the opportunity to improve the cardiovascular health of considerably more women than it is currently affecting. By expanding its use of communication channels and rethinking its advertisement placement, the Heart Truth could more thoroughly expose women of lower socioeconomic status to its messages. Adjusting the content of promotional materials to take social and cultural as well as environmental and economic factors into account would make the messages and behavior modification recommendations more realistic and accessible to both women of color and disadvantaged women. Incorporating the factors women explicitly say affect their health behavior into the campaign, as well as acknowledging that obstacles to adopting a given health behavior do exist (potentially through the use of behavioral models beyond the HBM), would serve to make the intervention a powerful resource and means of affecting health behavior change. If these modifications can be made, the Heart Truth still has a chance to make a true impact and meet the goal of not only reminding women of the need to protect their heart, but also inspiring them to do so.

References
1 Getting the message: Heart Disease is the #1 Killer of Women. 2005. Available at: http://www.nhlbi.nih.gov/health/hearttruth/whatis/message.htm. Accessed October 22, 2006.
2 Ogilvy Public Relations Worldwide. Case Studies: the Heart Truth. DATE?. Available at: http://www.ogilvypr.com/case-studies/heart-truth.cfm. Accessed November 3, 2006.
3 U.S. Department of Transportation, Bureau of Transportation Statistics. 2001 National Household Travel Survey Data. Long Distance Passenger Travel. Available at: http://www.bts.gov/publications/transportation_statistics_annual_report/2004.Accessed October 29, 2006.
4 U.S. Department of Transportation, Bureau of Transportation Statistics. 2001 National Household Travel Survey Data. Long Distance Travel by Income, Gender, and Age. Available at: http://www.bts.gov/publications/transportation_statistics_annual_report/2004.
Accessed October 29, 2006.
5 Time, Inc. October 18, 2006. In Style secures its third consecutive readership increase. Available at: http://www.timeinc.com.au/news/IN_STYLE_News/10_8_2006_IN_STYLE_secures_its_third_consecutive_readership_increase.aspx. Accessed November 11, 2006.
6 Real Simple Media Kit. Spring 2006. Available at: http://www.realsimplerewards.com/rsn/mediakit/PDFs/RS06demos_0506.pdf. Accessed November 11, 2006.
7 US Census Bureau. Computer and Internet Use in the United States: 2003. Available at: http://www.census.gov/prod/2005pubs/p23-208.pdf. Accessed October 22, 2006.
8 National Telecommunications and Information Administration. US Department of Congress, July 1998. Falling Through the Net: Defining the Digital Divide. Available at: http://www.ntia.doc.gov/NTIAHOME/FTTN99/part2.html. Accessed, October 27, 2006.
9 Baker L, Wagner TH, Singer S, Bundorf MK. Use of the Internet and E-mail for Health Care Information. JAMA 2003 May; 289(18):2400-6.
10 U.S. Department of Health and Human Services. September 2003. The Heart Truth for African American Women: An Action Plan. Available at: http://www.nhlbi.nih.gov/health/hearttruth/material/factsheet_aa.pdf. Accessed October 22, 2006.
11 U.S. Department of Health and Human Services. September 2003. The Heart Truth for Latinas: An Action Plan. Available at: http://www.nhlbi.nih.gov/health/hearttruth/material/factsheet_latina.pdf. Accessed October 22, 2006.
12 Keller C, Fleury, J. Factors related to physical activity in Hispanic women. Journal of Cardiovascular Nursing 2006 Mar-Apr; 21(2):142-5.
13 Schrop SL, Pendleton BF, McCord G, Gil K, Stockton L, McNatt J, Gilchrist VJ. The medically underserved: who is likely to exercise and why? Journal of Health Care for the Poor and Underserved 2006 May; 17(2):276-89.
14 Sanchez-Johnsen LA. Smoking cessation, obesity and weight concerns in black women: a call to action for culturally competent interventions. Journal of the National Medical Association 2005 Dec; 97(12):1630-8.
15 Kerner JF, Breen N, Tefft MC, Silsby J. Tobacco use among multi-ethnic Latino populations. Ethnicity & Disease 1998; 8(2):167-83.
16 Holt CL, Haire-Joshu DL, Lukwago SN, Lewellyn LA, Kreuter MW. The role of religiousity in dietary beliefs and behaviors among urban African American women. Cancer Control 2005 Nov;12 Suppl 2:84-90.
17 McGuire WJ. Input and Output Variables Currently Promising for Constructing Persuasive Communications. In R. E. Rice & C. K. Atkin (Eds), Public Communication Campaigns (3rd ed., pp. 22–48). Newbury Park, CA: Sage Publications.
18 Armstrong K, Rose A, Peters N, Long JA, McMurphy S, Shea JA. Distrust of the health care system and self-report health in the United States. Journal of General Internal Medicine 2006 Apr; 21(4):292-7.
19 Boulware LE, Cooper LA, Ratner LE, LaVeist TA, Powe NR. Race and trust in the health care system. Public Health Reports 2003 Jul-Aug; 118(4):358-65.
20 White, RM. Misinformation and misbeliefs in the Tuskegee Study of Untreated Syphilis fuel mistrust in the healthcare system. Journal of the National Medical Association 2005 Nov; 97(11):1566-73.
21 Brandon DT, Isaac LA, LaVeist TA. The legacy of Tuskegee and trust in medical care: is Tuskegee responsible for race differences in mistrust of medical care? Journal of the National medical Association 2005 Jul; 97(7):951-6.
22 Kaplan SA, Calman NS, Golub M, Davis JH, Ruddock C, Billings J. Racial and ethnic disparities in health: a view from the South Bronx. Journal of Health Care for the Poor and Underserved 2006 Feb; 7(1):116-27.
23 Collins TC, Clark JA, Petersen LA, Kressin NR. Racial differences in how patients perceive physician communication regarding cardiac testing. Medical Care 2002 Jan;40(1 Suppl):I27-34.
24 What Are the Risk Factors for Heart Disease? 2003. Available at: http://www.nhlbi.nih.gov/health/hearttruth/lower/risks.htm. Accessed October 22, 2003.
25 Tips for Heart Health. 2003. Available at: http://www.nhlbi.nih.gov/health/hearttruth/lower/tips_hearthealth.htm. Accessed October 22, 2006.
26 When Delicious Meets Nutritious: Recipes for Heart Health. January 2005. Available at: http://www.nhlbi.nih.gov/health/hearttruth/material/factsheet_recipes.pdf. Accessed October 22, 2006.
27 Turrell G, Hewitt B, Patterson C, Oldenburg B, Gould T. Socioeconomic differences in food purchasing behavior and suggested implications for diet-related health promotion. Journal of Human Nutrition and Dietetics 2002, Oct; 15(5):355-64.
28 Herman DR, Harrion GG, Jenks E. Choice made by low-income women provided with an economic supplement for fresh fruit and vegetable purchase. Journal of American Dietetic Association 2006, May; 106(5):740-4.
29 Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2:328-335.
30 Salazar MK. Comparison of four behavioral theories. American Association of Occupational Health Nurses Journal 1991; 39:128-135.
31 Harris Interactive. One in Four U.S. Women Recognize the Red Dress as the National Symbol for Women and Heart Disease Awareness. January 2005 Commissioned by WomenHeart: the National Coalition for Women with Heart Disease. Available at: http://www.nhlbi.nih.gov/health/hearttruth/whatis/reddress_recognized.htm. Accessed October 22, 2006.
32 Lifetime Women’s Pulse Poll. New Lifetime Poll Shows More Than Half of Women Know Heart Disease is their #1 Killer, Yet Only One in Three Believe They are Personally At Risk. Released February 1, 2006. Available at: http://www.nhlbi.nih.gov/health/hearttruth/press/risk_awareness.htm. Accessed Octoer 22, 2006.
33 Mosca L., Mochari H, Christian A, Berra K, Taubert K, Mills T, Burdick KA, Simpson SL. National study of women's awareness, preventive, and barriers to cardiovascular health. Circulation 2006 Jan 31; 113(4):525-34.