Introduction

The office of disease prevention and health promotion lists heart diseases and the leading causes of death in the United states and stroke as the fifth leading killer. These two health conditions are preventable but are also expensive to treat costing the economy approximately $ 320 annually.¹ The purpose of his project is to develop a health communication intervention to address the prevalence, the causes, prevention and treatment of heart disease and stroke. The population that is targeted are the adults living in Augusta county in central Virginia estimated to be slightly over 50000 people.

The proposed intervention is on creating awareness of these two conditions by educating the public on their causes, prevention, early detection and seeking treatment when already affected. The controllable risk factors to the two medical conditions are those risk factors that an individual can control therefore decreasing the chances of getting the medical condition. Factors that have been identified include diabetes, cigarette smoking, high blood pressure unhealthy diet, physical inactivity, overweight and obesity and high blood pressure.¹ Their control minimizes the chances of getting these diseases, decreasing deaths and expenses that are directly involved in treating them and at the same time improving the quality of life for the individuals who would otherwise spend most of their time sickly. Primary prevention involves the measures taken to prevent healthy individuals from getting sick and secondary measure are measures to those already with risk factors such as high blood pressure and diabetes to prevent them from having heart diseases or stroke.

This literature review is divided into 3 parts: The introduction that describes the problem, the proposed intervention, and the selection criteria to include and exclude references.

References included here are those that have been written in the last 8 years and those that reported needs for health communication intervention. The literature excluded is that older than 8 years and that from general information and encyclopedia websites. The first reference is on both heart disease and stroke, references 2 to 6 are n heart diseases and 7 to 10 are on stroke.

Body of Evidence

Heart diseases are a risk to every individual and especially the adults. There are however factors that put some people more at risk than others. The traditional risk factors to heart disease affect both women and men and include age, race, diabetes, obesity, and inactivity, among others. Nontraditional risk factors include the pregnancy related disorders ,autoimmune diseases, radiation and chemotherapy from breast cancer, stress and depression among others and are more predominant to women than men.²  Women over the age of 55 are at a greater risk of stress and getting cardiovascular diseases more than men and stress reduction is important for maintaining a healthy heart in the women.² The assessment and strategies should start early in life as they get into adulthood to get a long lasting benefit to prevent this diseases as most of the causes of heart disease are preventable.

Secondary prevention of heart diseases involves taking measures to prevent cardiac diseases among the individuals already identified as having the risk factors such as high blood pressure, elevated cholesterol, reducing stress and stopping to smoke. One method recommended for delivery of secondary prevention interventions is using internet.³ The users have the benefit of having information available to them 24 hours a day and reduces inconveniences such as travelling and the costs that come with it. These interventions reach a larger group of people and they may also be able to contact professionals through emails, chats, and other electronic channels for guidance.³

The burden of heart diseases is not only in the United states but all over the world. In Singapore heart disease is the second leading cause of death. Previous studies showed that working Singaporeans adults were less likely to identify risk factors and adopt healthy lifestyles and that most of them work an average of 45 hours a week most remaining in the sitting positions for extended periods.⁴ With smartphone users estimated to over 76.1%,the increase in their usage laid a foundation for use in a 4-week quasi experiment study using a smartphone app known as Care4Heart.There were four stations that were included for study  covering the topics of coronary artery disease facts, modifiable and nonmodifiable risk factors, components of a healthy lifestyle and stress management^.4This study that was carried out in the year 2018 and the results published in 2019 expanded knowledge from the traditional face to face interventions to the more modern electronic methods that are today increasingly being researched and utilized for various public health interventions.

The use of internet, telephone and video conference communication has emerged as a flexible model for secondary interventions to heart illnesses. In Australia, a prospective, randomized controlled trial for patients previously diagnosed with myocardial infection (MI) was carried out between December 2007 and March 2010. Patients who had MI were recruited for the study and interventions started 2 weeks after the discharge from the hospital.⁵ They were followed up with 10 calls lasting 30 minutes at their convenient times, followed by three weekly sessions, three fortnightly sessions and four monthly sessions over a period of six months with the aim of encouragement of self-management of coronary heart diseases.⁵ With the help of coaches, the participants were motivated to set SMART goals for specific behaviors, barriers and enablers identified and acted upon. The coaching sessions were geared towards reduction of clinical risk factors such as high blood pressure, modification of behavioral risk behavior such as smoking, compliance with pharmacological management and management of the emotional well-being.⁵ The traditional secondary prevention for heart diseases has had low participation levels as patients drop off after discharge and recovery. Innovative methods such as the use of telephone for structured follow up and delivery of health messages increases participation, compliance and reduces readmissions and deaths resulting from heart diseases.

When delivering health messages, it is important to be aware of factors that would impede optimal delivery of the messages. A study carried out in two hospitals in China sought to find out the relationship between health literacy and adherence to the secondary prevention measures. The investigators used a descriptive cross-sectional design and recruited a total of 598 patients and data was collected by self-report on secondary adherence measures such as medication taking and heart-healthy lifestyle prior to their hospital admission.⁶ Health literacy was measures using the short version of the European Health Literacy Survey Questionnaire (HLS-EU-Q16) that was translated to the Mandarin languages and the data collected was analyzed using the SSPS software.⁶ Awareness of the factors that may contribute against adherence to health education communication interventions are unique to the different individuals and groups of people. The communicators should be prepared in advance on how to deal with these impediments once they encounter them.

Hypertension is one of the most common risk factors to development of a stroke. Health education has however only been focused to the general population and the families of the patients that have stroke. Patients with hypertension are mainly educated on exercise, diet, and treatment compliance and not the recognition of a stroke. In Taiwan, stroke is the third leading killer disease and a study was carried out in the year 2015 among 103 hypertension patients in a quasi-experimental design to find out the effects health education impact on the knowledge and cognation of stroke in hypertensive patients.⁷ Recruited participants were provided with materials including CD-ROM and printed information, sessions were held face to face the CD-ROM played and discussions held while the control group received the general outpatient care. Appointments for participants were given for different return dated to avoid sharing of information and a pretest was administered after the first visit and a posttest after 4-8 weeks.⁷ The control group was then given the CD-ROM and the printed materials after the study. Targeted health communication focusing on patients and individuals with a particular health condition could be more effective than giving the general information to the public. Health communicators should be able to prepare and present health messages to specific vulnerable people.

Successful treatment of a stroke patient depends on administration of clot busting medications known as thrombolytic therapy. The treatment with these medications is however limited to a period of 3-4^1/2 hours from the onset of the stroke. Currently there are however only 3-5% of those diagnosed with stroke that receive the thrombolytic treatment mainly because of the publics inability to identify stroke symptoms when they occur.⁸ In 2013, a two arm-arm cluster randomized trial was conducted in New York City to evaluate the effectiveness of two culturally tailored stroke education films with one being in English and the other in Spanish on changing the behavioral intent to call 911 for suspected stroke compared to usual care. The films were showed in the 14 participating churches and participants were recruited targeted to the minority groups with the proposed outcomes being recognition of stroke symptoms and behavioral intent to call 911 measured using the Stroke Action Test at the 6-month and 1-year follow-up.⁸ This study showed that the context for the health communication should be a factor to consider for the health communicators. For example, different cultural groups will view and respond differently to a particular health concern and therefor dissemination of information should not be uniform for all.

Education on stroke has been evolving over the years and updated information is not always readily available not only to the public but also to the educators. In Bangalore india,12 Accredited Social Health Activists (ASHAS) were recruited for a cross-sectional qualitative approach whose aim was to explore awareness about stroke.⁹ The topics covered included causes,riskfactors prevention and treatment and was carried out in a focus group discussion (FGD) and the discussion was transcribed and manually analyzing for emerging themes.⁹ As health communicators target their clients, they also should be updated with the latest information and refresher courses to keep them knowledgeable about the latest information for themselves and their clients.

Barriers to screening patients by the physicians for stroke do exist just like in other medical conditions. understanding these barriers and dealing with them is paramount. In Indonesia,23 physicians were recruited to participate in 3 three focus groups. The questions covered included stroke risk screening, current physician practices and barriers to motivations for patient education and counselling.¹⁰ The answers to the discussions provided the information for better understanding of Indonesian primary care physicians’ practices regarding stroke screening, patient education, and counselling about stroke risk factors.¹⁰

Summary and conclusions

Risk factors to heart diseases and stroke have a different impact to different individuals. Women, black people, and those above the ages of 50 years are more prone than the general population and therefore the health communicators should be aware of these facts to deliver messages appropriate to their audiences. Literacy levels of the audience should also be in the mind of health communicators during the planning, delivery, and evaluation of the health messages.

The use of telemedicine that includes, emails, video calls and chats has been used in delivery of health communication and especially in secondary prevention where participation to the traditional methods has low participation rates.

When delivering health messages risk factors that are greatest concern should be emphasized. Regarding hypertension as a risk factor to stroke specific symptoms should be taught to recognize stroke symptoms and the need to seek treatment soon enough to benefit from thrombolytic treatment. 

Randomized controlled trials, cross-sectional studies and quasi experiments were used in the studies. These are methodologies that have been used successfully in other public health communication programs and have been found to be effective.

Health educators need to be continually updated with the latest information so as not to be sharing outdated health messages and in addition physicians and other health practitioners need refresher trainings to be able to identify barriers to patient education and counselling and be able to overcome them.

Health information communication when used effectively can decrease morbidity and mortality rates from heart diseases and stroke. In this program, messages on primary and secondary prevention will be shared among the congregants in Methodist churches through verbal and written materials, screening by measuring weight, height, bmi, blood pressure and blood sugar after the Sunday services and appropriate referrals done. During the screening 250 participants with risks of heart disease and stroke will be identified for follow-up through telephone calls and physical visits aimed at eliminating or minimizing the risk factors to the two conditions.