ECOLOGICAL THINKING – CARDIOVASCULAR DISEASE1

Ecological Thinking – Cardiovascular Disease

Lindsay Ann Abrigo

Dr. Joseph Costa, DHSc., PA-C

MPH 525 – Health Policy and Management

June 23, 2013

The Structural Model of Behavior (SMB), according to DiClemente, Salazar, and Crosby, emphasizes environmental influences of behavior. The SMB highlights four environmental factors critical in shaping health behaviors: 1) availability/accessibility, 2) physical structures, 3) social structures and policy, and 4) media and cultural influences. One aspect of ecological thinking, according to DiClemente, Salazar, and Crosby (2013) is that the environment provides important influences on health and behavior. The authors also state that environments have the potential to set the stage for individuals and entire communities to engage in risky behaviors. It is evident that a structural intervention is necessary for Huntington, WV. I will focus on cardiovascular disease in Huntington and discuss how the SMB can be applied to effectively prevent and improve the rates of cardiovascular disease by addressing each of the environmental factors aforementioned.

Cardiovascular diseases (CVDs) contribute greatly to the mortality, morbidity and economic burden of illness globally. According to the World Health Organization (WHO), approximately 17 million people die annually as a result of CVDs (Mabrey, Apton, & Lima, 2009). CVD remains a leading cause of death and many people have at least one CVD-related risk factor that may include being overweight/obese, physical inactivity, and smoking, which makes these people more prone to developing serious CVD in the future (Mabrey, Apton, & Lima, 2009).

Availability/Accessibility & Physical Structures

The principle of availability/accessibility is focused on the concept that “behavior is influenced by access: the greater the access, the more likely the behavior is to occur” (DiClemente, Salazar, & Crosby, 2013). Physical structures influence many health behaviors and health-related outcomes, such as diet and physical activity (DiClemente, Salazar, & Crosby, 2013), which can influence cardiovascular health and also prevent cardiovascular diseases (Buttar, Li, & Ravi, 2005). Twenty two percent of Huntington residents have heart disease, 31 percent don't exercise, and the smoking rate is pretty high (Associated Press, 2008). Huntington residents attribute the problem of physical inactivity and lack of exercise to crumbling sidewalks in the city and a lack of walkways along busy rural roads (Associated Press, 2008). Dr. Thomas Dannals, a Huntington family physician pointed out that the town's infrastructure is not conducive to exercising outdoors and that most roads do not have a shoulder for running or biking (Mabrey, Apton, & Lima, 2009). He continues that those who are undereducated about exercise are not driven to engage in physical activity and exercise because they do not see the value in it (Associated Press, 2008).

What can be done to promote positive change?

  • Community leaders can encourage physical activity by working to increase safe routes and sidewalks in the community, especially near busy roads.
  • Community leaders need to improve sidewalks and routes for walking, jogging, and biking to make it more accessible for people to utilize these sidewalks and routes; revitalize public parks, playgrounds, and other community centers or provide fitness programs that will encourage individuals and families to be active.
  • Create paths that make it easy for people in the community to walk or bike from destination to destination. If these paths are available and accessible from central locations in a community and allow individuals to get places efficiently, it is likely they will continue to use them, thus increasing and maintaining physical activity.
  • Offer fun fitness programs at community centers and local parks that will allow residents to interact with others and have fun while staying physically active.

Social Structures

The importance of social structures is evident in the rules and organizations that “create an invisible structure that profoundly shapes how we live our lives and how healthy we are” (DiClemente, Salazar, & Crosby, 2013). Dr. Harry Tweel, director of the Cabell-Huntington Health Department asserted, “People here have an attitude of ‘You're not going to tell me what I can eat.’ The cultural attitude is ‘My parents ate that and my grandparents ate that,’” (Associated Press, 2008). Many people in Huntington consider exercise and healthy eating to be luxuries. Keri Kennedy, manager of the state health department's Office of Healthy Lifestyles stated that fast food is a staple in Huntington because many of the residents believe they cannot afford to buy healthier foods (Associated Press, 2008). "It's cheap to be fat…it’s expensive to be healthy" stated Michelle Isenberg (Mabrey, Apton, & Lima, 2009). Smoking, which is “a common sin in West Virginia”, has been difficult to control. When the health department tried to restrict smoking in local bars and restaurants, local businesses and hospitals fought smoking restrictions all the way to the state Supreme Court (Associated Press, 2008).

What can be done to promote positive change?

Huntington can partner with the Let’s Move initiative that is dedicated to solving the obesity problem in the younger generations by giving parents helpful information and fostering environments that support healthy choices, ensuring every family has access to healthy, affordable food, and helping children become more physically active.

Ensuring that underserved areas have access to healthy, affordable food. The Healthy Food Financing Initiative, launched by the Obama administration, is a partnership between the U.S. Departments of Treasury, Agriculture and Health and Human Services to provide financing for developing and equipping grocery stores, small retailers, corner stores, and farmers markets selling healthy food in underserved areas.

Together with Let’s Move, Huntington can support the sale of local foods across the community by offering incentives and encouraging the establishment of farmers’ markets. Many markets now participate in the WIC, Supplemental Nutrition Assistance Program, Double Dollar, and senior benefits program so that fresh produce is not out of reach for those with limited or fixed incomes.

Families can start their own gardens at home in the yard or in the kitchen. This will give families the opportunity to get everyone involved each step of the way, from choosing what foods to plant, tending the garden, and enjoying delicious meals.

Build and maintain community gardens where residents will be able to grow and harvest their own fresh fruits and vegetables. Because they benefit the community, are collaborative effortsand incorporate sustainable practices, community gardens are assets that benefitentire neighborhoods, cities and towns. The United States Department of Agriculture's (USDA) People's Garden initiative has grown into a collaborative effort of over 700 local and national organizations all working together to establish community and school gardens.

Informational sessions available to parents and families to educate them that buying healthy foods in local grocery stores can be done and providing them with useful tools to shop for healthy foods in the grocery store without breaking the bank.

Effects of Media

Media largely influences health behaviors. Advertising can be used to shape social norms about acceptability and attractiveness of engaging in certain health-related behaviors, according to DiClemente, Salazar, and Crosby (2013). Mass media products include the internet, radio, television, movies, music, PSAs distributed to nearly all radio and TV station through the country, and print. In Huntington, a TV commercial where KFC challenged a family to put together dinner for $10 or less that would be comparable to their $9.99 meal. This commercial is “an extremely persuasive ad for a low-income family” and is a perfect example of how media in Huntington shapes the health behaviors of the residents by encouraging them to continue to eat fried foods that are unhealthy simply because it is more affordable.

What can be done to promote positive change?

  • Replace commercials that promote fast food restaurants and unhealthy foods with commercials on TV and on the radio that promote local farmers markets, local businesses that sell locally grown produce, and community gardens. This will not only promote the farmers markets and community gardens, but it will encourage residents of Huntington to opt for buying locally grown produce or to start their own garden at home.
  • In addition to the TV and radio commercials, will distribute monthly newsletters that will offer healthy recipes for families to try out at home. They will use produce that can be found in their own community/home gardens or at the farmers markets and will also provide additional useful tips for residents to shop smart and get the most of their money when buying items from the grocery store.
  • Air TV programs that are tailored to Huntington residents so that they will be able to better relate to the issue of cardiovascular disease. This will not only educate individuals on the risks, but will also provide them with vital information on how to modify their current health behaviors to minimize their risk or improve their current health status. Bellicha and McGrath state that there is great potential in “a half-hour TV program on three cardiovascular risk factors, high blood pressure, high blood cholesterol, and smoking” that can be used by TV stations by localizing it for their communities (1990). The authors also state that PSAs are one slice of a mass media effort and mass media is one slice in a larger national education program geared toward reducing cardiovascular disease (Bellicha & McGrath, 1990).

Associated Press. (2008, November 16). CDC: Huntington, W. Va. Nation’s Unhealthiest City.Fox News, Retrieved from

Bellicha, T., & McGrath, J. (1990). Mass media approaches to reducing cardiovascular disease risk. Public Health Reports, 105(3), 245-252. Retrieved from

Buttar, H. S., Li, T., & Ravi, N. (2005). Prevention of cardiovascular diseases: Role of exercise, dietary interventions, obesity and smoking cessation. Experimental & Clinical Cardiology,10(4), 229-249. Retrieved from

DiClemente, R., Salazar, L., & Crosby, R. (2013).Health behavior theory for public health: Principles, foundations, and applications. Burlington, MA: Jones & Bartlett Learning.

Mabrey, V., Apton, D., & Lima, M. (2009, February 19). A tale of two cities: Fattest and fittest towns in America.abcNEWS. Retrieved from

U.S. Department of Agriculture; U.S. Department of Health and Human Services, (2013). Let's move: Active communities. Retrieved from website:

U.S. Department of Agriculture; U.S. Department of Health and Human Services, (2013). Let's move: Healthy communities. Retrieved from website: