Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Friday, April 18, 2008

The CDC’s Attempt to Reach out to Low Income Women Across America: A Critique of the WISEWOMEN Program – Erin Najuch

In 1993 the Centers for Disease Control and Prevention (CDC) established the Well-Integrated Screening and Evaluation for Women Across the Nation Program (WISEWOMEN). WISEWOMEN is a program that aims to help low income women gain access to screening and prevention of cardiovascular disease and other chronic illnesses (1). WISEWOMEN attempts to address risk factors such as high cholesterol, high blood pressure, diabetes, obesity, physical inactivity, unhealthy diet, smoking and other factors that significantly influence the health of women (1).  

Federal money is provided to the CDC, which then is distributed to state and territorial health departments and tribal agencies (2 -3). The state agencies are then responsible for the WISEWOMEN programs. Each of the fourteen state programs are unique and designed differently. All WISEWOMEN programs are required to screen for high blood pressure and high cholesterol levels. The WISEWOMEN program also provides funding for confirmation of screening results and annual follow-up examinations. The WISEWOMEN program does not provide any treatment (2). 

Cardiovascular Disease in US Women
Cardiovascular disease is the leading cause of death for white, black, Hispanic and American Indian/Alaskan Native women in the United States (5-6). Approximately half a million women die each year from cardiovascular disease and 2.5 million women are hospitalized each year from cardiovascular disease (6). One in three female adults has some form of cardiovascular disease (5). Since 1984, the number of cardiovascular disease deaths for females has exceeded the number of cardiovascular disease deaths for males (5).

Numerous research studies show a correlation between socioeconomic status and cardiovascular disease in women. Women of low-socioeconomic status have a greater risk of cardiovascular disease than women of higher socioeconomic status (8-12). Women of low socioeconomic status have lower education levels and less access to health care than women of higher socioeconomic status (8-12). It is apparent that a national program to reduce cardiovascular disease in women with low socioeconomic status is needed, however, WISEWOMEN is not adequately designed to achieve such a goal. Based on the WISEWOMEN eligibility criteria, national locations of the program and the assumption that intention leads to behavior, the WISEWOMEN program is not an effective way to screen and prevent cardiovascular disease and chronic illness to all of the low income women in the U.S.  

Criteria to joining a WISEWOMEN program
Criteria to join a WISEWOMEN program either exclude or deter many women who could potentially benefit from the program. The WISEWOMEN programs are restricted to females between the ages of 40 and 64. Participants must be enrolled in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and either uninsured or underinsured and eligible for Medicare, but are unable to pay the premium (monthly payment) to enroll in Medicare, Part B. (1)  

WISEWOMEN is advertised as a national program to help low income women across the nation. However, this program only helps certain women. Cardiovascular disease increases with age. (5). Women that are age 65 and older are at the greatest risk for cardiovascular disease (5). In 2004, women over the age of 65 were accountable for 401,784 deaths from cardiovascular disease (5). Although women that are 65 years and older would benefit from joining a WISEWOMEN program, the age requirement restricts them from joining. In order to help decrease the prevalence of cardiovascular disease in low income women, the age requirement to join a WISEWOMEN program should be altered to include all women over the age of 40.

The second criteria to join a WISEWOMEN program is enrollment in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). NBCCEDP is also funded by the CDC and provides low-income, uninsured women screening and diagnostic services for breast and cervical cancer (13). Guidelines to join the NBCCEDP include uninsured and underinsured women at or below federal poverty level; ages 18–64 for cervical screening; ages 40–64 for breast screening (13). Originally, WISEWOMEN was an expansion of the NBCCEDP. Congress only provided enough funding for one-fifth of the women who qualify for NBCCEDP. (14). This directly affects the women that could potentially join a WISEWOMEN program. If eligible women cannot join a NBCCEDP program because of the lack of funding then they are not able to join a WISEWOMEN program (14).

The last criteria to join a WISEWOMEN program is that women must be uninsured. According to the U.S. Census Bureau, 47 million American are uninsured (15-16). Approximately 46% of the uninsured population are women (15-16). Although WISEWOMEN does provide health screenings to some of the uninsured women it does not provide health screenings to all of them.  

The lack of health insurance has been associated with lower health screening rates, reduced access to care and lower quality hospital care (10, 12, 15). Women without insurance are less likely to seek preventative care and more likely to seek emergency care than women who have health insurance coverage (10, 12, 15). Failing to have annual physicals and cardiovascular screenings is associated with increased mortality in women (12). A study conducted by the Division of Nutrition and Physical Activity concluded that uninsured women have worse cardiovascular disease risk factors, predominantly factors related to lifestyle such as smoking and exercise than women who have health insurance coverage (12).  

The WISEWOMEN programs provide health screenings and annual follow-up examinations but they do not provide treatments. Since WISEWOMEN does not provide treatment, women enrolled in the program who need follow-up treatment are going to have to pay high out of pocket costs for procedures and prescription drugs. Many women will have to decide between food or medication. Both may be necessary. In addition to the high out of pocket health care costs, the uninsured population may face other barriers such as language and transportation. Approximately 12.5 million Americans without health insurance are foreign born and may face language barriers to health care (16). Women that do not speak English or do not have an interpreter are less likely to seek medical care. Without the proper screenings, these women may be at risk for cardiovascular disease (16). Transportation is another barrier to health care. Women with a low socioeconomic status may not have reliable transportation to bring them to and from the doctor’s office or pharmacy. Public transportation is an alternative option but some smaller towns may not have public transportation available. 

Locations of the WISEWOMEN Programs
In addition to the criteria to joining a WISEWOMEN program, the limited states in which WISEWOMEN is available also contributes to making the program ineffective. WISEWOMEN projects are only available in fourteen states. Unfortunately, geography is a barrier to joining the program. If a WISEWOMEN program is not available in your state you cannot travel to another state, it is advised to contact your congressman and express your interest in the program if you would like to start one in your state. There is an association between income level and education and education and health insurance coverage (17). Most uninsured women below poverty level have a low education level as well (6). They probably do not know who there congressman is and they most likely will not have the resources to find out.

The WISEWOMEN program started in three states, Massachusetts, North Carolina and Arizona (18-19). Since its beginning, WISEWOMEN has expanded to fourteen states and has fifteen programs in total. In order to receive funding for a WISEMWOMEN program each state that applied went through a competitive bidding process (14). At the end of the funding period each state has to reapply for continued funding. Although the goal of WISEWOMEN is to reduce the prevalence of cardiovascular disease in low income women; poverty level, uninsured rates and cardiovascular rates of each state were not determinants as to whether or not a state receives funding from the CDC (14).

The majority of the WISEWOMEN projects are in the Midwest where the poverty rate, uninsured rate and deaths from cardiovascular disease are low compared to other regions in the nation (5, 20). The south on the other hand, has two WISEWOMEN projects and has the highest poverty rate, uninsured rate and deaths from cardiovascular disease (5, 20). In fact, out of the ten states with the highest rate of cardiovascular disease, only two of them have WISEWOMEN programs. Currently, the WISEWOMEN programs are not aimed at the target audience.

The Health Belief Model – Intention does not always lead to Behavior
The WISEWOMEN program appears to be based on the Health Belief Model (HBM). The Health Belief Model assumes that intention leads to behavior. The primary objective of the Health Belief Model is to make someone understand that he or she is susceptible to certain illnesses and diseases (cardiovascular disease). Components of the HBM include perceived susceptibility, perceived benefits, perceived barriers, cues to action and self-efficacy (21-23). The HBM is based on the individual considering the extent of risk involved and making a decision about whether or not to partake in a health behavior (21-23). WISEWOMEN provides women with the tools and knowledge that they need in order to make healthy lifestyle decisions. The lifestyle changes include becoming more physically fit, adopting healthy eating habits and leading a smoke-free life (18-19). WISEWOMEN programs recommend that women exercise on a consistent basis. WISEWOMEN does not provide fitness memberships to all women who need to exercise. Instead, WISEWOMEN suggests that women purchase a fitness membership with their own money. Low-income women need to provide food, shelter and clothing for themselves and their families before they can even consider a fitness membership. WISEWOMEN may suggest daily walks. This will work for some women but not for all. Most low income women live in government subsidized or low rent housing. These areas may be unsafe and therefore women will not be utilizing “free exercise” (24).

The WISEWOMEN program may recommend that women decrease their caloric and fat intake each day. This would require women purchasing and eating fruits and vegetables. Eating healthier foods may be more expensive to purchase. Women that are below poverty level are going to buy the foods that they can afford which may be high in fat and calories. Women enrolled in the WISEWOMEN programs may rely on small neighborhood stores that do have fruit and vegetable options (2). Women enrolled in the WISEWOMEN program may have every intention of eating healthier and exercising more in order to reduce their risk of cardiovascular disease but their socioeconomic status may prevent them from doing so.

The second reason why the WISEWOMEN program should not be based on the HBM is because the HBM assumes that everyone has both access to care and knowledge to make rational decisions about a health behavior (21). Access to health care is not something that is feasible to all low income women. In addition, there is an association between socioeconomic status and education level (16). The women that the WISEWOMEN program is trying to target may not have the knowledge to make rational decisions about their health.  

Instead of basing the WISEWOMEN program on the Health Belief Model, it should be based on a model that takes into account the relationship between the individual and all the external factors that play a role in a low income woman’s life. Socioeconomic status, environment, culture and education level significantly influences the lives of the women enrolled in the WISEWOMEN program. It order to be a successful program, WISEWOMEN needs to be comprised of the external factors as well as the individual factors.
 
WISEWOMEN has the ability to be an effective cardiovascular disease screening and prevention program for low income women. By expanding the eligibility criteria and re-evaluating the program to include the states with the highest rates of uninsured and cardiovascular disease, WISEWOMEN could be a very influential program. Although WISEWOMEN projects have helped thousands of women, there are thousands of women still waiting for help. When the program is re-evaluated the critical barriers such as language, unsafe neighborhoods and the access to healthy foods must be considered significant factors. WISEWOMEN has the ability to become a program that could successfully help alter the cardiovascular and chronic illness rates of low income women in the United States.

References

1. Centers for Disease Control and Prevention. WISEWOMEN Program. Atlanta, GA: Centers for Chronic Disease Prevention and Health Promotion, 2007
2. Will J. et al Health Promotion Interventions for Disadvantages Women: Overview of the WISEWOMEN projects, Journal of Women’s Health 2004; 13: 484-500
3. Farris R. et al Expanding the Evidence for Health Promotion: Developing Best Practices for WISEWOMEN, Journal of Women’s Health 2004; 13: 634 -643
4. Finkelstein E. et al Evaluation of Public Health Demonstration Programs: The Effectiveness and Cost-Effectiveness of WISEWOMEN, Journal of Women’s Health 2004; 13: 625 -633
5. American Heart Association. Heart Disease and Stroke Statistics. Dallas TX: American Heart Association, 2007
6. Winkleby M. et al Ethnic and Socioeconomic Differences in Cardiovascular Disease Risk Factors, The Journal of the American Medical Association 1998; 280: 356-362
7. Centers for Disease Control and Prevention. Prevalence of Heart Disease - United States, 2005, The Journal of the American Medical Association (Reprinted) 2007; 297: 1308-1309
8. Ross J. et al Use of Health Care Services by Lower-Income and Higher Income Uninsured Adults, The Journal of the American Medical Association (Reprinted) 2006; 295: 2027-2036
9. Shavers V. Measurement of Socioeconomic Status in Health Disparities Research, Journal of the National Medical Association 2007; 9: 1013-1023
10. Luepker R. et al Socioeconomic Status and Coronary Heart Disease Risk Factor Trends. The Minnesota Heart Survey, Circulation 1993; 88: 2172-2179
11. Healthcare Coverage for the Uninsured, Oncology Nursing Forum 2007; 34: 761-762
12. Ford E. et al Health Insurance Status and Cardiovascular Disease Risk Factors among 50-64- Year-Old Women: Findings from the Third National Health and Nutrition Examination Survey, Journal of Women’s Health 1998; 7: 997 -1006
13. Centers for Disease Control and Prevention. National Breast and Cervical Cancer Early Detection Program. Atlanta, GA: Centers for Chronic Disease Prevention and Health Promotion, 2007
14. Massachusetts Department of Public Health, WISEWOMEN, Boston, MA: Massachusetts Department of Public Health, 2007
15. Ayanian J. et al Unmet Health Needs of Uninsured Adults in the United States, The Journal of the American Medical Association (Reprinted) 2000; 284: 2061-2069
16. (9)6. US Census Bureau. Income, Poverty and Health Insurance in the United States: 2006. Washington, DC. US Census Bureau
17. Congressional Budget Office. Health Care Spending and the Uninsured. Washington, DC: Congressional Budget Office. http://www.cbo.gov/doc.cfm?index=4989&type=0
18. Viadro C. et al The WISEWOMEN Projects: Lessons Learned from Three States, Journal of Women’s Health 2004; 13: 529 -538
19. Viadro C. et al Taking Stock of WISEWOMEN, Journal of Women’s Health 2004; 13: 480 -483
20. Kaiser Family Foundation. United States Uninsured Rates for nonelderly by gender, state (2005-2006), U.S. (2006). Kaiser Family Foundation. http://www.statehealthfacts.org/profileind.jsp?rgn=1&cat=3&ind=142
21. Edberg M. Essentials of Health Behavior, Social and Behavioral Theory in Public Health. Sudbury, MA: Jonas and Bartlett Publishers, Inc. 2007.
22. Wikipedia.HealthBeliefModel.
Wikipedia. http://en.wikipedia.org/wiki/Health_Belief_Model
23. Salazar M. Comparison of the Four Behavior Theories, AAOHN Journal 1991; 39: 128-135
24. Bennett G. Safe to Walk? Neighborhood Safety and Physical Activity Among Public Housing Residents, PLOS Medicine 2007; 4: 1599-1607







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1 Comments:

  • At April 24, 2008 at 2:30 AM , Anonymous Ting said...

    Women over age 65, in general, should be eligible for Medicare part A & B with a monthly premium for part B which should cover the screening services that WISEWOMEN offers. Wouldn't expanding the age range raise the cost of the program prohibitively potentially forcing cutbacks in the services offered to those women ages 40 through 64 and limiting the possibility of expanding the program to other underserved areas?

     

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