Prescribing a new treatment in heart disease communication

Heart disease remains the leading cause of mortality in the United States despite being largely preventable with subtle lifestyle changes early in life. Campaigns like The Heart Truth and other federally funded communication efforts have tried to raise awareness and educate public audiences to modest success. Studies evaluating cardiovascular disease awareness showed mixed results in awareness of cardiovascular disease across studies, sometimes increasing awareness over time while others demonstrate decreasing understanding. Some studies show gaps in comprehension between cohorts, while other cohorts show consistent understanding of cardiovascular disease. So why have these cardiovascular health awareness efforts not gained more traction, and why are current campaigns impactful in some populations and not others? While there is not a simple answer, it is clear that at least some of the responsibility lies with the medical community itself. Instead of following the social scientific evidence about what communication tools will be effective, we often rely on our intuition when it comes to promoting heart health – with dire consequences for public health.

Many of our well-intended efforts continue to rely on the assumption that individuals will align their beliefs and behaviors with the scientific community if we can just provide them with correct(ive) information. This kind of “knowledge deficit” thinking, as it is often called, has a lot of intuitive and normative appeal but, unfortunately, little grounding in empirical social science. It’s therefore unsurprising that knowledge deficit approaches to heart health campaigns have failed to create the urgency in patients necessary to mitigate future heart health consequences.

In Gallup surveys, the proportion of Americans who see “heart diseases” as the most urgent health threat has steadily declined from an already low 7% in 1987 to 1% in Gallup’s recent data in 2021, when heart disease ranked among the least urgent of perceived health threats. Trailing “government interference,” “immunizations/vaccines,” and “cost/access” as more pressing concerns among the U.S. public. Making matters worse, heart disease often arises later in life, often leading it to be overshadowed by seemingly more pressing health threats in younger patients’ mental hierarchies. Pandemics like COVID-19 can end up being the proverbial final nail in the coffin of effective communication on heart disease, pushing the issue even further down patients’ mental hierarchies.

Given our new post-COVID normal, heart health awareness campaigns face challenges that simply cannot be remedied by “more of the same” approaches to health communication. Instead, heart health awareness campaigns will have to be as scientific about how to best reach their intended audiences as they are about constructing their recommendations of heart healthy behaviors. Specifically, current heart health campaigns face two major pitfalls, how they communicate with individuals and how to get a non-immediate threat to the forefront of individuals already crowded mental hierarchy. How can the medical community communicate the urgency needed to prevent a disease which is seen as an abstract, down-the-road threat to many in their intended audience. Health awareness campaigns, after all, are designed to get individuals to increase heart healthy behaviors to decrease their long-term risk factors and reduce incidences of heart disease long term. Instead, heart disease diagnoses have steadily risen year over year.

This is not to say that heart health campaigns should adjust their targets. Campaigns should still aim to increase the adoption rate of heart healthy behaviors to mitigate risk factors associated with heart disease. The communication techniques they utilize, however, need to be revamped toward more effective, social science-informed models of priming, framing, and enhanced active choice in order to have a more tangible impact upon target individuals’ mental hierarchy.

Priming occurs when a campaign makes medically-relevant considerations more salient in people’s memory, increasing the likelihood that it will shape subsequent judgments and decisions¹. When forming attitudes or evaluating decisions, all of us rely on a handful of considerations that are most easily retrieved from memory at the time we make a judgment. A good illustration of priming in heart health awareness campaigns is the American Heart Association’s “Heart Check” symbol, which is designed to prime considerations related to selecting nutritious foods.

Demonstrating the symbol’s ability to prime consumers to select heart healthy foods, 60% of consumers claimed that “Heart Check” “encourages them to purchase specific products”². Capitalizing on the same mechanisms, one could imagine campaigns that prime mental associations that make individuals more likely to adopt healthy lifestyle changes alongside healthy food decisions. Applying priming directed to increase adoption of healthy behaviors would increase heart health campaign effectiveness not by conveying information or explaining risks, but by catapulting heart healthy behaviors to the top of individuals’ mental hierarchies for the next time that they make a heart conscious decision.

Decades of social scientific work on framing has also demonstrated that the way information is presented to individuals can fundamentally alter how scientific facts are perceived and interpreted¹. Health communication often relies on either “gains framing” where the benefits are emphasized, or “loss framing” where the negatives or downsides are emphasized. Work during the COVID-19 pandemic showed that campaigns that framed protective measures as saving the community (i.e., gains) led to much higher COVID-19 protective behavior adoption, compared to loss framing of protective measures as necessary to prevent losses within the community³. This holds valuable lessons for heart health communication. Gains frames emphasizing how performing heart healthy behaviors lead to more energy, lower stress, and improved cardiac function, might turn out to be much more effective than loss framing that describes heart healthy behaviors primarily as a means to prevent heart disease.

The third communication technique to benefit heart health campaigns is enhanced active choice. Focused more explicitly on behavior change, enhanced active choice (or nudging, as behavioral economists would call it) uses insights from psychology, communication research, or decision sciences to tailor messages toward audiences in ways that increases their likelihood to engage in behaviors without necessarily changing their understanding of the science behind those decisions⁴. The impact of enhanced active choice has long been examined across different social scientific disciplines to identify whether utilizing enhanced active choice can promote healthier lifestyle choices. One recent study examined the effectiveness of enhanced active choice on food intake, demonstrating that individuals presented with information utilizing enhanced active choice had higher consumption rates of fruits and vegetables compared to individuals that received traditional health communication materials⁵. Enhanced active choice might prove to be particularly useful for heart health campaigns focused on behaviors, incentivizing lifestyle and nutritional choices consistent with the best available medical science, while simultaneously discouraging behaviors related to increased risks for heart disease health.

While COVID continues its endemic trajectory, successfully tackling the ongoing “secret pandemic” of heart disease urgently requires a more scientific approach to how we communicate our science. Heart health campaigns informed by insights from cutting-edge social science will benefit both patients and the medical community in the long run. Patients will have improved heart health, in turn reducing the strain on the medical system from the currently ever-increasing heart disease patient number. Priming, framing, and enhanced active choice are just a few examples of what we can learn from neighboring social disciplines about how heart health campaigns can tackle our “secret pandemic” by changing patients’ mental health hierarchies and behaviors.