ABSTRACT
Objective: We studied the effect of communicating cardiovascular risk factors on intended healthy behavior in women with a history of preeclampsia or uncomplicated pregnancy. Methods: Intention for healthy behavior was assessed before and after cardiovascular risk assessment. Changes were calculated for women with and without cardiovascular risk factors. Results: In women with cardiovascular risk factors, the intention to quit smoking increased; whereas, intended healthy diet and sufficient exercise did not change. In participants without risk factors, none of the healthy behaviors changed. Conclusion: Communicating risk factors alone does not seem to be effective as an intervention to achieve lifestyle changes.
Introduction
Preeclampsia is a common and serious condition in pregnancy, affecting about one in 15 pregnant women, and is a leading cause of maternal and neonatal morbidity and mortality (Citation1). It has become evident that women who have had preeclampsia face an increased cardiovascular risk later in life (Citation2,Citation3). This is illustrated by the twofold increased risk of both hypertension and dying from overall cardiovascular disease (Citation4). The risk is even higher in women who have had early onset preeclampsia, whose risk of dying from cardiovascular disease is increased nine fold compared to women without hypertensive disease in pregnancy (Citation5).
Cardiovascular disease is the leading cause of death in women in the Western world (Citation6,Citation7). Risk factors leading to cardiovascular disease can be successfully modified by lifestyle changes, also in women with previous preeclampsia (Citation8,Citation9). However, it is not clear how these women can best be motivated to change their lifestyle. Many express the intention to live a healthy postpartum lifestyle, but most fail to achieve this (Citation10). In many health-promoting guidelines, like the Guidelines for the prevention of cardiovascular disease in women from the American Heart Association, the first step after the evaluation of risk factors is lifestyle recommendations (Citation11). Guidelines mention the proven effectiveness of lifestyle interventions but most pass over the preceding step, i.e. how to motivate these women to change their health-related behavior.
Two Cochrane reviews in the field of cardiovascular risk in relation to pregnancy disorders indicate the current lack of understanding of the relationship between the identification of future risk factors and the motivation to change behavior. The Cochrane review on Dietary advice in preventing gestational diabetes states that interventions should be based on “addressing potential risk factors” (Citation12). A Cochrane review on Dietary advice for reducing cardiovascular risk suggests that “individuals found to be at high risk may have the motivation to make large changes” (Citation13). Both statements encompass the idea that informing an individual about the presence of risk factors or the prevalence of high risk has a motivating effect, but literature supporting this assumption in the field of increased cardiovascular risk in women after pregnancy disorders is lacking. It is not clear what the effect of communicating risk factors is on the intention of these women to change to healthier behavior.
In behavioral science, the Theory of Planned Behavior is a model used extensively to identify correlates and determinants of health-related behavior (Citation14). According to the Theory of Planned Behavior, behavior is primarily determined by intention. Intention, in turn, is determined by attitude (positive or negative value of behavior), subjective norm (perceived judgement of significant others to perform behavior), and perceived behavioral control (perceived ease or difficulty in performing behavior). This model, with intention as the primary precursor of behavior, offers an opportunity to study the effect of communicating risk factors on the intention to change to healthier behavior.
We examined the effect of communicating risk factors on intended healthy behavior with regard to cardiovascular risk. We studied this in a population of women where the potential gains of healthy behavior may be large; namely, women who suffered preeclampsia and are now in their fifth decade of life, when first signs of cardiovascular disease often start to occur. We hypothesized that these women who were informed about their increased risk of cardiovascular disease reported increased intention to change to healthier behavior compared with the women who were informed that they did not have cardiovascular risk factors.
Methods
Design and procedure
This prospective survey study was embedded in a risk-assessment study (Citation15). The aim of the risk-assessment study was to assess cardiovascular risk factors and investigate diastolic function from 9 to 16 years after delivery in women with a history of early-onset preeclampsia (blood pressure ≥140/90 mmHg, proteinuria ≥300 mg/L, delivery before 34 weeks of gestation) compared to women with an uncomplicated pregnancy history (blood pressure <140/90 mmHg, delivery ≥37 weeks of gestation). The risk assessment consisted of blood pressure measurement, anthropometrics, blood sampling, urine collection, and cardiac ultrasound. Following informed consent, the first questionnaire on intended healthy behavior was sent to the women’s home addresses and filled out prior to the risk assessment in hospital. Two weeks after risk assessment, participants received written feedback on their cardiovascular risk factors (). Risk factors included smoking, intake of more than 2 units alcohol per day, body mass index (BMI) >25 kg/m2, waist circumference ≥88 cm, blood pressure measured ≥140 and/or ≥90 mmHg, abnormal laboratory result in blood and/or urine (lipids, glucose, HbA1c, glomerular filtration rate, NT-proBNP, and microalbumin in urine), abnormal result in echocardiography, and diastolic dysfunction. Echocardiography was communicated as abnormal for all abnormalities found by ultrasound that required referral to a cardiologist. Two weeks after receiving written feedback, participants were sent the second questionnaire on intended healthy behavior.
Table 1. Risk communication to participants.
This survey study was embedded after the risk-assessment study was started. Therefore, the first 40 participants of the risk-assessment study did not receive the questionnaires regarding intention to change their behavior.
Participants
Following the risk assessment, two groups were distinguished: women who did not have cardiovascular risk factors at risk assessment and those who had one or more risk factors.
Women who had a history of early-onset preeclampsia were informed in the invitation letter about their a priori increased cardiovascular risk due to former preeclampsia. The control group, women with an uncomplicated pregnancy history, did not receive information about their a priori cardiovascular risk. Because of this discrepancy, a subgroup was made of women who did not have risk factors in risk assessment, but who were informed about their increased cardiovascular risk due to their history of early-onset preeclampsia.
Survey
The questionnaire concerned three healthy lifestyle behaviors: healthy diet, sufficient exercise, and smoking cessation for smoking participants. Intention, as a proxy for actual behavior, was assessed by a set of the following three questions per behavior and had to be scored on a five-point Likert scale.
Are you willing to perform the behavior?
How likely or unlikely is it that you will perform the behavior?
How confident are you that you will perform the behavior?
Statistical analysis
A sample size calculation could not be made because this survey study was incorporated in a risk-assessment study.
The primary outcome measure was the difference in intended healthy behavior before and after cardiovascular risk assessment, per healthy lifestyle behavior, for women who did not have cardiovascular risk factors at risk assessment and women who had one or more risk factors. These differences were calculated with the mean of the three intention questions before risk assessment and the mean of the three intention questions after risk assessment, per healthy lifestyle behavior, using the Wilcoxon signed rank test.
Characteristics of women who did not have cardiovascular risk factors at risk assessment and women who had one or more risk factors were reported as means with standard deviations for normally distributed data, as medians with interquartile ranges for not normally distributed data and as percentages for categorical data. Differences were assessed by unpaired Student’s t-test, Mann-Whitney U test, and Fisher’s exact test wherever appropriate. Cronbach’s alpha was calculated to check the internal consistency of the composite outcome score on intended healthy behavior.
Secondary, multivariate linear regression analyses were used to study the effect of variables including a pregnancy history of early-onset preeclampsia or uncomplicated pregnancy and which cardiovascular risk factors were reported as abnormal, on the delta of intended healthy behavior, per healthy lifestyle behavior. Deltas were calculated as mean intention after risk assessment minus mean intention before risk assessment. Significance was set at a p-value of 0.05. Data were analyzed using SPSS 22 software (Chicago, IL).
Results
The questionnaire on intended healthy behavior before risk assessment was received by 147 women. In total, 147 participants filled out the questionnaire before risk assessment (100%) and 107 filled out the questionnaire after risk assessment (73%). Of all the participants, 30 women did not have cardiovascular risk factors and 117 women had one or more risk factors at risk assessment (). The subgroup of women without risk factors, but with increased cardiovascular risk due to early-onset preeclampsia in their history, consisted of 18 women. Pregnancy history, age, time post-index pregnancy, ethnicity, educational level, and exercise were comparable between the groups. Women without risk factors had lower BMI compared to women with one or more risk factors (22.1 [20.3–23.4] vs. 26.3 [23.1–28.7] kg/m2, p < 0.001). The difference persisted for the subgroup without risk factors but with a history of preeclampsia compared to women with one or more risk factors (22.2 [20.6–23.4] vs. 26.3 [23.1–28.7] kg/m2, p < 0.001).
Table 2. Characteristics of participants with and without risk factors at cardiovascular risk assessment.
In women who were informed that they did not have cardiovascular risk factors at risk assessment, no change was identified in the intention to engage in any of the three healthy lifestyle behaviors (). In women who were informed that they had one or more risk factors at risk assessment, only the intention to stop smoking increased (before 2.89 ± 1.12 vs. after 3.47 ± 0.91, p 0.007). In the subgroup of women without risk factors, but with increased cardiovascular risk due to early-onset preeclampsia in their history (n = 18), change was neither identified in intended healthy diet (before 3.20 ± 1.35 vs. after 3.50 ± 1.10, p = 0.250) nor in intended sufficient exercise (before 3.40 ± 1.08 vs. after 3.53 ± 0.69, p = 0.719).
Table 3. Intended healthy behavior before and after cardiovascular risk assessment.
Multivariate regression analysis demonstrated in women who had cardiovascular risk factors that communicating the ‘diastolic dysfunction’ risk factor was of significant influence on the delta of intended healthy diet, β −0.665 (−1.211, −0.119) p = 0.018. Analysis also showed in these women that the communication of the ‘high blood pressure’ risk factor was of significant influence on the delta of intended smoking cessation, β 1.256 (0.394, 2.119) p = 0.008. A pregnancy history of early-onset preeclampsia had no influence on intended healthy behavior, neither in women with or in women without cardiovascular risk factors.
Discussion
In view of the lack of studies supporting the assumption that it is motivating for an individual to be informed about the presence of risk factors, we examined this assumption in the field of increased cardiovascular risk in women following pregnancy disorders. Based on this assumption, many healthcare professionals communicate risk factors in the hope that this will motivate their patients to improve their health-related behavior. In this survey study, we studied the effect of communicating risk factors on intended healthy behavior in women who face an increased cardiovascular risk after preeclampsia. Our results indicated that communicating the presence or absence of cardiovascular risk factors in these high-risk women had no effect on the intention to change to a healthier diet or the intention to change to adequate exercise levels. Communicating the presence of risk factors only affected the intention to stop smoking. Nor did having a history of early-onset preeclampsia or uncomplicated pregnancy affect the intention to change to healthier behavior. Our hypothesis that informing women about present cardiovascular risk factors would lead to an increased intention to change to healthier behavior compared to women who were informed that they did not have cardiovascular risk factors is not supported by our data. Our findings, therefore, challenge the assumption that communicating individually targeted risk factors would be motivational.
A reason for the lack of change in intention to change healthy behavior after receiving a personalized cardiovascular risk profile may be that people need additional guidance. According to the precaution adoption process model (PAPM), a model used in behavioral science, people need practical information to actually make behavioral changes (Citation16). This is in line with a review by Artinian et al. on interventions to promote lifestyle changes to reduce cardiovascular risk factors (Citation17). The authors stated that behavior change interventions should essentially be based on cognitive-behavioral strategies. These strategies contain such elements as setting specific tailor-made behavioral goals; self-monitoring to increase the individual’s awareness and identify the barriers to the healthy behavior; feedback by the healthcare provider on the performance of the healthy behavior; and a scheduled follow-up. An assessment of cardiovascular risk factors determines who is at risk and needs further intervention, but is not part of the intervention itself.
Further research is needed to investigate what interventions, which promote lifestyle changes to reduce cardiovascular risk at what time after pregnancy, are most effective in women after complicated pregnancies. These interventions have great potential because complicated pregnancy disorders are common, and given the relatively young age of pregnant women, intervention can potentially be started early.
In this study, the use of the Theory of Planned Behavior was suitable as a first step to study intention for healthy behavior rather than actual measured behavior. Studying intended behavior remains a proxy for actual behavior, but was for the purposes of this study nonetheless appropriate, because it has proven to be a good predictor of behavior. Future research can use other parts of the Theory of Planned Behavior model to uncover new clues for effective interventions. Investigating three types of healthy behavior was strength of this study because it enabled the researchers to study whether communicating risk factors had an effect on overall healthy behavior or only on specific healthy behaviors.
A limitation of the study was that this survey study was incorporated in a risk-assessment study and we therefore did not have the opportunity to adjust the sample size but were limited by the available number of participants. To enable assessment of the clinical relevance of the intention before and after risk assessment, we have presented the mean differences with 95% confidence intervals. A further factor was that participants received risk information in written form. Communicating risk factors in a personal discussion might have a different effect. Another possible limitation was that the second questionnaire on intended healthy behavior was sent two weeks after the participants were informed about present or absent risk factors. This relatively short interval might overstate the observed effect because it was still fresh in the memory of the participants. Asking someone’s intention to engage in particular behavior might also influence the observed effect because participants might have overestimated themselves or given a socially desirable response. Moreover, the 73% that filled out the second questionnaire might have been the most motivated part.
In conclusion, communicating risk factors in women who face an increased cardiovascular risk after preeclampsia does not seem to be effective as a stand-alone intervention.
Disclosure statement
No potential conflict of interest was reported by the authors.
References
- Mol BW, Roberts CT, Thangaratinam S, Magee LA, de Groot CJ, Hofmeyr GJ. Pre-eclampsia. Lancet. 2016;387(10022):999–1011. doi:10.1016/S0140-6736(15)00070-7.
- McDonald SD, Malinowski A, Zhou Q, Yusuf S, Devereaux PJ. Cardiovascular sequelae of preeclampsia/eclampsia: a systematic review and meta-analyses. Am Heart J. 2008;156(5):918–30. doi:10.1016/j.ahj.2008.06.042.
- Ahmed R, Dunford J, Mehran R, Robson S, Kunadian V. Pre-eclampsia and future cardiovascular risk among women: a review. J Am Coll Cardiol. 2014;63(18):1815–22. doi:10.1016/j.jacc.2014.02.529.
- Heida KY, Bots ML, de Groot CJ, van Dunne FM, Hammoud NM, Hoek A, et al. Cardiovascular risk management after reproductive and pregnancy-related disorders: a Dutch multidisciplinary evidence-based guideline. Eur J Prev Cardiol. 2016;23(17):1863–79. doi:10.1177/2047487316659573.
- Mongraw-Chaffin ML, Cirillo PM, Cohn BA. Preeclampsia and cardiovascular disease death: prospective evidence from the child health and development studies cohort. Hypertension. 2010;56(1):166–71. doi:10.1161/HYPERTENSIONAHA.110.150078.
- Bellamy L, Casas JP, Hingorani AD, Williams DJ. Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis. BMJ. 2007;335(7627):974. doi:10.1136/bmj.39335.385301.BE.
- Nichols M, Townsend N, Scarborough P, Rayner M. Cardiovascular disease in Europe: epidemiological update. Eur Heart J. 2013;34(39):3028–34. doi:10.1093/eurheartj/eht356.
- NICE guidelines. Prevention of cardiovascular disease. June 2010, The National Institute for Health and Care Excellence (NICE), United Kingdom.
- Berks D, Hoedjes M, Raat H, Duvekot JJ, Steegers EA, Habbema JD. Risk of cardiovascular disease after pre-eclampsia and the effect of lifestyle interventions: a literature-based study. BJOG. 2013;120(8):924–31. doi:10.1111/1471-0528.12191.
- Hoedjes M, Berks D, Vogel I, Franx A, Duvekot JJ, Oenema A, Steegers EAP, Raat H. Motivators and barriers to a healthy postpartum lifestyle in women at increased cardiovascular and metabolic risk: a focus-group study. Hypertens Pregnancy. 2012;31(1):147–55. doi:10.3109/10641955.2010.544803.
- Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women–2011 update: a guideline from the American Heart Association. J Am Coll Cardiol. 2011;57(12):1404–23. doi:10.1016/j.jacc.2011.02.005.
- Tieu J, Shepherd E, Middleton P, Crowther CA.Dietary advice interventions in pregnancy for preventing gestational diabetes mellitus. Cochrane Database Syst Rev. 2017; 1:CD006674.
- Rees K, Dyakova M, Wilson N, Ward K, Thorogood M, Brunner E. Dietary advice for reducing cardiovascular risk. Cochrane Database Syst Rev. 2013;(12):CD002128. DOI: 10.1002/14651858.CD002128.pub5
- Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991;50(2):179–211. doi:10.1016/0749-5978(91)90020-T.
- Bokslag A, Teunissen PW, Franssen C, van Kesteren F, Kamp O, Ganzevoort W, Paulus WJ, de Groot CJM. Effect of early-onset preeclampsia on cardiovascular risk in the fifth decade of life. Am J Obstet Gynecol. 2017;216(5):523e1–e7. doi:10.1016/j.ajog.2017.02.015.
- Weinstein ND, Sandman PM. The precaution adoption process model. In: Glanz K, Rimer BK, Lewis FM, editors. Health behavior and health education: theory, research and practice. San Fransisco, CA: Jossey-Bass; 2002. p. 121–43.
- Artinian NT, Fletcher GF, Mozaffarian D, Kris-Etherton P, van Horn L, Lichtenstein AH, et al. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: a scientific statement from the American Heart Association. Circulation. 2010;122(4):406–41. doi:10.1161/CIR.0b013e3181e8edf1.