CARE WHITE PAPER SERIES 2013 VOL. 1

Women’s Heart Health in Singapore: A Culture-Centered Framework Sarah K. Comer & Mohan J. Dutta THE CARE WHITE PAPER SERIES IS A PUBLICATION OF THE CENTER FOR CULTURE-CENTERED APPROACH TO RESEARCH AND EVALUATION (CARE), NATIONAL UNIVERSITY OF SINGAPORE Requests for permission to reproduce the CARE White Paper Series should be directed to the Department of Communications and New Media, Faculty of Arts and Social Sciences, National University of Singapore.

DEPARTMENT OF COMMUNICATIONS AND NEW MEDIA CARE WHITE PAPER SERIES 11 Computing Drive, AS6 Level 3 National University of Singapore Singapore 117416 T (65)6516-4971 W http://www.fas.nus.edu.sg/cnm Women’s Heart Health Mohan J. Dutta, Head [email protected] in Singapore: A Culture-Centered Framework Copyright of this paper resides with the author(s) and further publication, in whole or in part, shall only be made by authorization of the author(s). Sarah K. Comer & Mohan J. Dutta

Design, layout, and editing: Daniel Teo, CARE Research Assistant

CARE is online at http://www.care-cca.com.

CARDIOVASCULAR DISEASE (CVD) is the Stampfer, Hu, Manson, Rimm, & Willett, ABOUT CARE leading cause of death globally (Bonow, 2000), diet (Heidemann et. al, 2008; Funded by a $1.9 million grant from the the problems conceptualized by them. Smaha, Smith, Mensah, & Lenfant, Odegaard, Koh, Gross, Yuan, & Pereira, National University of Singapore (NUS), 2002; Bonow, Smaha, Smith, Mensah, & 2011; Rankin & Bhopal, 2001), and CARE seeks to: (a) create a strategic CARE is a global hub for health commu- research core for the social scientific study Lenfant, 2011; Howson, Reddy, Ryan, & smoking cessation (Bhalla, Fong, Chew, nication research that uses participatory of health communication issues in Asia Bale, 1998; Mathers, Boerma, & Ma Fat, & Satku, 2006; Cutter, Tan, & Chew, and culture-centered methodologies driven by the cultural worldviews of local 2009; McKay, & Mensah, 2004; Michaud, 2001; Doll, Peto, Boreham, & Suther- to develop community-driven health communities, (b) develop health commu- Murray, & Bloom, 2001; Murray & land, 2004; Woodward et al., 2005; Yusuf communication solutions. CARE is an nication interventions and policies that are affiliate organization of the Department Lopez, 1997; National Institutes of Health et al., 2004; Yusuf, Reddy, Ôunpuu, & culturally-centered via the participatory of Communications and New Media at the [NIH], 2012; World Health Organization Anand, 2001). However, cultural values capacity of local communities to create Faculty of Arts and Social Sciences, NUS. [WHO], 2012). It is a non-infectious, affect conceptualizations of health, and culturally meaningful and locally respon- non-transmissible disease that can be in effect, engagement in preventative CARE is driven by the core principle that sive health solutions, (c) disseminate the prevented by protective behaviors such behaviors. We argue that the presenta- communities know best the solutions that core principles and lessons learned from are relevant to the problems that they the culture-centered projects within Asia as exercise (Goldstein et. al, 2001; Lee, tion of health promotion materials will identify as critical. CARE works closely with and across other sectors of the globe, and Sesso, Oguma, & Paffenbarger, 2003; lead to decreases in unhealthy behavior community organizations, policymakers, (d) build health communication research program planners and evaluators in capacity in Asia by creating a training hub Sarah K. Comer is a Research Assistant at CARE. She holds a Masters Degree in developing culturally-centered solu- for the next generation of health commu- Interpersonal and Health Communication from the University of Georgia. tions that are envisioned by community nication theorists, researchers, practi- members in the grassroots in response to tioners, and policymakers across Asia. Mohan J. Dutta is Director of CARE and Head of the Department of Communications and New Media at the National University of Singapore. 2 3 CARE WHITE PAPER SERIES WOMEN’S HEART HEALTH IN SINGAPORE

only when the culture of the target one of the top three causes of death for accounting for non-European voices needs and capacity assessments, com- public is centralized in the development worldwide through year 2030 (Mathers in heart disease prevention. Entities like munity-based programs, and popula- of intervention programs. & Loncar, 2006; WHO, 2012). the American Heart Association (AHA) tion-based approaches. In other words, have developed community guidelines culturally-centered data that is specific It is critical to develop culturally for heart health promotion to provide to the local population is required to appropriate health interventions that GLOBAL RESPONSE TO a framework for community leaders, develop appropriate and effective heart are rooted in the cultural logics of WOMEN’S HEART HEALTH policy makers, and healthcare prac- health interventions. local communities (Dutta, 2008, 2011; titioners to effectively promote CVD Dutta-Bergman, 2004a, 2004b) to ef- In response to CVD rates among prevention through strategies including fectively identify and address the barriers women, a wide variety of heart health education via mass media and environ- WOMEN’S HEART HEALTH to health behavior. Additionally, the interventions have been developed mental change (Montoya et al., 2011; INFORMATION IN SINGAPORE structural loci of factors causing heart globally (e.g., Mosca et al., 2007; Pearson, et al., 2003). disease, such as stress, access to healthy Rosamond et al., 2000; Wilcox, Parra- Singapore is a nation dealing with food, access to spaces for exercising, and Medina, Thompson-Robinson, & Will, Overall, scholars have suggested that chronically high CVD mortality rates. access to preventive heart health care, 2001; Yusuf et al., 2004). Previous heart health initiatives created for a CVD has remained the major causes of suggest the relevance of heart health interventions have shared two common Western audience may not be suited for mortality for Singaporeans (Registry advocacy directed at promoting heart focuses: (a) maximizing interven- other non-Western target populations, of Births and Deaths, 2004, Registry of healthy social and community struc- tion effect through targeting a broader such as Singaporean women. Noting the Births and Deaths, September 2012), tures (Dutta, 2008; Fuster & Kelly, 2010; population to increase efficiency at worldwide variance in CVD risk factors especially women. In 2008, CVD was Melkote, 2000; Yusuf, Reddy, Ôunpuu, minimal cost (Bovet & Paccaud, 2012; (both behavioral and biological), Yusuf responsible for the deaths of 2,500 & Anand, 2001). CVD is especially Murray et al., 2003; Pearson et al., 2003; et al. (2004) observed that: women in Singapore, almost a third of important to women, being the largest Yusuf et al., 2004), or (b) targeting the all female deaths for the year (Robless, single cause of mortality among women individual in promoting healthy preven- … researchers are unsure to what extent 2012; Singapore Heart Foundation worldwide (Jacobs & Eckel, 2005; tative behaviors (Dehghan et al., 2012; […] findings apply worldwide. Some data [SHF], 2010). Mikhail, 2005; Society for Cardiovas- Odegaard, et al., 2011; Rossouw et al., suggest that risk factors for coronary heart cular Angiography and Interventions 1993; Tian et al., 1995). disease vary between populations – e.g., However, amidst the high rates of [SCAI], 2012; Soroptimist, 2007; WHO, lipids are not associated with this disorder CVD in Singaporean women, research 2004a; Women’s Heart Foundation , Major global initiatives such as the in South Asians, and increases in blood focusing on Asian women with CVD in 2006;). CVD causes 8.5 million deaths INTERHEART project (Yusuf et al., pressure might be more important in Singapore is “sorely lacking” (National among women annually, accounting 2004) focused on specific risk factors Chinese people. (p. 937) University Heart Centre Singapore for one-third of all deaths in women for CVD as a necessary precursor to [NUHCS], 2009, para. 3). Few up-to- around the globe (American Heart intervention development. This project Similarly, Fuster & Kelly (2010) rec- date nationwide reports on the state of Association[AHA], 2004; Odegaard et (a) illuminated the need for more non- ognized the need to have localized CVD among women exist. The most al., 2011; WHO, 2004b; World Heart Eurocentric studies for CVD; (b) pointed knowledge of a population and its heart recent report was published by SHF in Federation, 2013). Furthermore, there out that it would be a mistake to assume health situation. The scholars recom- 2010. There is also an alarming lack of does not seem to be an end in sight with that all CVD interventions are applicable mended a more comprehensive approach literature on the experiences of women researchers projecting CVD to remain everywhere; and (c) suggested the need to heart health interventions focusing on which contribute to their risk of CVD,

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calling into question how past efforts to Programme. Implemented in 1992, the CULTURE-CENTERED Methodological Biases improve the heart health of Singaporean National Healthy Lifestyle Programme HEART HEALTH PROMOTION women were developed. was a nation-wide initiative to improve Within populations, there remain the overall health of Singaporeans CVD might be a global issue, but there differences in access, participation, and and prevent disease. The campaign is not one all-encompassing global understanding. For instance, several PREVIOUS NATIONAL EFFORTS TO engaged a multitude of stakeholders, solution. Instead, a more localized, researchers note that the South Asian IMPROVE HEART HEALTH AMONG such as government ministries, health culture-centered view of the issue with sample is a difficult population to access SINGAPOREAN WOMEN organizations, employers, schools, attention given to the voices of the (Rankin, & Bhopal, 2001; Yusuf et al., and mass media to encourage healthy target population would provide a solid 2004). Much research has resorted to In addition to the paucity of localized living among Singaporeans. However, foundation for effective and meaning- using methods like cross-sectional CVD information, past health a follow-up evaluation to the program ful health promotion for CVD that is surveys of South Asian immigrants in campaigns aimed at improving the found that the prevalence of CVD risk grounded in localized, lived experiences. other non-Asian countries (e.g., Rankin, heart health of Singaporean women factors such as hypertension, obesity, The culture-centered approach (CCA) & Bhopal, 2001), retrospective cohort appear to have had little effect on high blood cholesterol levels, and foregrounds the importance of acknowl- studies, or utilizing Western evaluative awareness, knowledge, and behavior smoking among women had increased edging the disparate burden of heart measures for CVD research. Western of the target population. In 2009, in the six years following the program’s disease that is experienced by women measures become particularly problem- SHF randomly polled 1,030 Singapo- inception (Cutter, Tan, & Chew, 2001). as a result of culturally and structur- atic for studying the burden of heart rean women in 2009 to evaluate their ally rooted gendered values and beliefs, disease in Singapore because as Xie et 2007 national health campaign. The The large-scale heart health inter- and suggests the need for developing al. (2011) suggest, the identifiable risk campaign consisted of a series of com- ventional research in Singapore (see culturally-driven policies and programs factors for young women in Asia can munity-based educational events and Singapore London, 2011; Cutter, Tan, & by foregrounding the voices of women be different from women in Western nationwide messaging strategies. SHF Chew, 2001; GoRed Campaign, 2011) living in Singapore as entry points to populations. Focusing on a monolithic (2010) found that less than 10% of the also call into questions the methodol- the development of health policies and Singaporean culture does not meaning- women thought that CVD was a signifi- ogy and metrics used for evaluation, health programs (Dutta, 2008). fully articulate the lived experiences of cant health problem facing Singaporean issues which will be elaborated on in the various sub-cultures in Singapore. women. Similarly, knowledge levels of the following section. Overall, past CCA notes the importance of CVD was also reported to be low – 42% CVD interventions in Singapore have fostering spaces for listening to the Yet another methodological gap is of the women did not associate chest had limited success in improving the voices of the women most affected by the absence of qualitative data on heart pains with heart attacks (SHF, 2010). CVD situation among women, espe- CVD in Singapore and who represent health in general, and specifically on Rankin and Bhopal (2001) also reported cially in terms of raising awareness and the target population under study. women’s heart health in Singapore. The that 35% of the participants in their knowledge levels of the problem, and en- Working toward improving heart health absence of in-depth qualitative data study said they did not understand the couraging preventative health behaviors. is deeply intertwined with the experienc- therefore suggests the absence of con- meaning of the term “heart disease.” This limited success can be attributed to es of Singaporean women. Hence, there textual and culturally-rooted informa- the absence of an approach which fore- is a need to foreground the experiences tion on meanings and interpretations Past Singapore campaigns aimed at grounds the culture of these women in of women as narrators of stories as a of heart disease. Similarly, an overview encouraging heart healthy behaviors the development of CVD interventions framework for developing heart-healthy of research studies on heart health in include the National Healthy Lifestyle from the bottom-up. policies and programs. Singapore evidences the absence of the

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voices of communities that are affected landscape on health. The Singapore health communication research needs to ously not involved in intervention de- by heart disease. Rankin and Bhopal Health Promotion Board (HPB) formed understand the needs of the community velopment and thus could provide better (2001) report that accurate understand- a Women’s Health Advisory Council with the goals of minimizing hospitali- outcomes for intervention efforts. ing of a population’s knowledge about a with the following mission: “The aim is zations and prevalence of CVD, which disease “is a prerequisite for individu- to tap a diverse pool of health experts will hopefully lower costs for at-risk The advantages of employing CCA als and communities to take action to and experienced advocates in order to populations. The CCA foregrounds the in developing heart health promotion control these health problems” (p. 253). develop national initiatives that will structural contexts of health, noting programs are as follows: Also, instead of merely assessing the equip women with health knowledge” the importance of addressing health • CCA proposes a progressive method health needs of a population through (HPB, 2012, para. 5). While expertise problems as being situated within the in hopes of bridging the gaps in cur- descriptive statistics, we propose is important in developing health larger socially driven structures. rent intervention methodology and exploring why Singaporean women are solutions, neglecting of the voices of conceptualizations of health cam- not engaging in the protective lifestyle the target population can be counter- paigns for women in Singapore. behaviors through qualitative assessment. productive. Expert input needs to be RECOMMENDATIONS dialogically engaged with the heart • CCA aims to engage women in open Women experience disparity in health experiences of women and their CVD rates for women in Singapore dialogue about their experiences with obtaining CVD care in Singapore due everyday experiences with the dispari- are high and awareness of risk and the CVD to help us understand their to lack of access and comprehension of ties in care in order to avoid a strictly engagement in preventative behaviors meaning-making process pertaining CVD information. According to Chou top-down approach to intervention. By are low (SHF, 2010). The existing dispari- to health. et al. (2007): “Studies have shown that engaging the women in Singapore in ties in heart health outcomes for women • CCA engages localized understand- women with cardiovascular disease dialogue, their experiences may offer suggest the importance of dialogically ings of gender, geography, ethnic (CVD) are screened and treated less entry points toward developing solutions engaging women in conversations to not background, and socioeconomic aggressively than men and are less that are meaningful to the women and only get a better idea of the actual lived status as entry points to developing likely to undergo cardiac procedures” their lived realities. experiences of CVD in Singapore, but localized health promotion methods. (p. 1). Understanding the contextual also to help inform stakeholder decision- • CCA co-constructs meanings of and cultural environments would offer Engaging the Economics of Heart making. Furthermore, CCA notes that cardiovascular disease prevention in in-depth insights into the nature of the Health Promotion placing the power of decision-making conversations with women in Singa- heart health disparities as experienced in the hands of women, where they pore to create a meaningful health by women. Dialogically engaging the The WHO suggests that CVD can conceptualize the problems and develop intervention framework. experiences of the women suffering from contribute to household poverty (see solutions, offers a meaningful framework • CCA attends to the voices of women, CVD is essential to understanding their also Fuster & Kelly, 2010) due to the high for addressing the issue of heart disease and in doing so, offers a solid foun- health behaviors and their localized costs of hospitalizations and treatment among women. The formative stages of dation for effective and meaningful meanings of heart health. often borne by the patient (Bloom et al., health intervention planning can all be health promotion for cardiovascular 2000). Noting the structural contexts of guided by creating dialogic spaces for disease. Engaging Decision-making Structures heart health disparities, CCA suggests women to voice their barriers to heart the importance of addressing the health. This process of bringing the The Ministry of Health (MOH) financial aspects of care. Attending to women’s voices to the fore will provide plays a key role in shaping the policy the economic contexts of heart health, new grassroots insights that were previ-

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