In the Netherlands, a substantial burden of morbidity and mortality persists for cardiovascular diseases in women. Despite this, the reduction of cardiovascular diseases in women has plateaued. This is against the backdrop of an ageing population and the prevalence of sedentary and unhealthy lifestyles.
This research presents a novel model to explore the problem space. A multi-disciplined microsimulation model is presented that incorporates theories and data aggregated from individual health data, population studies, social network studies, and behaviour studies. To our knowledge, it is the first model of its kind. We used the city of The Hague as our case study, as we were able to use a treasure trove of individual health data to inform the model, and thus inform the answer to the research question. The model was developed to answer the research question:
How can behavioural interventions decrease the healthcare burden of cardiovascular diseases among women in The Hague?
Our methodology consisted of multiple phases. First, we conducted a literature study to identify
cardiovascular risk factors and entry points for interventions. Second, we developed health data models to be integrated into the microsimulation model. Third, we designed and implemented a microsimulation model and explored a plausible future cardiovascular health burden. Fourth, we looked at the impact of certain interventions applied to the entry points. The chosen interventions are based on the hypothesis that was derived from the literature read during the first phase. The hypothesis was as follows:
How can recurring interventions targeting diet, exercise or smoking behaviours decrease the healthcare burden of cardiovascular diseases among women in The Hague?
During the literature study we conducted, we made multiple findings. First, current studies seem to omit relevant risk factors for women, such as pregnancy complications. So far, studies primarily focus on men, even though that cardiovascular diseases are the leading cause of morbidity and mortality for women in the world. Second, studies that examine risk factors oversimplify the nature of the problem and neglect cultural, social and even biological context. The problem is complex and multi-faceted. Thus, it warrants a fitting approach, such as the one presented in this research. Third, there is too little evidence on the efficacy of interventions targeting behaviours that lead to an increased risk of cardiovascular diseases.
During the development of the data models, we found that the cardiovascular risk of a young female is significantly higher if she has multiple risk factors – something that is currently not mentioned in the cardiovascular guidelines. We also found that smoking is the most dominant modifiable risk factor. However, since, in the model we developed, exercise and diet behaviour affect a woman’s blood pressure, total cholesterol and blood sugar, indirectly, BMI may be just as, if not more, important. Our data model and our literature study thus confirm that these are important entry points that need to be exploited by interventions.
The simulation runs made the staggering revelation that, unless we do something about it, the future for women with regard to CVD looks bleak. The health issue is obstinate, and much of the prevention potential seems to be lost. The effects of many temperate interventions, such as education in schools, are negated, due to the oversaturation of unhealthy lifestyle behaviours. We also found that the effect of repeating interventions is more sustainable and long-term. However, our experiments implied that true progress can be made if extreme interventions are introduced repeatedly. Due to the intensity, it is unlikely the population of The Hague and additional stakeholders would approve of these interventions. We nuance the findings by the fact that the model is a simplified representation of the real world.
Choices were made during the design, and certain elements of human behaviour and of cardiovascular pathophysiology were omitted from the model. In some aspects, there simply was not enough data, such as on the effect of policies on a woman, but also how a woman is exactly influenced by her network and by external influences. These were some of the unknowns that could be addressed in future research.
This research concludes that there is an urgent need to introduce interventions that realise a sustainable, lasting change in the behaviours of women in The Hague. Three potential entry points are food intake, exercise, and smoking. Promoting healthier lifestyles is however only possible if we also address the social and cultural context. This model shows it is less effective to just change the behaviours of one woman, as social pressures may persuade her to fall back to her previous behaviours. We can set up women for success by involving her social network and as such decrease the barrier for her to permanently adopt a healthier lifestyle.