Promoting Cardiovascular Health in the Developing World A Critical Challenge to Achieve Global Health (2010) / Chapter Skim
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5 Reducing the Burden of Cardiovascular Disease: Intervention Approaches
5 Reducing the Burden of Cardiovascular Disease: Intervention Approaches
Pages 185-274
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From page 185... ...
It cannot be addressed through a singular, time-limited commitment but rather requires long-term interventions and sustainable solutions. This chapter first outlines the ideal vision of a comprehensive approach to promote cardiovascular health and reduce the burden of cardiovascular disease.
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From page 186... ...
Concurrent modalities could include policy and regulatory changes, health promotion campaigns, innovative applications of communications technologies, efficient use of medical therapies and technologies, and integrated clinical programs. For individuals already at high risk or with existing disease, this approach would combine education, support, and incentives to both address behavioral risk factors and improve adherence to clinical interventions.
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POLICY APPROACHES (Global, National, Local) Globalization Financial Legal Regulatory Trade Health Health Workforce Workforce Environment to Enable Individuals to Make Demographicn Globalizatio and Maintain Healthful Choices Change WIDER SOCIETY Social Drugs & Drugs and Determinants Technologies Technologies Biological Risk INDIVIDUAL Health FAMILY Inequities Quality o Care Quality off Care Therapeutic, Behavioral NEIGHBORHOOD, COMMUNITY Risk Rehabilitative Services Preventive, Diagnostic, Education DETERMINANTS Access to Care Access to Care Enhancement of Knowledge, Motivation, and Skills of Individuals Cultural and HEALTH CARE DELIVERY Social Norms Media Community Interventions Settings Based Systems Systems nfrastructure IInfrastructure HEALTH COMMUNICATION FIGURE 5.1 Comprehensive strategy to address cardiovascular disease.
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From page 188... ...
Chapter 7 will continue the discussion of feasibility and prioritizing the use of limited resources in low and middle income countries with a synthesis of the available economic evidence and future economic research needs for the intervention approaches described in this chapter. Building a Strategy to Address CVD The following briefly outlines the series of components needed for countries and supporting global stakeholders to build a strategy to promote cardiovascular health.
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From page 189... ...
In many low and middle income countries, this will require the development of sufficient capacity and infrastructure to carry out population-based approaches for measuring cause-specific mortality and behavioral and biological risk factors. In countries with very limited capacity at baseline, at first it may be nongovernmental organizations, foreign assistance agencies, and other donors who need to carry out a needs assessment and prioritization before implementing programmatic efforts.
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From page 190... ...
Improving health care delivery includes, for example, provider-level strategies, financing, integration of care, workforce development, and access to essential medical products. The need to strengthen health systems in low and middle income countries is not specific to CVD, and it is important that ongoing efforts in this area take into account not only traditional focus areas such as infectious disease and maternal and child health but also CVD and related chronic diseases as well as chronic care needs that are shared among chronic non-infectious diseases and chronic infections such as HIV/AIDS and tuberculosis (TB)
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From page 191... ...
Because of the lack of community-based models that have been successfully implemented, evaluated, and sustained in low and middle income country settings, the critical next step in these settings is to support research to develop and evaluate demonstration projects through implementation trials. In many cases, the focus can be on adapting and evaluating programs with demonstrated success in developed countries.
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From page 192... ...
The intent is that good epidemiologic observational data on the role of risk factors and the preventive effects of reductions in those risk factors will lead to hypotheses about causal pathways that interventions are designed to influence. Ideally, these hypotheses will be confirmed by prospective interventional studies that are repeated and reaffirmed in a variety of settings.
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However, the committee did restrict its review of the evidence to published studies that included some comparison condition, either through a control group or a comparison to before and after an intervention was implemented. The second standard for evidence set out by the committee is one of relevancy, an issue of particular importance here, although it is by no means exclusive to low and middle income countries.
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From page 194... ...
For components where there is limited or no effectiveness or implementation data, the logical basis for intervention approaches is discussed as being derived from knowledge about the determinants of CVD, modifiable risk factors, and characteristics of ideal intervention design and implementation. Conclusion 5.1: Context matters for the planning and implementation of approaches to prevent and manage CVD, and it also influences the effectiveness of these approaches.
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From page 195... ...
For example, they rely on tax rates on tobacco set by economic agencies, food subsidy policies set at agricultural agencies, access rules for public service advertising set by communication agencies, curricular choices by education agencies, and commitments to product reformulation by multinational corporations. Thus, success in achieving the specific priority goals for CVD programs will rely heavily on decisions made outside of health agencies, and that success will only come if there is substantial intersectoral collaboration.
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From page 196... ...
The focus is on examples from low and middle income countries when possible. Evaluations of policy interventions are not common, especially in low and middle income country settings, but where an evaluation has generated evidence on policy this is presented as well.
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. Therefore, evaluation strategies are needed to examine the effects of tobacco control policies in low and middle income settings, and there is a need for more knowledge and analysis of the barriers to successful implementation and how to overcome them (Bump et al., 2009)
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. Therefore, it is reasonable to conclude that there is potential for cardiovascular health to be promoted by finding economically feasible ways to globalize agricultural and food policies that promote more healthful food production and make more healthful foods affordable to developing country populations, including the poor.
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. Therefore, the Mauritius experience serves as an example of how a middle income country can mobilize governmental policies to achieve future health improvement,
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suggest that price policies can influence food choices, in these examples with a negative effect on CVD risk. The consumption of edible oils in China has increased substantially with recent drops in edible oil prices stemming from changes in trade patterns (with especially strong effects on the poor)
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. These strategies have the potential to be adapted both to low and middle income country efforts as well as to be scaled up for broader, coordinated global efforts (He and MacGregor, 2009)
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. The rapid rise in palm oil consumption in some low and middle income countries has also had a significant negative impact on the environment and has strained fragile natural ecosystems.
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From page 203... ...
As described in Chapter 3, trends show that the changes in the built environment due to urbanization are generally associated with several risk factors for CVD, including an increase in tobacco use, obesity, and some aspects of an unhealthful diet, as well as a decline in physical activity and increased exposure to air pollution (Brook, 2008; Gajalakshmi et al., 2003; Goyal and Yusuf, 2006; Langrish et al., 2008; Ng et al., 2009; Steyn et al., 2006; Yang et al., 2008; Yusuf et al., 2001)
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While there may be some commonalities between individuals from both urban and rural regions of the developed and developing world, differences in social norms, culture, existing built environment, and local variations in baseline daily activity levels are likely to have a substantial impact on the potential effectiveness of a change in the built environment in leading to behavior change. On the other hand, low and middle income countries undergoing rapid development and urbanization provide promising opportunities to help fill the evidence gap through future prospective research given the multitude of neighborhoods and cities in the early stages of land use development.
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From page 205... ...
. In summary, there is limited evidence of the effects on CVD-related outcomes of strategies and investments to alter the existing built environment, and urban planning policies are likely not a CVD priority in many low and middle income countries.
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From page 206... ...
This focus can be most effective when using multiple intervention approaches to achieve the same ends, with large-scale communication programs as one important component. CVD-Related Communication Campaigns in Low and Middle Income Countries There is currently very limited evidence about the effects of communication interventions on CVD-related behaviors (or morbidity)
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From page 207... ...
Blood pressure, smoking, and composite risk were lowered compared to the control town, but there was no difference between the two treatment conditions. Thus, this was a replication of a successful use of a mass media strategy and was a test of these methods in a middle income country.
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This includes those that focused on a single outcome (smoking, physical activity, high blood pressure control, cholesterol reduction, salt consumption) and those that addressed multiple CVD risk factors within a single program.
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From page 209... ...
. While it is not possible to make definitive attributions of influence, it is reasonable to connect this form of media advocacy to behavior change and to view it as an important model for tobacco control in low and middle income countries as well as for possible extension to other areas of behavior relevant to CVD.
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From page 210... ...
. The Stanford Three Community Study showed evidence for effects on important risk factors of smoking, blood pressure, cholesterol, and body weight and a large decrease in total CVD risk (Farquhar et al., 1977; Williams et al., 1981)
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Therefore, these earlier projects may have faced fewer obstacles to change than might be faced earlier or later in the epidemiological transition cycles. Potential Lessons from Other Health Communication Programs in Low and Middle Income Countries Even when communication programs in high income countries have demonstrated success, these programs may be difficult to generalize to developing-country contexts.
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From page 212... ...
However, from the perspective of trying to prioritize and act synergistically with policy interventions to achieve change in risk factors or the behaviors associated with them, it may not be wise to try to address multiple CVD risk factors in one campaign. There may be greater potential to achieve behavior change by constructing independent programs that address each factor by itself (e.g., tobacco use, salt consumption, transfat consumption, saturated fat consumption, physical activity, and obesity)
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. However, although programs are emerging that depend on interactive communication technology, there is insufficient evidence at this time to determine if these approaches will be effective in low and middle income countries.
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Adaptations to the culture, resources, and capacities of specific settings will be required for population-based interventions to have an impact in low and middle income countries. Recommendation: Implement Policies to Promote Cardiovascular Health To expand current or introduce new population-wide efforts to pro mote cardiovascular health and to reduce risk for CVD and related chronic diseases, national and subnational governments should adapt and implement evidence-based, effective policies based on local pri orities.
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This section focuses on both areas of health care delivery within which there are specific CVD needs and also touches on broader health systems needs that are relevant for chronic diseases and synergistic with the emerging emphasis on global health systems strengthening and integrated primary care rather than disease-specific clinical programs. Efforts to improve broad health systems functioning are the focus of significant current efforts in global health and have been well described elsewhere (Lewin et al., 2008; Taskforce on Innovative International Financing for Health Systems Working Group 1, 2009; WHO, 2007a)
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In addition to CVD-specific clinical solutions, there are common elements to effective delivery of chronic disease care that have potential to work for many health problems in low and middle income countries (e.g., diabetes, cancer, prenatal care, growth monitoring in children, TB, and HIV)
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From page 217... ...
Indeed, as global health begins to shift toward generalized strengthening efforts with a focus on primary care, chronic diseases and models of chronic care and disease management cannot be overlooked. Patient-Level Interventions The following section reviews patient-level interventions that are delivered within the health care system to reduce CVD risk and manage disease, including behavior change strategies and clinical interventions for prevention and treatment.
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In addition, the generalizability of these findings to low and middle income country contexts is not known. Several randomized trials in high income countries have demonstrated the effectiveness of financial incentives to address tobacco use.
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From page 219... ...
There are few published examples that are directly related to CVD outcomes, but a program in Mexico can be informative for addressing related CVD risk factors, specifically child nutrition and obesity. PROGRESA/ Oportunidades examined the effect of conditional cash transfers in 506 rural, low income communities that were randomly assigned to be enrolled immediately or after an 18-month period, allowing for comparison between the two groups during the waiting period.
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. As described in more detail in the section on economic analysis in Chapter 7, hypertension control is also one of the interventions with the most potential to be cost-effective in low and middle income countries.
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47) recent WHO reports have indicated that essential CVD medicines are largely not available in the public sector in low and middle income countries (Cameron et al., 2009; Mendis et al., 2007a)
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, the financial burden on individuals and families has the potential to be substantial. Clearly, much needs to be done to ensure a guaranteed supply of affordable CVD medicines to the majority of the low and middle income country population.
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From page 223... ...
However, it is important to ensure that CVD-related procurement needs are coordinated with existing efforts in the global health community, so as not to perpetuate the difficulties caused by parallel distribution systems. In HIV/AIDS for example, The Global Fund to Fight AIDS, Tuberculosis and Malaria and PEPFAR each have their own supply chain management protocols, funding streams, and procurement requirements.
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Technical performance refers to the extent to which services are performed according to standards and can be improved through supervision and lifelong training (Taskforce on Innovative International Financing for Health Systems Working Group 1, 2009)
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Therefore, where evidence is lacking quality improvement on strategies to address CVD and related risk factors in low and middle income countries, there is a discussion in the following sections of evidence that can be generalized from relevant chronic disease-related approaches in high income countries and in some cases, from strategies targeted at other areas of health care in low and middle income countries in order to develop strategies for CVD and related chronic diseases in low and middle income countries. Guidelines There are multiple national and international guidelines for prevention, treatment, management, and control of CVD and CVD-related risk factors, including hypertension and elevated lipids, many of which have been tailored for a range of high income countries and low and middle income countries.
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; the Canadian Guidelines for the Diagnosis and Treatment of Dyslipidemia and Prevention of Cardiovascular Disease in the adult (Genest et al., 2005) ; the Canadian Hypertension Education Program (Canadian Hypertension Education Program, 2009)
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in the Philippines provides recent evidence from a middle income country of links between clinical performance feedback and improvements in quality, outcomes, and satisfaction. QIDS was an evaluation to compare the impact of two interventions on physician practices, health behaviors, and health status of children under 5 years: (1)
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purchasers reward quality improvements and providers create the information and organizational infrastructure to achieve them." Work on public reporting in developing countries is limited. However, there have been documented examples of its use.
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. QIDS in the Philippines, described earlier, compared the impact on physician practices, health behaviors, and health status of children under 5 years of either expanded insurance coverage to increase access to care or a pay-for-performance scheme in which bonus payments were given to physicians based on quality scores using a randomized design (Shimkhada et al., 2008)
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. Thus evidence from low and middle income countries is sparse and the potential for effective transfer of chronic care models to low and middle income settings remains to be demonstrated (Beaglehole et al., 2008)
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. With the expected increase in the burden of the global CVD epidemic, it is likely that the shortage in the global health care workforce and leadership will be even more acutely felt in low income countries during the upcoming several decades.
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. A review of work in the United States suggests that interventions for prevention and control of CVD can be effectively delivered by community health workers, which suggests that there may be potential for adapting this approach to develop CVD-specific strategies in low and middle income countries (Brownstein et al., 2005)
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From page 233... ...
These models have been used extensively for training in the infectious disease field, but the adaptation of chronic disease approaches in this area in developed countries to low and middle income settings remains largely an untapped opportunity. The National Heart, Lung, and Blood Institute (NHLBI)
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Analogously, in order to decrease the demand for health worker migration, one proposal has been to increase the national self-sufficiency of the high income country health workforce and reduce reliance on recruitment of migrant health workers from low income countries (O'Brien and Gostin, 2008)
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From page 235... ...
. Even though chronic disease prevention and treatment is becoming an increasingly important component of primary health care and primary health care is a growing area of emphasis on the global health agenda, there is limited evidence about how to effectively integrate care for chronic diseases into developing primary care systems (Beaglehole et al., 2008)
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From page 236... ...
As described in Chapter 4, the use of electronic and mobile technologies is emerging in a range of global health contexts with the potential to be adapted or expanded to include chronic diseases. Investment in information and communication technology is an important potential component 2 This section is based in part on a paper written for the committee by Alejandro Jadad.
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There have been some examples of intervention approaches using mobile health (m-health) technology in low and middle income countries, in some cases with applications for chronic diseases.
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From page 238... ...
raising money, or raising revenue for health systems through general taxation and social insurance; community-based insurance; and private insurance; (2) pooling risk, which is the accumulation and management of revenue so that the risk of paying for health care is borne by all members of the pool (out-of-pocket payments are the least desirable method of pooling risk, yet are often a significant source of funding in low income countries)
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Taking into account variations in national data due to limitations in availability, reliability, and validity, WHO-standardized National Health Expenditure account data show that in 2006 low income countries spent, on average, 4.3 percent of gross domestic product (GDP) on health-related expenditures, lower-middle income countries 4.5 percent of GDP, upper-middle income countries 6.3 percent of GDP, and high income countries 11.2 percent of GDP (WHO, 2006)
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Individuals and Households In developing-country settings, individual households bear the primary burden of financing health care needs beyond primary care because out-of-pocket spending is the predominant way that health care is financed. In a recent analysis of global health financing the average share of total health spending from out-of-pocket payments was 70 percent for low income countries, 43 percent for low-middle income countries, and 30 percent for upper-middle income countries.
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From page 241... ...
Current efforts to strengthen health systems in many low and middle income countries provide an opportunity to improve delivery of high quality care to prevent and manage CVD, including chronic care ap proaches that are applicable to other chronic diseases and infectious diseases requiring chronic management, such as HIV/AIDS. Recommendation: Include Chronic Diseases in Health Systems Strengthening Current and future efforts to strengthen health systems and health care delivery funded and implemented by multilateral agencies, bi lateral public health and development agencies, leading international nongovernmental organizations, and national and subnational health authorities should include attention to evidence-based prevention, di
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From page 242... ...
This broad reach into the community is advantageous because nearly all people in a community are at some level of risk for CVD and may benefit from interventions to encourage and reinforce healthful behavior, leading to potential population impact on highly prevalent risk factors. In fact, most CVD does not occur among the relatively few adults at highest risk, but rather than among the many at modeeate risk (Blackburn, 1983; Kottke et al., 1985; Puska et al., 1985; Schooler et al., 1997)
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From page 243... ...
In addition to the policy changes and large-scale communications campaigns described earlier in this chapter, this total environmental change may be accomplished through the work of entrepreneurs recognizing a growing market and developing new products to accelerate behavior change, through workplaces that fund wellness programs, through schools that modify food available to children and require physical activity, and through programs in other settings in the community. Thus, the goal is to create a cascade of behavior change, and that may come from the synergistic interactive effects that can occur when individual components are embedded in a total community-based program campaign that encourages institutional change, leaves space for entrepreneurs, and includes mass media and environmental change (Schooler et al., 1997)
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From page 244... ...
For example, businesses that have insurance incentives to reduce smoking and obesity might invest in CVD prevention programs, but there is not a lot of precedent for long-term sustainability and effectiveness in high income countries -- and the potential incentives for businesses in low and middle income countries are even less clear. Similarly, physical activity may be central in some schools, but schools may not be able to stay engaged if there is competition for limited resources with their primary academic mission.
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Potential Lessons from CVD-Related Community Trials in High Income Countries The evidence for effective community-based programs in high income countries is mixed, and the reasons for success and failure can provide some useful lessons to inform the design of future efforts to adapt these programs for trials in low and middle income settings. A wave of successful community trials in the 1970s and 1980s in the United States, Finland, Australia, Switzerland, and Italy were described earlier in this chapter because, although they involved a number of intervention components, a dominance of broadcast and print mass media underlied their success in reducing smoking, blood pressure, and body weight.
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, both of which made efforts to target low income residents, also show that local community support is important. Another important factor in these two projects was linkage to their excellent health care systems, which unfortunately in many low and middle income countries is not available.
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In the later years of the research phase, the health department began to support project activities, indicating a trend toward maintenance by the community. Thereafter, county activities moved into health promotion for all residents, with attention to chronic disease prevention needs and of the growing Hispanic population (Flora et al., 1993; Monterey County Health Department, 2007)
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Initiation by respected academic institutions, public awareness of the health problems being addressed, and enlightened leadership are essential. Potential Lessons from Community-Based Programs Targeting HIV/AIDS in Low and Middle Income Countries Community-based methods analogous to those used in high and middle income countries to target CVD have been used to target other outcomes in low and middle income countries, such as HIV/AIDS; this provides some reason for optimism regarding transferability of these approaches.
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Population surveys at a 7-year interval showed mixed effects on CVD risk factors, including blood pressure, smoking, and obesity (Yu et al., 1999, 2000)
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A project on salt reduction from Ghana provides important lessons on intervention approaches delivered in community settings in a low income country (Cappuccio et al., 2006)
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Principles to Guide Future Design and Evaluation of Community-Based Programs Despite the strong rationale for the approach, there is very limited evidence demonstrating effectiveness and successful implementation of broad multicomponent community-based approaches to reduce CVD or risk for CVD in developing countries. The capacity for planned community organizing that favors reduction in CVD risk has been demonstrated, on a very limited scale, in middle income settings in China, Mauritius, and South Africa and in low income settings in Ghana, Jamaica, and Nigeria, although evidence for effectiveness was limited in these programs.
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The methods for the design of the approaches in high income countries have been reviewed extensively elsewhere (Farquhar and Fortmann, 2007) , and only a few key messages that relate to transferability to low and middle income country settings are repeated here.
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There is little evidence that school-based programs significantly affect intermediate CVD risk factors such as blood pressure, blood lipids, or blood glucose. Like many of the intervention components discussed in this chapter, it is very important to note that the vast majority of these studies were conducted in high income countries, with very little evidence from low and middle income countries.
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and WHO (WHO and WEF, 2008) jointly produced a report that reviewed wellness-in-theworkplace programs targeting chronic disease risk factors.
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From page 255... ...
Health-related behaviors such as tobacco use, fruit consumption, salt consumption, and physical activity all were better among the industrial groups who received the workplace intervention. Another workplace intervention in China's Capital Steel and Iron Company demonstrated benefits in healthrelated knowledge, salt intake, blood pressure, and stroke mortality.
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From page 256... ...
Many countries do not currently have sufficient infrastructural capacity. Current efforts to strengthen health systems in many low and middle income countries provide an opportunity to improve delivery of high-quality care to prevent and manage CVD, including chronic care approaches that are applicable to other chronic diseases and infectious diseases requiring chronic management, such as HIV/AIDS.
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American Journal of Public Health 77(2)
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2009. A promotora de salud model for addressing cardiovascular disease risk factors in the U.S.-Mexico border region.
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2009. The benefits of statins in people without established cardiovascular disease but with cardiovascular risk factors: Meta-analysis of randomised controlled trials.
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1995. The Pawtucket heart health program: Community changes in cardiovascular risk factors and projected disease risk.
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2003. Tobacco control policy: Strategies, successes, and setbacks.
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1990. Effects of communitywide education on cardiovascular disease risk factors.
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2007. Euro pean guidelines on cardiovascular disease prevention in clinical practice: Fourth joint task force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice.
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2006. Agricultural and food policy for cardiovascular health in Latin America.
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2009. Preventing and managing cardiovascular diseases in the age of mHealth and global telecommunications: Lessons from low- and middle-income countries.
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2009. The impact of conditional cash transfers on health outcomes and use of health services in low and middle income countries.
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1996. Community education for cardiovascular disease prevention.
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1986. Communitywide prevention of cardiovascular disease: education strategies of the Minnesota Heart Health Program.
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2009. Why have physical activity levels declined among Chinese adults?
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2009. Impact of a worksite intervention program on cardiovascular risk factors: A demonstration project in an Indian industrial population.
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1990a. A review of five major community-based cardiovascular disease prevention programs.
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1995. Changes in sodium intake and blood pressure in a community-based intervention project in China.
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2001. Prevention of cardiovascular disease in Sweden: The Norsjo community intervention programme -- motives, meth ods and intervention components.
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2001. Global burden of cardiovascular diseases: Part I: General considerations, the epidemiologic transition, risk factors, and impact of urbanization.
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