CVD Control Programs Preventive Strategies Sunita Dodani Department

CVD Control Programs: Preventive Strategies Sunita Dodani Department of Epidemiology University of Pittsburgh

Presentation overview § Burden Of CVDs And Health Expenditures in developing countries § Constraints For CVD Prevention In Developing Countries § Barriers to Implementation of Preventive Services § Prevention Strategies § CVD Control Programs § Population based & high risk approach

§ CVD identified as the primary NCD throughout the developing world and inflicting major economic and human costs. § One of the main reasons are the epidemiologic transition. § The observed ethnic diversity in the CVD and risk factors profile in South Asian Immigrant studies makes this population high -risk. § A paucity of cause-specific mortality data and epidemiologic studies is a major impediment to the estimation of the absolute and relative death toll of CVD. § Need to establish appropriate research studies, increase research capacity and preventive cardiology programs.

Potential For Prevention CVD risk factors: large potential for prevention Nonmodifiable RF: Age, Sex, FM history of CVD Behavioral RF: Smoking, Unhealthy diet Sedentary Lifestyles Socioeconomic & cultural determinants Early life Characteristics * Modifiable Physiological RF: • Hypertension • Cholesterol • Diabetes • Obesity Endpoints: Heart Disease Stroke Vascular Disease Cancer

Burden Of Disease And Health Expenditures Of Industrialized And Developing Countries The ’ 90/10 Disequilibrium’ EME= established market economy

Burden Of CVDs And Health Expenditures § The mismatch between healthcare needs and resources is widened. § An expanded list of health conditions calls for policy maker’s attention and public health action. § Policy has to prioritize on the basis of disease burdens, cost-effectiveness and equity. § The rising burdens of CVD exemplify the high costs and the adverse effects on development that would result from mid-life death and disability.

Constraints For CVD Prevention In Developing Countries § Limited recognition and available data on CVD § Lack of commitment § Prevention not taken seriously (market pressure favoring therapy) § Stroke/ CHD considered as diseases for specialists to treat § Health care needs not addressed “prospectively” by existing health system § Costs are rising and resources are dwindling

Barriers To Achieving CVD Reduction Agencies Involved in Prevention Government § very bureaucratic § slow and ineffective § failure to influence polices Cardiac societies and foundations § effectiveness in reaching out to the public through the media Community and societal barriers § strong health beliefs and lack of awareness, education and knowledge

Barriers to Achieving CVD Reduction Medical Education System § Focused towards secondary & tertiary care than Public health and prevention § In- adequate training of medical professionals in research methods § Communication skills: knowledge deficit in most providers § Providers attitudes about prevention

Barriers to Implementation of Preventive Services § Health Care Systems – Acute care priority – Lack of resources – Lack of systems for preventive services – Time and economic restraints – Lack of policies and standards § Community/Society/ patients – Lack of motivation – Cultural factors – Social factors – Lack of knowledge

Barriers to Implementation of Preventive Services § Physician Level – Problem-based focus – Little positive feedback – Time – Lack of training § Poor knowledge § Lack of skills § Perceived low efficacy – Lack of specialist-generalist communication

Preventive Cardiology Programs: How Can We Do Better? § § § Development of strategies for the prevention of cardiovascular disease (CVD) presents an important policy question for society Do the benefits of these programs justify the investment? Substantial costs …affordable ? How limited health care resources should be allocated to these activities? Will it cover the majority who are at risk? Who will benefit the most? What are the best approaches ?

CVD Control Programs The essential components of any CVD control program would be: § Establishment of efficient systems for estimation of CVD-related burden and its secular trends. § Estimation of the levels of established CVD risk factors in representative population samples to help identify risk factors that require immediate intervention. § Evaluation of emerging risk factors § Development of a health policy that will integrate population-based measures for CVD risk modification and cost-effective case management strategies for high risk group.

Prevention Strategies Strategic Goals 1. Build a nationwide Cardiovascular Disease Prevention and Control Program 2. Eliminate health disparities among priority populations 3. Create a national surveillance system for CVD 4. Develop research capacity and skills by training the trainers 5. Support applied research

Prevention Strategies Three types of prevention are advocated by WHO Primordial: prevention of appearance of risk factors e. g In the case of CAD and hypertension Primary: control of risk factors of CVD e. g. Hypertension, smoking etc & Secondary: control of CVD to control complications and further deterioration e. g. RHD, MI or Angina

CVD Control Programs § All of these require a strengthening of policy-relevant research that can support and evaluate CVD control programs in the developing countries. § The challenge of CVD control is complex in settings in which epidemiological data CVD events as well as population-attributable risk CVD risk factors are not readily or reliably available at present. Research training and Pubic health knowledge are an important tool for CVD control in developing countries

Research training in Pakistan § There are more than 50 medical universities and colleges § Only 2 institutes have accredited public health/ research training programs § There is no school of public health § Those trained, majority leaves § Few publications in international journals § Three journal are indexed

CVD Control Programs Research Priorities § Public health action for CVD control linked to a policy-relevant research § The classic sequence of long-term cohort studies followed by intervention trials to initially identify and later modify risk factors will be time consuming and is likely to be impeded by financial constraints. Public health action cannot afford to wait that long to initiate interventions.

CVD Control Programs The appropriate strategy would be to: (1) Commence control strategies, based on what we can readily extrapolate from the knowledge available from other populations. (2) Evaluate known and putative risk factors through cross-sectional studies of populations (ecological comparisons) and case -control studies, preferably using incident cases of CVD (3) Use of South Asian Immigrant study data as a surrogate to develop preventive programs

From Epidemiological Evidence to Prevention Program Two complementary strategies that are advocated for primary prevention are Population based and High risk strategies approach Population based approach § community wide interventions § modify behavior § influence the distribution of risk factors in a population § modest changes in risk factors -substantial reduction in the cumulative population risk of CVD in a community § small benefits to each individual

Strategies to prevent CVDs High risk approach § identify few who are at high risk § targeted behavioral or pharmacological interventions § greatest risk reduction in individuals

Population and high risk preventive strategies D i s t r i b u t i o n D e s t i n y Population approach Risk factors Original distribution Combined Strategies High risk approach Risk Factor

Strategies to prevent CVDs Primary Prevention (Limit the number of cases) Population Strategies High risk Strategies • Public health approach • Clinical management • Targets Population • Targets individual

Strategies To Prevent CVDs Population based approach: How to do it? § Culturally and linguistically appropriate and effective community health promotion and disease prevention programmes should be encouraged and made available. § If they already exist they should be strengthened and integrated with the formal health care sector. § Cardiovascular disease prevention should be integrated with primary heath care. § Cardiovascular health education should be integrated with other health promotion initiatives.

Strategies To Prevent CVDs Population based approach § § § Target population-wide lifestyle interventions, Population-wide screening for risk factors Lifestyle advice should center on tobacco cessation, weight control, a heart healthy diet, physical activity and stress management. e. g. Smart Heart Program Cardiovascular health promotion should be part of the national media strategy. e. g. National Action Program Cardiovascular health should be addressed in schools as part of the curriculum, e. g. Smart Heart Program Cardiovascular health education should be offered in places of religious worship and worksites where appropriate.

Strategies To Prevent CVDs Population based approach § Infrastructure support and local capacity § § building for research should be prioritized. Train the trainers" approach should be adopted for promoting CVD prevention at the professional level. Community empowerment through education (mass and targeted) and policy change (to provide an enabling environment) are essential for health promotion.

Strategies To Prevent CVDs Some famous population based programs 1. North Karelia Project. Puska P 1975 2. Non-communicable disease intervention programme in Mauritius. Dowsen GK Br. Med J. 1995; 311: 1255– 9 3. Five standford city project. Winkleby Am J Public Health 86 (1996), pp. 1773– 1779.

Strategies To Prevent CVDs High risk approach § Identification of High Risk population from a community ( those with CVD, ≥ two risk factors of CHD, diabetics) § Cost-effective and customized diagnostic and management algorithms should be developed for the treatment § These guidelines should be made widely available to and adopted by health professionals in primary and secondary care settings. § The availability of effective and affordable drugs, devices and procedures should be ensured. § Referral chains should be established to provide effective links between primary, secondary and tertiary health care centers whenever required.

Strategies To Prevent CVDs High risk approach § Physicians in South Asia usually lack support of related health professionals such as dietitians as is the norm in the developed world. § A customized risk management curriculum should be introduced for physicians and health professionals during the course of formal and informal training. § Specialist opinion should be sought whenever essential and feasible. The cut-off points for specialist referral for every risk category should be recognized.

Public Health Approach Vs. High Risk Strategy Population- based § Radical ( incidence) § Potential large benefits § Cost effective (Policy) § Can target unaware Population Limitations § Need for mass change is hard to communicate § Interventions other than policies hard to implement § Benefit for individual small, weak motivation of physicians § Intervention can challenge vested interests/societal norms High-Risk § Benefit for individual large § Easy to understand, hence motivation and rewards for individuals § Needs person’s co-operation Limitations § Impact on total burden small § Often misused § Costly (screening) § Palliative (does not solve overall problem, ‘rescue’) § Distracts from population approaches

Strengthening Research Capacity § § § Build Capacity & Skills To Conduct Research Activities Standardized morbidity data to estimate CVD burden. Prevalence data from valid cross-sectional sample surveys of selected communities Incidence data from selected cohort studies would provide a reasonable basis for extrapolation. Develop disease surveillance system Develop CVD registries and data centers

Strengthening Research Capacity How much research training required for Health care professional to obtain basic research skills. Basic knowledge of Epidemiology, Biostatistics and Public health should be core components of post-graduate education and CME training programs for doctors.

Five Essential Components Of The Action Plan 1. Taking Action Ø Putting present knowledge to work 2. Strengthening Capacity Ø Transforming the organization and structure of public health agencies and partnerships 3. Evaluating Impact Ø Monitoring the Disease Burden, measuring progress, and communicating urgency CDC model, 2003

Five Essential Components Of The Action Plan 4. Advancing Policy Ø Defining the issues and finding the needed solutions 5. Engaging in (regional and global) partnerships Ø Multiplying resources and capitalizing on shared experience

Action Framework For A Comprehensive Public Health Strategy To Prevent Heart Disease And Stroke A Vision of the Future Social and Environmental Conditions Favorable to Health Policy and Environmental Change Behavioral Patterns that Promote Health Behavior Change Low Population Risk Factor Detection and Control Few Events/ Only Rare Deaths Full Functional Capacity/ Low Risk of Recurrence Emergency Care/Acute Case Management PREVENTION Intervention Approaches Unfavorable Social and Environmental Conditions Adverse Behavioral Patterns Rehabilitation/ Long-term Case Management The Present Reality Major Risk Factors First Event/ Sudden Death Disability/ Risk of Recurrence Good Quality of Life Until Death End-of-Life Care Fatal CVD Complications/ Decompensation

Action Framework For A Comprehensive Public Health Strategy To Prevent Heart Disease And Stroke A Vision of the Future Social and Environmental Conditions Favorable to Health Policy and Environmental Change Behavioral Patterns that Promote Health Behavior Change Low Population Risk Few Events/ Only Rare Deaths Adverse Behavioral Patterns Good Quality of Life Until Death TREATMENT Risk Factor Detection and Control Emergency Care/Acute Case Management Intervention Approaches Unfavorable Social and Environmental Conditions Full Functional Capacity/ Low Risk of Recurrence Rehabilitation/ Long-term Case Management The Present Reality Major Risk Factors First Event/ Sudden Death Disability/ Risk of Recurrence End-of-Life Care Fatal CVD Complications/ Decompensation