Transcript 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.

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
120
Percent
100
80
DALYs
60
Health
Expenditure
40
20
0
EME
All Other
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?
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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
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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
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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
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
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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
 Putting present knowledge to work
2. Strengthening Capacity
 Transforming the organization and
structure of public health agencies and
partnerships
3. Evaluating Impact
 Monitoring the Disease Burden,
measuring progress, and communicating
urgency
CDC model, 2003
Five Essential Components Of
The Action Plan
4. Advancing Policy
 Defining the issues and finding
the needed solutions
5. Engaging in (regional and global)
partnerships
 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
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