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

2. 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

3. One of the main reasons are the epidemiologic transition.
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.
A paucity of cause-specific mortality data in the developing countries is a major impediment to the estimation of the absolute and relative death toll of CVD or in evaluating the time trends in mortality. the observed ethnic diversity in the profile of CVD and varied risk associations in different populations

4. Potential For Prevention
CVD risk factors: large potential for prevention
Nonmodifiable RF:
Age, Sex, FM history of CVD
Physiological RF:
Hypertension
Cholesterol
Diabetes
Obesity
Endpoints:
Heart Disease
Stroke
Vascular Disease
Cancer
Behavioral RF:
Smoking, Unhealthy diet
Sedentary Lifestyles
there is an urgent need to establish appropriate research studies, increase awareness of the CVD burden, and develop preventive strategies in developing countries
Socioeconomic & cultural
determinants
Early life Characteristics
* Modifiable

5. Burden Of Disease And Health Expenditures Of Industrialized And Developing Countries The ’90/10 Disequilibrium’
EME= established market economy
Murray et al. National health expenditures. WHO, Global Forum for Health Research (

6. 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.
As the developing countries experience a rapid health transition, the mismatch between healthcare needs and resources is widened by an expanded list of health conditions that vie for policy maker’s attention and public health action, while posting competing claims for clinical care. The complexities are compounded when policy has to prioritise on the basis of disease burdens, cost-effectiveness and equity, while the delivery systems have to simultaneously cope with the transformative pressures of economic restructuring and healthcare reforms. The rising burdens of CVD exemplify the high costs that unchecked epidemics of NCDs will impose on healthcare systems, and the adverse effects on development that would result from mid-life death and disability

7. 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

8. 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
In industrialized countries, societies and foundations such as the World Heart Federation (WHF) and WHO have been most active. Observance of World Heart Day, World Health Day and World Non-Smoking Day has increased awareness and the seeking of medical help. In Pakistan, the concept of a World Heart Day is slowly gaining acceptance at nation wide level.
Similarly, American Heart Association (AHA)/American College of Cardiology (ACC), National Heart, Lung and Blood Institute, British Heart Foundation, Heart Foundation of Australia and New Zealand, the European Society of Cardiology and the European Heart Network have been very effective in reaching out to the public through the media.
However, governments are usually very bureaucratic, slow and ineffective. To give an example, for the past several years the Pakistan cardiac society have been knocking at the doors of the Government of Pakistan for a hearing and a policy statement on heart disease. Governments, especially in the developing countries, can do a lot by way of legislation against the use of tobacco for e.g. and for labeling of processed foods to declare their fat and sodium content. The government must have the political will to eradicate the disease by proper transfer of technology to the states. The Government of Pakistan has failed to provide an impetus to eradicate RHD as it mostly affects the poor.
The fundamental contribution of lifestyle behaviors to the prevention and reduction of risk factors, and the high prevalence of risk factors in most population groups, mandate a public health approach to preventing CVD. In countries are Pakistan, communities carry very strong beliefs food rich in fat. E.g saturated fat is better than oil etc. The influence of myths on patient behavior and the effect of dispelling myths are important areas for study.
The emphasis in medical school and training is on diagnosing and treating acute illness. Physicians receive very little education in public prevention and the management of chronic conditions. Cardiologists, in particular, often view their role as managing the acute event; they frequently defer long-term prevention issues to primary care providers. the lack of specialist attention reinforces the perception on the part of primary care providers and patients that the treatment of chronic risk factors and lifestyle modification are discretionary practices

9. 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
The plethora of available guidelines which have focused on the relative risk of specific risk factors rather than on absolute risk of CHD given the presence of several risk factors in an individual patient cause confusion in understanding especially those with very minimal back ground of public health, research & Epidemiology. The physician and patient may feel overwhelmed as to how to prioritize risk factor reduction in a realistic and cost-effective manner. Health care providers need to understand and be able to communicate what the anticipated absolute benefit of a given risk-factor reduction strategy is in a specific patient.
The other major knowledge deficit for most providers is in techniques for enhancing adherence to medication and lifestyle changes. Although 95% of medical schools currently instruct students in communication skills, these skills are rarely reinforced in postgraduate training and continuing medical education programs. There is a large body of evidence of the effective health counseling techniques. And most physicians lack confidence in their ability to enhance their patients' adherence to medication and behavior-change regimens.

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

11. 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

12. 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 ?
The development of many strategies for the prevention of cardiovascular disease (CVD) presents an important policy question for society: do the benefits of these programs and interventions justify the investment in them? Preventive strategies may provide attractive opportunities to avoid or defer disease and disability, but they may have substantial costs and must often be applied to many subjects in order to reach the few in the group who will benefit the most. Whether and how limited health care resources should be allocated to these activities is therefore an important area of inquiry for health care policy makers and practitioners.
Although primary prevention is more attractive on an emotional level, economic analysis usually finds secondary prevention to be more efficient. This is due to the rather simple fact that patients who have clinical disease are at higher risk, and therefore more likely to benefit, than a group of lower-risk subjects, only a few of whom will ever develop disease.

13. 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.
The essential components of any CVD control program would be the following: (1) establishment of efficient systems for estimation of CVD-related burden of disease and its secular trends; (2) estimation of the levels of established CVD risk factors (eg, smoking, elevated cholesterol, or blood pressure) in representative population samples to help identify risk factors that require immediate intervention; (3) evaluation of emerging risk factors (eg, glucose, abdominal obesity, fibrinolytic status, homocysteine) that may be of special relevance to the populations concerned; (4) identification of the determinants of health behavior that influence the levels of both traditional and emerging risk factors in the specific context of each society; and (5) development of a health policy that will integrate population-based measures for CVD risk modification and cost-effective case management strategies for individuals who have clinically manifested CVD or are detected to be at a high risk of developing it.

14. 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
The need to contain the epidemic as well as combat its impact and minimize the CVD toll in terms of mortality and morbidity in the developing countries is, therefore, obvious and urgent. Although feasible, national strategies to meet this objective must be developed and effectively implemented by individual countries, new regional and global initiatives by international agencies concerned with health care program facilitation, policy development, and research funding are also required to strengthen and speed up these national efforts. In addition, a considerable body of evidence suggests that current risk-factor prevention programs and low-cost case management of CVD offer feasible, cost-effective ways to reduce CVD mortality and disability in developing country populations.

15. 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
Three types of prevention are advocated by WHO: primordial, primary and secondary. Prevention may be population-based or target high-risk groups. In some types of heart disease (e.g. RHD), secondary prevention is the most practical. In the case of CAD and hypertension, scientists now recommend primordial prevention (prevention of appearance of risk factors) as primary prevention, i.e. control of risk factors has been done in many interventional studies in Europe and the USA with only partial response.

16. 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
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 especially complex in settings in which epidemiological data related to the incidence of fatal and nonfatal CVD events as well as population-attributable risk of various risk factors of CVD are not readily or reliably available at present.

17. 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

18. 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.
Public health action for CVD control in the developing countries is therefore linked to a policy-relevant research agenda. However, 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. The appropriate strategy would be to (1) commence control strategies, based on what we can readily extrapolate from the knowledge available from other populations (eg, tobacco control); (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; and (3) follow-up the cross-sectional survey populations prospectively to obtain incidence data on CVD-related morbidity and mortality as well as to assess the independent and interactive risks associated with known and emerging risk factors.

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

20. 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
Two complementary strategies that are usually advocated for primary prevention are the “population approach” and “high-risk approach.
population approach:community wide interventions seek to modify behaviors and thereby influence the distribution of risk factors in the population. Even modest changes in risk factors are expected to contribute to a substantial reduction in the cumulative population risk of CVD because of the large number of people affected.

21. Strategies to prevent CVDs
High risk approach
identify few who are at high risk
targeted behavioral or pharmacological interventions
greatest risk reduction in individuals
The high risk strategy, on the other hand, seeks to identify the few individuals who are at high risk, either because of marked elevation of single or multiple risk factors; targeted behavioral or pharmacological interventions follow

22. Population and high risk preventive strategies
Population approach
Distribution Destiny
Risk factors
Original distribution
Combined Strategies
High risk approach
Two complementary strategies that are usually advocated for primary prevention are the “population approach” and “high-risk approach.” In the former, community wide interventions seek to modify behaviors and thereby influence the distribution of risk factors in the population. Even modest changes in risk factors are expected to contribute to a substantial reduction in the cumulative population risk of CVD because of the large number of people affected. The high risk strategy, on the other hand, seeks to identify the few individuals who are at high risk, either because of marked elevation of single or multiple risk factors; targeted behavioral or pharmacological interventions follow. The population strategy aims to reduce the burden of disease in the whole community while conferring small benefits to each individual. The high-risk strategy, on the other hand, provides large benefits to the few individuals who are most vulnerable but the benefits to the whole community may be relatively limited because the beneficiaries are few. 68
Risk Factor

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

24. 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.
" Public health " 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. " The public health approach should target population-wide lifestyle interventions, population-wide screening for high blood pressure and screening of the high-risk group for diabetes and hypercholestrolaemia. " Lifestyle advice should center on tobacco use cessation, weight control, a heart healthy diet, physical activity and stress management. " Cardiovascular health promotion should be part of the national media strategy. " Cardiovascular health should be addressed in school based health education and/or as part of the science curriculum. " Cardiovascular health education should be offered in places of religious worship and worksites where appropriate. " Infrastructure support and local capacity building for research should be prioritized.

25. 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.

26. 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.
" All physicians must commit the time to make a proper assessment and initiate preventive efforts. Physician's advocacy of healthy habits including tobacco-use cessation, healthy eating, weight control, and physical activity should be universal.
Community empowerment through education (mass and targeted) and policy change (to provide an enabling environment) are essential for health promotion in populations at all stages of health transition.

27. Strategies To Prevent CVDs
Some famous population based programs
North Karelia Project. Puska P 1975
Non-communicable disease intervention programme in Mauritius. Dowsen GK Br. Med J. 1995; 311: 1255–9
Five standford city project.
Winkleby Am J Public Health 86 (1996), pp. 1773–1779.
The success of such comprehensive programmes has been demonstrated in the varied settings of developed, as well as developing, countries

28. 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.
Cost-effective and customized diagnostic and management algorithms should be developed for the treatment of all common cardiovascular diseases. These guidelines should be made widely available in the region. The availability of effective and affordable drugs, devices and procedures should be ensured. Referral chains should be established which should provide effective links between primary, secondary and tertiary health care centers whenever required. Train the trainers" approach should be adopted for promoting CVD prevention at the professional level. All physicians must commit the time to make a proper assessment and initiate preventive efforts. Physician's advocacy of healthy habits including tobacco-use cessation, healthy eating, weight control, and physical activity should be universal. Physicians in South Asia usually lack support of related health professionals such as dietitians and the support services of specialized anti-smoking, weight reduction and diabetic clinics, as is the norm in the developed world. Therefore 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.
Suitable clinical algorithms for diagnosis and low-cost life-saving interventions (eg, aspirin) must be widely available to and adopted by health professionals in primary and secondary care settings.

29. 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.

30. 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

31. 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
Obtaining a fuller estimate of the burden of disease also requires standardized morbidity data. Although gathering such data on a national basis would be impractical, obtaining prevalence data from cross-sectional sample surveys of selected communities and incidence data from selected cohort studies would provide a reasonable basis for extrapolation. Health services of large organized sector industries may offer opportunities for convenient and cost-effective prospective studies and registries.

32. 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.

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

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

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

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