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Cardiovascular Problems 5 Mitigation – of

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03.06.2018

Content:

  • Cardiovascular Problems 5 Mitigation – of
  • Physical Activity and Cardiovascular Disease: How Much is Enough?
  • Eat a healthy, balanced diet
  • Sounds simple doesn't it? Heart disease is the No. 1 cause of death in the United States. Stroke is the No. 5 cause of death in the United States. One of the. A Proactive Approach to Mitigating Cardiovascular Disease If we combine these risk factors, we can see that 5% of clients are at high-risk. WebMD offers 8 ways you can reduce your risk of heart disease. 5. Follow a heart-healthy diet. Eat foods that are low in fat and cholesterol.

    Cardiovascular Problems 5 Mitigation – of

    Smoking is a major risk factor for developing atherosclerosis furring of the arteries. It also causes the majority of cases of coronary thrombosis in people under the age of Research has shown you're up to four times more likely to successfully give up smoking if you use NHS support together with stop-smoking medicines, such as patches or gum.

    Read more about stopping smoking. Read more about drinking and alcohol. You can keep your blood pressure under control by eating a healthy diet low in saturated fat, exercising regularly and, if required, taking the appropriate medication to lower your blood pressure. If you have high blood pressure, ask your GP to check your blood pressure regularly. Read more about high blood pressure. You have a greater risk of developing CHD if you are diabetic. If you have CHD, you may be prescribed medication to help relieve your symptoms and stop further problems developing.

    If you're prescribed medication, it's vital you take it and follow the correct dosage. Don't stop taking your medication without consulting your doctor first, as doing so is likely to make your symptoms worse and put your health at risk. People who don't exercise are twice as likely to have a heart attack as those who exercise regularly. In addition, these studies would require a significant financial investment, either on the part of the research funding institution or the local community Sallis et al.

    There has also been little economic analysis of the potential costs associated with modifying an element of the built environment, which could be a barrier in developing countries. In addition, it is important to note that the majority of data on the correlation of environments and increased physical activity comes from high income countries. With the exception of some work in Latin America described below, there is a lack of evidence from a range of developing country settings, and most guidance documents do not address generalizability or adaptation to low and middle income country settings.

    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. The need for investment of resources in this research may be lessened in settings where the intervention is not an alteration of an existing environment but rather an element of design planning where investment has already been committed to future urbanization projects.

    The Agita program in Brazil is one of the few programs with an evaluation that uses health outcomes. This was a multicomponent program that included changes in the environment through an increase in the number of walking areas, facilities for bicycling, and recreational facilities.

    Changes related to the practice of physical activity during the intervention period were observed. An annual survey showed that over 5 years there was a decrease from Changes were also observed in targeted groups, such as groups of patients suffering from hypertension or diabetes and patients and workers in hospitals and health centers Matsudo et al. 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.

    However, for policy makers in countries undergoing rapid urbanization, there is a strong evidence-based rationale to take advantage of the opportunity going forward to implement and evaluate strategies to encourage cardiovascular health by making cities walkable, cyclable, safer, and free of air pollution.

    Health communication programs are typically designed to reach a large audience with messages as part of their established exposure to communication sources such as radio, television, billboards, newspapers and other printed material including mass mailings, and the Internet.

    Such exposure is often passive, relying on routinely accessed sources, rather than requiring the motivation of actively seeking a new communication source by an individual. Communication programs may affect behavior through three paths: The effectiveness of policies and programs can be enhanced if linked to health communication programs targeted to the same objective—for example, to complement lobbying of policy authorities and food manufacturers to restrict salt content with public education about salt reduction.

    In addition, linking communication programs to policy approaches can make them more likely to gain presence in the public mind and thus gain public support. A communication program may also be designed to precede the policy change to nurture the public support needed for legislative action.

    Health communication strategies can also be an important complementary component of health systems and community-based approaches. Depending on the infrastructure within a country, communication and health education efforts can occur at multiple levels, from the national government to local authorities and community-based organizations. The following section describes the evidence and considerations for designing and implementing communication campaigns at scale under the kinds of conditions that would be expected in real-world public health systems rather than research programs.

    An analysis of the current literature, described in more detail below, indicates that what might be most feasible for short-term implementation, and for coordination with policy approaches, is a focus on reasonably narrowly defined CVD -related targets, rather than trying to change all determinants of CVD at once.

    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.

    There is currently very limited evidence about the effects of communication interventions on CVD -related behaviors or morbidity in low and middle income countries, with few reported examples of communication programs with rigorous evaluations. The evidence is also challenging to interpret because large-scale communication programs tend to be components of multifaceted programs.

    Even when such multifaceted programs are evaluated, the effects of separate components are difficult to distinguish. In addition, in many reported evaluations no control condition is present, and as a result the effects of secular change can be difficult to discriminate from the effects of intervention efforts. There are descriptive reports about some programs implemented in middle income countries that incorporate communication elements Grabowsky et al.

    Some of these reports, described below, describe an evaluation and infer effects on CVD -related outcomes, but in some cases these effects are weakly supported, with little evidence of sustained impact. There were three nonrandomized, matched towns: Before-and-after cross-sectional surveys measured knowledge of risk factors, smoking habits, and medical history as well as BMI , blood pressure, and cholesterol.

    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.

    However, the program focused only on middle income white South Africans, so the generalizability to other low and middle income countries may be limited. After the initial intervention was implemented, a maintenance program was established and surveyed at 4-year intervals. The authors speculate that this can be explained by strong secular trends and local factors. This highlights the challenge of maintaining long-term effects in these interventions.

    The Healthy Dubec Project was a single-community, 2-year education campaign in the country that was then Czechoslovakia, with a before-and-after analysis that surveyed height, weight, blood pressure, and cholesterol, as well as sociodemographic variables and behavioral CVD risk factors Komarek et al.

    Significant improvements were noted in blood pressure, cholesterol, and saturated fat intake. No effect was observed on smoking or BMI Albright et al. This provides another example of some documented effects in a middle income country. Like many of the available examples of evaluated programs, this was a single-community model, which carries less evidentiary weight than studies with one or more control communities. Nonetheless, this study demonstrated the ability to achieve culturally appropriate adaptations of the print materials used in the Stanford Five City Project.

    This is an important lesson about the potential for transferability of materials tested in high income countries. This was accompanied by a country-wide contest and different local interventions sports events, outdoor family picnics. Questionnaires administered to the participants of the contest and more than 1, people in the Polish population showed increased awareness of low physical activity as a problem. In addition, almost 60 percent of participants reported increased frequency and duration of exercise during the campaign Ruszkowska-Majzel and Drygas, To achieve these objectives, the program organized three main types of interventions: The program succeeded in obtaining significant media coverage: As described in the previous section, an annual survey carried out over 4 years showed increased self-reported levels of physical activity Matsudo et al.

    Although evidence is limited from CVD -related programs in low and middle income countries, there are evaluations of programs in high income countries that offer some lessons for designing and implementing programs in low and middle income countries. 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.

    Some of these programs whether they address a single risk factor or multiple risk factors make communication a central or the central component of the intervention. Others make use of communication as one component of a multicomponent intervention. Even from these high income country programs the evidence is mixed, but a few general conclusions can be drawn.

    Tobacco Use There is substantial evidence in support of youth anti-tobacco communication programs, which is described in more detail in Chapter 6 Wakefield et al.

    There is also some evidence, particularly time-series evidence, supporting the influence of communication on adult smoking National Cancer Institute, A detailed synthesis of evidence on the effectiveness of media strategies employed in tobacco control campaigns, including marketing and advertising and news and entertainment media, can be found elsewhere and is not repeated here National Cancer Institute, In addition to tobacco control campaigns, there is good reason to believe that important reductions in tobacco use in part reflect deliberate efforts by the antitobacco movement to shift public opinion to recognize the dangers of secondhand smoke, to publicize the deliberate efforts by the tobacco industry to deceive the public and addict children and young people, and to achieve recognition of the right to restrict the free exercise of individual smoking rights when they affect the health of others.

    These efforts often included deliberate efforts to shape media coverage of the tobacco issue, and to use that as a path to changing public policy Shafey et al. 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.

    Tobacco also offers an example of how communication can be used in ways that run counter to the promotion of health. For instance, the tobacco industry has used the media to promote tobacco products Sepe et al. Tobacco advertising has proliferated on the Internet, and pro-tobacco messages are widely available on social networking websites WHO, However, the media can also be effectively used for counter advertising, as has been demonstrated in different regions Emery et al.

    Moreover, controls on tobacco advertising and marketing can be effective if they are comprehensive, include both direct and indirect advertising and promotion, and are combined with other antitobacco efforts Frieden and Bloomberg, ; Pierce, ; Saffer and Chaloupka, Other Risk Factors There is some evidence in high income countries of the success of communication efforts in reducing salt consumption He and MacGregor, and improving awareness, treatment, and control of hypertension Roccella and Horan, There is less evidence for communication efforts alone to influence physical activity outcomes, particularly sustained physical activity changes Kahn et al.

    There is also some credible evidence for the effects of communication programs targeted to multiple CVD -related risk factors Schooler et al. Six successful community-based, multilevel, multifactor CVD prevention projects in high income countries in the s and s had effects that can be attributed largely to their use of a mass media health communication approach, which is the aspect of these programs discussed here.

    These projects are also discussed later in this chapter in the section on community-based programs. They were done in the United States, Finland, Australia, Switzerland, and Italy and have been reviewed extensively elsewhere Schooler et al.

    The North Karelia project in Finland continued for many years and, after its successes on all CVD risk factors during the first 5 years, its methods were applied throughout Finland and culminated in major declines in CVD mortality Puska et al. 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.

    The Stanford follow-on study the Five City Project showed relatively large effects on smoking and blood pressure, with somewhat lesser effects on overall risk than in the previous Three Community Study, and no effect on body weight Altman et al. Indeed, the North Karelia program and Three Community Study galvanized substantial further major trials and worldwide consideration of community-focused programs to address CVD burdens.

    Across the major projects that followed, including CORIS in South Africa, there has been replication of reductions in smoking and blood pressure in all seven projects, cholesterol in three, and body weight in two Schooler et al. These replications provide evidence that rather small cities and towns in high income settings appear to have responded well in their risk-factor change to educational programs based largely on mass media.

    In contrast, two other large programs that began somewhat later, in the mids, the Minnesota Heart Health Project and the Pawtucket Heart Health Project in Rhode Island, did not show appreciable effects Carleton et al. A likely reason for the lack of effect in the latter two programs is their relative lack Luepker et al.

    Other subsequent studies in Europe also tended to have greater success when extensive broadcast and print media were used Breckenkamp et al. These programs are also discussed again in the community interventions section below. The earlier studies, done in the s and early s, reflect the possibilities for mass education at that time, when radio and newspapers were a more important news source than at present, and while the trends for risk-factor levels and CVD events were beginning to decline.

    It was also a time before major changes had occurred in smoking rates, before the messages became more commonplace in the settings where they were implemented, and before the relatively easy changes in diet had occurred for many in the target populations. These studies also preceded the expansion of many of the broad drivers of CVD risk.

    Therefore, these earlier projects may have faced fewer obstacles to change than might be faced earlier or later in the epidemiological transition cycles. Even when communication programs in high income countries have demonstrated success, these programs may be difficult to generalize to developing-country contexts. Because there are so few models of CVD -related communication programs in low and middle income countries, it is worth looking to programs with evidence of effectiveness in these settings that have been targeted to other health-related behaviors for possible models of design and implementation, especially those programs that target outcomes that similarly require sustained behavioral change.

    There is a rapidly growing evidence base for communications in low and middle income countries related to a range of health issues. For example, there is credible evidence for communication program effects on child survival-related outcomes including immunization a repeated behavior requiring parents to bring their children to a clinic or other site , use of rehydration solutions for diarrheal disease a repeated behavior undertaken at home in response to disease symptoms , and breastfeeding a behavior already often performed but the campaigns are meant to shape the behavior and extend it in time Hornik et al.

    Health communication campaigns require careful planning, ideally involving professionals with adequate training in health communication. Strong communication programs choose messages based on behavior change theory and reflect thorough knowledge of their target audience, in terms of both their structural context—how the old and new behaviors fit into their lives—and their cognitive response to the behavior.

    From the epidemiological perspective of preventing CVD , it is natural to look at the set of risk factors for CVD as interrelated and to consider how to construct a program that will influence all those factors. 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. The institutional actors relevant to each of those risk factors are distinct, and the way one might construct communication campaigns for each can be sharply different.

    For example, there may be different focus audiences; different motivations for adopting new behaviors; and different types of behaviors with regard to timing, difficulty, and opportunity to act.

    The lack of commonalities among, for example, quitting smoking, maintaining physical activity, or purchasing foods low in saturated fats makes it very difficult to design one communication strategy that will maximally affect all relevant behaviors. However, hybrid campaigns may be preferred in some cases for greater efficiency when, for example, the trained health education staff is already in place. A communication program can get exposure for the intended message through a number of means.

    For example, it can be required if the government controls media outlets. However, health authorities may not have access to the media even when it is government controlled. Exposure can also be purchased, although purchasing media time can be expensive especially because the audience needs to be reached repeatedly with the intended messages.

    If it is necessary to purchase media time, achieving high levels of exposure and maintaining exposure over time could become the most expensive element of communication programs.

    Low and middle income countries therefore have an economic incentive to seek strategies to ensure the availability of low-cost educational media programming. Another strategy for program exposure is to make news and attract coverage from media outlets e. However, media coverage may not be reliable and can be biased depending on factors such as whether media outlets are private entities or government agencies, and whether or not they operate within a system that guarantees freedom of the press.

    New communications technologies may also provide opportunities to reach people with health-promoting messages and research suggests that channels such as computer programs, websites, and videogames may reach audiences missed by traditional health communication Barrera et al. 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.

    One potential disadvantage to these kinds of digital media interventions at least as they have been implemented up until now is that they require audiences to seek out, have access to, and make continuing active use of the sources. This is unlike mass media interventions, which assume that the audience can be reached passively through its routine use of media.

    The requirement for active seeking is likely to limit the proportion of the unreached population who are engaged. This essential weakness runs up against a frequent goal of population-focused programs, which is to involve people who are not substantially motivated to act.

    Another critical aspect of effective communication programs, like most behavior change programs, is that they cannot be single, fixed interventions.

    Rather, they need to evolve in response to changes in their audiences, to changes in the context in which the behavior is to be performed, and to changes in the social expectations of those around the individual. A good program is not defined by its specific communication actions such as the number of messages on specific channels over a specific time period but by the methods employed for changing messages and diffusion channels as circumstances change over time.

    They are more analogous to what a practicing physician might do, ideally, in working with a patient whose symptoms and illness level, readiness to comply with recommendations, and family support change over time. Finally, capacity is a consideration that cannot be ignored since the capacity to design, implement, and evaluate interventions is generally weak in governments and local nongovernmental organizations in low and middle income countries.

    Additionally, in local markets the capacity to produce creative executions of messages is often weak. Formally addressing weak capacity must nearly always be an objective, even within the overarching objective of improved health outcomes. Decisions to implement communication campaigns also need to take into account the competition among health communication campaigns for resources, government attention, and target group attention Smith, Risk for CVD and related chronic diseases is increased by modifiable behavioral factors such as tobacco use; high intake of salt, sugar, saturated and transfats, and unhealthful oils; excessive total caloric intake; lack of consumption of fruits and vegetables; physical inactivity; and excessive alcohol consumption.

    For some of these risk factors, behavior modification and risk reduction have been successfully achieved through health promotion and prevention policies and communications programs in some countries and communities. However, most policies and programs with evidence of effectiveness have been developed and implemented in high income countries, and even in these settings little population-level progress has been made in some areas, such as reducing total calorie consumption and sedentary behavior.

    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.

    To expand current or introduce new population-wide efforts to promote 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 priorities.

    These policies may include laws, regulations, changes to fiscal policy, and incentives to encourage private-sector alignment. To maximize impact, efforts to introduce policies should be accompanied by sustained health communication campaigns focused on the same targets of intervention as the selected policies.

    One of the key components in reducing the burden of CVD is an adequate health system to implement the services needed to promote cardiovascular health and control CVD. The need for adequate health care delivery is of course not unique to CVD, although there are aspects of care that need to be disease specific, such as guidelines and training.

    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. This encompasses public health approaches such as those described in the preceding sections of this chapter as well as the delivery of clinical health care services to identify and treat patients at high risk and to manage patients with diagnosed disease.

    Although the definition of health systems is an area of evolving discussions in the global health community, there is emerging consensus around six key building blocks of health systems articulated by WHO: There is also agreement that one fundamental goal of a health system is to provide effective, responsive, equitable, and efficient care Committee on the State of the USA Health Indicators, ; Kruk and Freedman, ; Liu et al. Effective care is timely, safe, improves health outcomes, and continues until a health issue is resolved; or, in the case of chronic diseases, provides ongoing care as needed.

    This care should also be responsive to the needs of patients through not only the technical competence but also the interpersonal quality of providers. Equity in health systems means that essential health services are accessible to and utilized by all members of society—including those who are disadvantaged or marginalized—and that payment for care is equitable and does not result in catastrophic health care expenditures.

    This is especially critical for chronic diseases, which require ongoing expenditures on health services. Efficiency means that the health system yields the greatest health gains from the resources that are available and that the system functions productively Kruk and Freedman, There is considerable knowledge of clinical care solutions for treatment of acute cardiovascular events, for management of CVD , and for prevention in high-risk patients that target blood pressure control, blood lipid control, blood glucose control, and smoking cessation.

    The effectiveness of these clinical solutions themselves, such as pharmacological interventions, are highly generalizable across countries and, as described in more detail below, guidelines and established practices for these clinical solutions, especially pharmacological interventions, are well developed.

    However, knowing an optimal clinical intervention that works to improve health outcomes is not sufficient. Clinical interventions need to be delivered appropriately to the patients who need them, which requires an effective and equitable system of health care delivery. 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.

    These core elements include first, as a precondition, access and affordability. Other elements include guidelines or established practices that, when followed, lead to clinical success, routine assessment and improvement of quality of care, and monitoring of health status and health outcomes.

    Ideally, to enhance support for the behavior changes needed to maximize the effectiveness of clinical interventions, these clinical strategies would also be implemented in the context of the broader public health system, including population-based and community-based strategies described elsewhere in this chapter.

    Therefore, the work that lies ahead is in improving health care delivery to reduce the burden of CVD in developing countries. There are several challenges that will need to be confronted when building on known, effective interventions in order to adapt and scale up to achieve equitable health care delivery. One challenge is that interventions and delivery mechanisms must be context-specific rather than generic applications of blueprint, uniform approaches.

    A second is to optimize comprehensive, integrated health programs and greater capacity in a fashion that encourages innovation yet addresses equitable distribution Victora et al.

    It is also critical that the delivery of health care be equitable. Ensuring an equitable health system requires establishing goals specifically for improved coverage for the poor, rather than in entire populations; planning and health interventions directed toward the needs of the disadvantaged; and empowerment of poor stakeholders to be vitally involved in health system design and operation Gwatkin et al.

    Meeting these challenges, although formidable, will go a long way to ensure that the benefits of CVD control programs reach the greatest number of individuals in need. This section considers in more detail the components of health care delivery that will be crucial to successfully implementing effective clinical prevention and disease management for CVD. These include patient-level interventions, provider-level interventions to improve the quality of care, human resources and workforce, access to care, financing, access to essential medical products and technologies, integration of care delivery, and information technology.

    For some of these components, there is evidence specific to CVD-related interventions and programs or to approaches that can be generalized to CVD. For others, the discussion focuses on the principles in place in current efforts to strengthen health care delivery in general, which can be inclusive of CVD and related chronic diseases.

    The tools and strategies described are options for decision makers, managers, and clinicians that can be used to strengthen health care in different country contexts in order to deliver interventions effectively, efficiently, and equitably.

    With resource and infrastructure constraints in developing countries, the translation of these strategies into improved health care delivery remains a challenge. However, it is possible to deliver good-quality care, even in resource-poor settings. The best strategies are often incremental and gradual and need to encompass action and motivation at all levels, from national leadership to local support Jamison et al.

    In recent years, infectious disease programs in resource-limited settings have begun to build health care delivery infrastructure, especially in the development of laboratory capacity, supply chain management, quality assurance, and renovation of health centers Justman et al. Such developments have brought a growing appreciation for the opportunity to use infectious disease-related systems strengthening to strengthen health systems in general Jamison et al.

    Here, efforts to address chronic disease have the opportunity to build on, rather than duplicate, health systems strengthening efforts. 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. 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.

    Guidelines for delivering clinical interventions are discussed in the section on provider-level interventions, followed by a section on integrated disease management and chronic care strategies. Strategies to Change Behaviors Provider advice and education are among the interventions delivered to patients as part of health care. There is mixed evidence on the effectiveness of these approaches. Therefore, more work is needed to determine the appropriate role and best delivery mechanisms for these intervention approaches.

    A review by Kane et al. According to the review, incentives were effective 73 percent of the time and small incentives produced finite changes.

    While this is encouraging, the authors recognize that although economic incentives for prevention appear to work, their mechanisms are not well understood.

    For example, it is not clear what size of incentive is needed to yield a major sustained effect and there is less evidence that economic incentives can sustain the long-term lifestyle changes required for health promotion. 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.

    Participants were given a lockbox to aid in daily savings, with a weekly deposit collection service available. Within 1 week of the 6-month maturity date, participants took a urine test for nicotine and its primary metabolite, cotinine. If they passed, their money was returned; otherwise, their money was forfeited to charity. This effect persisted in surprise tests at 12 months, indicating that CARES produced lasting smoking cessation. Conditional cash transfers are another strategy to provide incentives to promote adoption of healthy behaviors.

    In conditional cash transfer programs a cash payment is made to an individual or family contingent upon complying with certain conditions, such as preventive health requirements and nutrition supplementation, education, and monitoring designed to improve health outcomes and promote positive behavior change Lagarde et al.

    Programs of this kind have been implemented by governments or other organizations in low and middle income countries with the goal of improving options for poor families through interventions in health, nutrition, and education. A recent review supports the potential for conditional cash transfer programs to increase the uptake of preventive services and encourage some preventive behaviors Lagarde et al.

    However, mixed results and insufficient evaluations make it difficult to draw conclusions about the potential that these programs have for wide-scale implementation.

    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. It was recently evaluated for its impact on several CVD -related outcomes, and the cash transfer component was associated with better outcomes in children Fernald et al.

    A doubling of cash transfers was associated with lower body mass index BMI for age percentile and lower prevalence of being overweight. Although this is a promising result, the cash component was also negatively associated with adult health outcomes Fernald et al.

    A doubling of cumulative cash transfers to the household was associated with higher BMI, higher diastolic blood pressure, and higher prevalence of overweight, grade I obesity, and grade II obesity while controlling for a wide range of covariates, including household composition at baseline.

    Clinical Interventions to Reduce Risk and Manage and Treat CVD There is considerable knowledge of effective clinical solutions to reduce risks for CVD using pharmaceutical interventions to lower blood pressure, blood lipids, and blood glucose and to assist in smoking cessation.

    There is also considerable technical knowledge on the diagnosis of CVD, treatment of acute cardiovascular events, and post-event treatment and management Fuster, There is particularly strong evidence on the pharmacological management and control of high blood pressure or hypertension , with a corresponding reduction in cardio- and cerebrovascular mortalities and morbidities Fuster, Low-cost generic blood pressure-lowering medications are in use for controlling hypertension throughout the world Pereira et al.

    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. Pharmacological interventions to lower blood cholesterol and its main components, such as LDL cholesterol and serum triglycerides, have also proven to be very effective in reducing the cardiovascular mortality and morbidity in populations around the world Adult Treatment Panel III, ; Brugts et al.

    Indeed, aspirin, beta-blockers, ACE -inhibitors, and lipid-lowering therapies all have established effectiveness to lower the risk of future vascular events in high-risk patients. The benefits of each of these pharmaceutical interventions appear to be largely independent so that when used together in appropriate patients it is reasonable to expect that about two-thirds to three-quarters of future vascular events could be prevented.

    Therefore, the potential gains from combined drug therapies are large Yusuf, The effectiveness and safety of this promising approach is currently being evaluated in a number of trials in both developed and developing countries Holt, ; Xavier et al. Adherence to clinical interventions Lack of adherence to medical treatment is a widespread problem that can lead to worsening health status and increased future treatment costs.

    Treatment regimens that are easy to administer, accessible, and affordable can help to increase adherence. Affordability and access are discussed in more detail as part of the next section on access to clinical interventions.

    Financial incentives are one possible intervention to improve adherence. In a review of financial incentives to enhance patient compliance, Giuffrida and Torgerson found that 10 of 11 studies showed improved patient compliance with the use of financial incentives. However, the clinical aim of each study was different and the incentives varied.

    It is also important to note that all the randomized studies reviewed were carried out in the United States; thus, the results may not translate directly to another country with a different socioeconomic and cultural context. Adherence to TB treatment is an analogous challenge that is common in developing countries and may provide transferable lessons for pharmaceutical interventions for CVD. In two pilot sites in Tajikistan, Project HOPE used food incentives to enhance adherence to a TB treatment regimen, enable patients to complete treatment without burden on their families, and increase access to directly observed therapy DOT for the poor and vulnerable.

    In this intervention, directly observed therapy was linked with the incentive of a nutritious meal. Among new sputum positive patients who received directly observed therapy, 88 percent of those receiving meal supplements completed treatment and were cured, compared to 63 percent in the non-supplemented patients Mohr et al.

    Access to clinical interventions An evidence-based, cost-effective primary health care-centered approach that includes targeting screening for high-risk individuals and the provision of treatment for symptom control is critical to ensuring access to appropriate CVD care.

    Risk-prediction tools that assess risk on the basis of multiple risk factors and CVD history have been developed in the United States and other high income countries Bannink, ; Kannel, , but cannot be assumed to be directly applicable to all populations and settings. For greatest feasibility, screening in resource-limited areas may need to focus on simple methods like family history, medical history and physical measurements such as blood pressure and body mass index or waist-to-hip ratio Joshi et al.

    As a necessary follow-up to effective screening, access to essential medicines, medical products, and technologies is a critical part of access to care. While there is better availability of these medicines in the private sector, the end-user cost of these private-sector medicines is often quite burdensome to the majority of low and middle income populations. In addition, the pharmaceutical component of CVD prevention requires daily, long-term medication treatment, rather than short-course or one-time therapy, which increases the lifetime financial burden.

    Individuals may not be able to afford continuous treatment for long periods of time. Given that anywhere from 50 to 90 percent of the cost of medicines are financed through individual out-of-pocket payments in low and middle income countries Quick et al. 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. Several possible initiatives could potentially help address this problem, although the potential costs of these are difficult to estimate.

    As described above, the polypill, although not yet evaluated, is an attractive option that could be administered to a broad range of patients, especially if manufactured with generic components.

    If proven safe and effective, this has the potential to be a pragmatic response to the need for both simplified and affordable treatment regimens in low income countries with weak health systems Wald and Law, ; Yusuf, Another initiative to help address costs is generic substitution policies, which allow for generic medications to be offered as an alternative to more expensive brand-name medications Andersson et al.

    Elimination of tariffs on medicines, generally a regressive form of taxation, could also increase the equitable access to essential CVD medicines without significant impact on government revenues Olcay and Laing, In addition, negotiations with pharmaceutical companies have led to decreases in the price of anti-retroviral medications for HIV in low and middle income countries Borght et al.

    New advocacy and private-sector collaboration could lead to improved affordability of medicines for CVD in low and middle income countries. Government-sponsored health insurance schemes can also reduce the end-user cost of both drugs and other health services, as has been done in Rwanda, although this strategy still faces concerns about financial sustainability and availability of services and medicines.

    Health financing mechanisms are discussed later in this chapter Twahirwa, Finally, improved drug distribution and procurement efficiency has the potential to make drugs more readily available through the public system and affordable through the private system Joshi et al.

    The delivery of drugs, including statins, antihypertensives, nicotine replacement, or a newly created polypill to low-resource settings in a manner timely and reliable enough to maintain individual treatment regimens is an enormous logistical challenge. The strategies employed by the Supply Chain Management System include combining orders to purchase at wholesale rates, warehousing and distribution through regional distribution centers, preventing product expiration through inventory management that focuses on stock rotation and monitoring, forecasting demand and anticipating country needs, and benefiting from the establishment of long-term contracts Supply Chain Management System, These strategies could all potentially be adopted to improve CVD drug delivery.

    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. While each of these agencies expressly endorses coordination wherever possible, local actors still must balance the needs of distinct international funders The Global Fund, ; Partnership for Supply Chain Management Systems, In order not to compound this problem, it is important for the global CVD community to identify ways to work within or help adapt existing frameworks and supply chains.

    In addition to the existing efforts driven by global health organizations, extensive research and efficiency improvement efforts have also been undertaken by the private sector as businesses expand into global markets, and these strategies may offer uncommon insights that can benefit CVD initiatives Accenture, ; Council of Supply Chain Management Professionals, ; Kinaxis, While supply chain systems have grown steadily over the past decade, there is still a great deal of infrastructure and capacity yet to be developed.

    Ensuring that CVD medications are included during the planning and design phases of these new endeavors is a positive opportunity in which the global CVD community could take an important leadership role.

    As with medicines, CVD -related technologies—diagnostics and interventions—have the potential to contribute greatly to the control of global CVD; however, an effort equal in energy and intensity must be made to ensure equitable distribution and access to these technologies as they develop and proliferate.

    However, for diagnostic technologies to make any noticeable impact on CVD mortality, they need to be suitable to and affordable in the developing world, and there needs to be sufficient provision of health care following diagnosis, or the improved ability to correctly identify patients will be of little use.

    Some of these new technologies, such as portable electrocardiogram machines, are being produced or are under development in health technology companies in high income countries.

    They are being rolled out primarily for middle-income developing markets, but are already spreading more widely to poor countries, at least to segments of the population that can afford them Immelt et al.

    For example, it has been shown that poor patients in India suffer higher mortality after acute coronary syndromes, but that this mortality difference is eliminated after controlling for access to treatments Xavier et al. Thus, in some countries improving access to essential CVD -related services within broader efforts to improve access and maximize the equitable use of existing health systems infrastructure will likely enhance the role of technology for diagnosis and treatment, even without costly efforts specifically to increase technological capacity within a country.

    There are three main aspects of quality: Quality improvement strategies that act directly on provider behavior may focus on two aspects of performance—technical and interpersonal.

    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, Like the patient-level interventions described in the previous section, these approaches need to incorporate sufficient CVD specificity to provide relevant technical knowledge, although the strategies to deliver technical performance improvements can be generalized in a chronic disease model.

    Competence in this area is particularly important for CVD and other diseases that require chronic care and long-term relationships with providers. Establishing norms and codes of conduct, and the provision of supervision and basic amenities, are effective methods for increasing interpersonal performance Taskforce on Innovative International Financing for Health Systems Working Group 1, The strategies to improve quality of care by changing provider behavior described below include guidelines, disease management programs, audit and feedback on performance, public reporting, and performance incentive programs such as pay for performance.

    This is an area of quality improvement that has become well established in high income countries, but is much less well developed in low and middle income countries. A review of quality improvement intervention studies in low and middle income countries suggests that dissemination of guidelines alone is not effective, but that supervision and audit with feedback show more promise, as well as systems interventions at the level of the hospital or clinic.

    In addition, interventions with multiple components are likely to be more effective than single components Rowe et al. However, the review acknowledged the limited information on strategies to improve performance in low and middle income countries. There is a need for better understanding of the determinants of provider performance, better methods to measure performance, high quality studies to assess long-term effectiveness and costs, and a better understanding of the extent to which results for one setting and area of care can be applied to others Rowe et al.

    This knowledge gap is particularly striking for interventions related to improving CVD -related care in developing countries. 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.

    In principle, these existing, well-established guidelines describe effective care that should be highly transferable across settings.

    Physical Activity and Cardiovascular Disease: How Much is Enough?

    An increased risk of cardiovascular diseases, such as myocardial infarction, stroke Myocardial infarction. Pericardial disease. Valvular abnormalities, 5 Cardiovascular diseases – prevention and control. 2. Arteriosclerosis – prevention and control. 3. Risk factors. 4. Risk assessment. 5. Guidelines. I. World Health. Patients with rheumatoid arthritis (RA) have an increased risk of developing cardiovascular disease (CVD) and CVD-related mortality compared with the.

    Eat a healthy, balanced diet



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