Research needs for an improved primary care response to chronic non‐communicable diseases in Africa

With non‐communicable diseases (NCDs) projected to become leading causes of morbidity and mortality in developing countries, research is needed to improve the primary care response, especially in sub‐Saharan Africa. This region has a particularly high double burden of communicable diseases and NCDs and the least resources for an effective response. There is a lack of good quality epidemiological data from diverse settings on chronic NCD burden in sub‐Saharan Africa, and the approach to primary care of people with chronic NCDs is currently often unstructured. The main primary care research needs are therefore firstly, epidemiological research to document the burden of chronic NCDs, and secondly, health system research to deliver the structured, programmatic, public health approach that has been proposed for the primary care of people with chronic NCDs. Documentation of the burden and trends of chronic NCDs and associated risk factors in different settings and different population groups is needed to enable health system planning for an improved primary care response. Key research issues in implementing the programmatic framework for an improved primary care response are how to (i) integrate screening and prevention within health delivery; (ii) validate the use of standard diagnostic protocols for NCD case‐finding among patients presenting to the local health facilities; (iii) improve the procurement and provision of standardised treatment and (iv) develop and implement a data collection system for standardised monitoring and evaluation of patient outcomes. Important research considerations include the following: selection of research sites and the particular NCDs targeted; research methodology; local research capacity; research collaborations; ethical issues; translating research findings into policy and practice and funding. Meeting the research needs for an improved health system response is crucial to deliver effective, affordable and equitable care for the millions of people with chronic NCDs in developing countries in Africa.     

Management of NCD in Low- and Middle-Income Countries

Noncommunicable disease (NCD), comprising cardiovascular disease, stroke, diabetes, and chronic obstructive pulmonary disease, are increasing in incidence rapidly in low- and middle-income countries (LMICs). Some patients have access to the same treatments available in high-income countries, but most do not, and different strategies are needed. Most research on noncommunicable diseases has been conducted in high-income countries, but the need for research in LMICs has been recognized. LMICs can learn from high-income countries, but they need to devise their own systems that emphasize primary care, the use of community health workers, and sometimes the use of mobile technology. The World Health Organization has identified “best buys” it advocates as interventions in LMICs. Non-laboratory-based risk scores can be used to identify those at high risk. Targeting interventions to those at high risk for developing diabetes has been shown to work in LMICs. Indoor cooking with biomass fuels is an important cause of chronic obstructive pulmonary disease in LMICs, and improved cookstoves with chimneys may be effective in the prevention of chronic diseases.     

Control and prevention of cardiovascular disease around the world

The situation regarding cardiovascular disease in different parts of the world is presented, and the prevalence and trends in main risk factors based on Omran's epidemiological transition model are reported. A World Heart Federation survey documenting the limited human and technical resources in some developing countries and inadequate use of these resources in others is discussed. This survey also shows that few countries have guidelines for the management of cardiovascular disease and its risk factors, and reveals a lack of relationship between the percentage of countries with guidelines and the importance of a given disease or risk factor. Because economic resources for health in highly populated developing countries are limited, preventive measures for cardiovascular disease and its risk factors must be combined with those for all other chronic diseases. We recommend the following actions: a). improve the use of facilities for the dissemination of information; b). create suitable conditions for the development of research in developing countries; c). incorporate into primary care the innovations proposed by the WHO in 2002 to control chronic diseases, and d). assist in the development of the program proposed by the World Heart Federation.     

Selective primary health care. XXV. Management priorities

Provision of the greatest health benefits for the greatest number in developing countries requires setting priorities which will differ in each country according to its existing infrastructure. All programs are based on the foundation of immunization, control of diarrheal diseases, family planning and primary health centers. One of the major barriers to introduction of equitable health care in inadequate management, particularly at the provincial and local levels. In many countries solutions have been introduced with incomplete data, problem definition and monitoring. Typically health delivery systems of industrialized countries have been duplicated, emphasizing tertiary care facilities and curative treatment. The smallpox eradication campaign demonstrated the importance of surveillance, evaluation, management and the power of management. Major considerations in selection of priority programs are the major disease problems in terms of morbidity, mortality and cost, the existing health system, and skills needed. Successful programs have been remarkable for high literacy, particularly female literacy, and social organization acting beyond the individual. Development of an immunization infrastructure is one of the most important primary health care priorities, and forms the basis of the skills needed to supply other types of primary care. Besides traditional health problems, developing countries will need to deal with emerging issues brought on by smoking, alcohol, vehicle crashes and industrial exposure as they make the transition to development.     

Patient self-management support: novel strategies in hypertension and heart disease

Cardiovascular diseases (CVDs) have become the leading cause of death and disability in most countries in the world. This article addresses how patient self-management is a crucial component of effective high-quality health care for hypertension and CVD. The patient must be a collaborator in this process, and methods of improving patients' ability and confidence for self-management are needed. Successful self-management programs have often supplemented the traditional patient-physician encounter by using nonphysician providers, remote patient encounters (telephone or Internet), group settings, and peer support for promoting self-management. Several factors need to be considered in self-management. Given the health care system's inability to achieve several quality indicators using traditional office-based physician visits, further consideration is needed to determine the degree to which these interventions and programs can be integrated into primary care, their effectiveness in different groups, and their sustainability for improving chronic disease care.     

Prevalence,predictors, and clinical consequences of medical adherence in IBD： How to improve it？

Inflammatory bowel diseases （IBD） are chronic diseases with a relapsing-remitting disease course necessitating lifelong treatment. However, non-adherence has been reported in over 40% of patients, especially those in remission taking maintenance therapies for IBD. The economical impact of non-adherence to medical therapy including absenteeism, hospitalization risk, and the health care costs in chronic conditions, is enormous. The causes of medication non-adherence are complex, where the patient-doctor relationship, treatment regimen, and other disease-related factors play key roles. Moreover, subjective assessment might underestimate adherence. Poor adherence may result in more frequent relapses, a disabling disease course, in ulcerative colitis, and an increased risk for colorectal cancer. Improving medication adherence in patients is an important challenge for physicians. Understanding the different patient types, the reasons given by patients for non-adherence, simpler and more convenient dosage regimens, dynamic communication within the health care team, a self-management package incorporating enhanced patient education and physician-patient interaction, and identifying the predictors of non-adherence will help devise suitable plans to optimize patient adherence. This editorial summarizes the available literature on frequency, predictors, clinical consequences, and strategies for improving medical adherence in patients with IBD.     

A novel approach to cardiovascular health by optimizing risk management (ANCHOR): a primary prevention initiative examining the impact of health risk factor assessment and management on cardiac wellness

Cardiovascular disease (CVD) represents an increasing burden to health care systems. Modifiable risk factors figure prominently in the population-attributable risk for premature coronary artery disease. Primary care is well placed to facilitate CVD risk improvement. We plan to evaluate the ability of a novel primary care intervention providing systematic risk factor screening, risk-weighted behavioural counselling and pharmacological intervention to achieve 2 objectives: (1) optimized management of global CVD risk of patients and (2) increased patient adherence to lifestyle and pharmaceutical interventions aimed at decreasing global CVD risk. A pre-post longitudinal prospective design with a nonrandomized comparison group is being undertaken in 2 geographically diverse primary care practices in Nova Scotia with differing reimbursement models. Participants will complete a readiness to change and pre-post health risk assessment (HRA), that will trigger a 1-year intervention individualized around risk and readiness. The primary outcome will be the proportion of participants with Framingham moderate and high-risk strata that reduce their absolute risk by 10% and 25%, respectively. The secondary outcome will be the proportion of moderate and high-risk participants who reduce their risk category. The impact of the intervention on clinical and behavioural variables will also be examined. Low risk participants will be separately analyzed. Data from participants unable to change from the high risk category because of diabetes mellitus or established atherosclerotic disease will also be analyzed separately, with changes in clinical measures from baseline being assessed. A health economic analysis is planned.     

Burden of non-communicable disease: Global overview

Non-communicable diseases continue to be important public health problems in the world, being responsible for sizeable mortality and morbidity. Non-communicable diseases (NCDs) are the leading causes of death and disability worldwide. In 2005 NCDs caused an estimated 35 million deaths, 60% of all deaths globally, with 80% in low income and middle-income countries and approximately 16 million deaths in people less than 70 years of age. Total deaths from NCDs are projected to increases by a further 17% over the next 10 years. Knowing the risk factors for chronic disease means that approximately 80% premature heart disease and stroke, 80% of Type 2 diabetes and 40% of cancers are preventable. Within next 20 years, NCDs will be responsible for virtually half of the global burden of disease in the developing countries. Risk factors, such as tobacco and alcohol use, improper nutrition and sedentary behavior contribute substantially to the development of NCDs, which are sweeping the entire globe, with an increasing trend mostly in developing countries where, the transition imposes more constraints to deal with an increasing burden of over population with existing communicable diseases overwhelmed with increasing NCDs in poorly maintained sanitation and environment.By 2020, it is predicted that these diseases will be causing seven out of every 10 deaths in developing countries. A major feature of the developmental transition is the rapid urbanization and the large shifts in population from rural to urban areas. Even the rural people are increasingly adapting urbanized lifestyle. The changing pattern of lifestyle leads to the development of obesity, stroke, stress, atherosclerosis, cancer and other NCDs.Considering the future burden of NCDs and our existing health care system we should emphasize the need to prioritize the prevention and control of NCDs. Our strategies should be directed to monitor the incidence of NCDs along with their risk factors. Some NCDs have their common risk factors which should be addressed with minimum cost but maximum output. The three key components of the strategy are surveillance, health promotion and primary prevention, and management and health care.According to the WHO criteria there are three steps for screening of NCDs. Step 1: Estimation population need through assessing the current risk profile and advocate for action. Step 2: Formulate and adopt NCD policy. Step 3: Identify policy implementation steps. Management of NCDs should be to increased awareness among the public regarding the signs and symptoms of the disease and its complications.Health promotion strategies, with a strong focus on disease prevention, are needed to empower people to act both individually and collectively to prevent risky behavior, and to create economic, political and environmental conditions that prevent NCDs and their risks. Risk trends need to be monitored and intervention strategies need to be evaluated with respect to their expected outcomes. Issues such as rapid population ageing, gender and income inequality, persistent poverty and the needs of developing countries require close consideration as they influence the prevalence of NCDs – and the success of interventions.     

Chronic kidney disease management--what can we learn from South African and Australian efforts?

BACKGROUND: The prevalence of chronic kidney disease is on the rise. Our objective is to describe two programs to improve the awareness and management of hypertension, renal disease, and diabetes in remote Australian Aboriginal and urban and periurban South African communities. We focus on how the Australian Aboriginal and South African Chronic Disease Outreach Programs have worked together. METHODS: The establishment of prevention programs in developing countries is a challenge. The paper evaluates these challenges, including accessing international aid. The programs advocate that regular integrated checks for chronic disease and their risk factors are essential elements of regular adult health care. Programs should be run by primary health workers, following algorithms for testing and treatment, and a backup provided by nurse coordinators. Constant evaluation is essential to develop community health profiles and adapt program structure. RESULTS: Both programs are discussed, including how they are organized to deliver preventative and treatment strategies. The challenges and adaptations required are outlined. CONCLUSIONS: It is the aim of the international kidney community to prevent chronic kidney disease. The South African and Australian groups highlight the need for a systematic and sustained approach to the management of chronic diseases to achieve this goal.     

Planning primary prevention of coronary disease

Effective prevention of the current annual $400 billion losses from atherosclerosis and cardiovascular disease (CVD) will require preventing primary causes rather than just decreasing signs and symptoms (risk factors) produced by those causes. All CVD risk factors predict a likelihood of CVD, but not all are causes of CVD. As a result, reducing some health risk assessment biomarkers may not appreciably reduce CVD and death. Careful review of molecular events connecting diets to death identifies two modifiable food imbalances that cause major chronic diseases in Americans. They are 1) imbalance between ingestion and expenditure of food energy, and 2) imbalance between omega-3 and omega-6 essential fatty acid levels in ingested foods. Health insurers could reduce costs and revolutionize preventive health care by monitoring omega-3 and omega-6 proportions in blood fatty acids and by using personalized interactive food choice software to adjust food intakes to fit individual preferences.     

Hypertension and chronic kidney disease in Asian populations

The countries of Asia are home to multiple ethnicities. There are ethnic differences in diet, culture, and attitudes towards health screening, access to care, and treatment of chronic diseases. Chronic kidney disease (CKD) and end‐stage kidney disease (ESKD) have rising incidence and prevalence due to increased affliction with non‐communicable diseases of diabetes and hypertension. To prevent the expensive complications of ESKD, one of the most important risk factors to control is hypertension in patients with CKD. We performed a narrative review on the prevalence of CKD in patients with hypertension, the prevalence and control of hypertension in patients with CKD, and the dietary sodium intake in CKD populations.     

Diabetes trends in Africa

Diabetes is an important cause of morbidity and mortality in Africa. Although a dramatic increase in disease burden is projected, it remains to be seen what effect the ongoing devastation of HIV disease will have on the epidemiology of such chronic diseases as diabetes. Recent data on type 2 diabetes prevalence indicate low rates in some rural populations, moderate rates similar to those in developed areas in some countries, and alarmingly high rates in others. The frequent observation of moderate to high prevalence of impaired glucose tolerance, particularly in populations with a low prevalence of diabetes, may indicate the early stage of a diabetes epidemic. Risk factors include urbanization, age, and family history of disease, as well as such modifiable risk factors as adiposity and physical inactivity. For type 1 diabetes, limited data indicate that the prevalence is low in sub-Saharan Africa and that onset occurs later in life there than in other parts of the world. Mortality associated with diabetes is unacceptably high and is disproportionately due to preventable acute metabolic and infective causes. With long duration of disease, there is a high frequency of hypertension and microvascular complications. The apparent low frequency of chronic macrovascular complications needs fuller documentation - as does the apparent high frequency of hypertension even in the non-diabetic population. Efforts to prevent this disease and its complications in Africa are impeded by inadequate health care infrastructure, inadequate supply of medications, absence of educational programs, and lack of available health care facilities and providers.     

Comprehensive Strategies for the Prevention and Control of Diabetes and Cardiovascular Diseases in Africa: Future Directions

The countries of the Sub Saharan African region have insufficient resources and healthcare systems that are poorly adapted to cope with the longstanding burden associated with communicable diseases and the ongoing HIV/AIDS pandemic. In addition, the rising burden of non-communicable diseases, including diabetes, cardiovascular diseases, and their risk factors, poses additional challenges. These countries need to urgently develop strategies to address these challenges of disease prevention and control. These strategies will require a new vision and more relevant and ‘suitable’ vocabulary in dealing with healthcare design, planning and implementation (using a cross-sectorial approach). Lessons learnt from the past (e.g. primary health care) in sub-Saharan Africa and other regions of the world may equally prove useful in developing strategies for the prevention and control of non-communicable diseases. Any potential strategy must emphasize the crucial role of economic, social, and environmental health determinants as well as the use of appropriate health technology.     

A population-based analysis of health behaviours, chronic diseases and associated costs

Health behaviours influence the future incidence of certain common chronic diseases and thus have an impact on health status and utilization of health care services and costs.We analyzed person-level data of the Albertan adult population from the Canadian Community Health Survey, Cycle 1.1 (2000) to determine health care costs associated with specific health behaviours (smoking, sub-optimal diet, physical inactivity) and chronic disease states (heart disease, diabetes, COPD). We found that 74.7 percent of the population exhibited one or more risk behaviours, while 10.5 percent had one or more of the chronic diseases of interest. Greater health care utilization and costs were noted in groups exhibiting risk behaviour and chronic disease states. Approximately 31 percent of health care costs in Alberta were attributable to people having one or more of the three chronic diseases. Our findings of higher health care costs incurred by those exhibiting unhealthy behaviour prior to development of disease, as well as by those with multiple co-existent diseases, are important indicators to guide future prevention and treatment strategies of chronic illness.     

Managing type 2 diabetes in Soweto—The South African Chronic Disease Outreach Program experience

Diabetes (DM) and its resultant complications are a problem worldwide, and especially in developing countries like South Africa (SA). Risk factors associated with DM are potentially modifiable, but DM control is poor. Problems in SA include high prevalence of morbidity from DM and hypertension (HTN), lack of recognition of the importance of chronic kidney disease (CKD), late presentation to health care services, lack of education of health providers and patients, and poor quality of care in primary health care settings (PHC). In response, there has been growing advocacy for prevention strategies and improved support and education for primary health care nurses (PHCNs). A Chronic Disease Outreach Program (CDOP), based on the chronic care model was used to follow patients with DM and HTN, support PHCN, and improve health systems for management in Soweto. A group of 257 DM patients and 186 PHCN were followed over 2 years, with the study including the evaluation of ‘functional’ and clinical outcomes, diary recordings outlining program challenges, and a questionnaire assessing PHCNs’ knowledge and education support, and the value of CDOP. CDOP was successful in supporting PHCNs, detecting patients with advanced disease, and ensuring early referral to a specialist center. It improved early detection and referral of high risk, poorly controlled patients and had an impact on PHCNs’ knowledge. Its weaknesses include poor follow up due to poor existing health systems and the programs’ inability to integrate into existing chronic disease services. The study also revealed an overworked, poorly supported, poorly educated and frustrated primary health care team.     

HIV, aging and continuity care: strengthening health systems to support services for noncommunicable diseases in low-income countries

Although health systems in most low-income countries largely provide episodic care for acute symptomatic conditions, many HIV programs have developed effective, locally owned and contextually appropriate policies, systems and tools to support chronic care services for persons living with HIV (PLWH). The continuity of care provided by such programs may be especially critical for older PLWH, who are at risk for more rapid progression of disease and are more likely to have complications of HIV and its treatment than their younger counterparts. Older PLWH are also more likely to have other chronic noncommunicable diseases (NCDs), including hypertension, diabetes, cancers and chronic lung disease. As the number of older PLWH rises, enhanced chronic care systems will be required to optimize their health and wellbeing. These systems, lessons and resources can also be leveraged to support the burgeoning numbers of HIV-negative individuals with chronic NCD in need of ongoing care.     

Cardiovascular Diseases and Diabetes as Economic and Developmental Challenges in Africa

Current estimates and projections suggest that the burden of cardiovascular diseases (CVDs), diabetes and related risk factors in African countries is important, somewhat unique and rapidly growing. Various segments of the population are affected; however, the group mostly affected is young adults residing in urban areas, and increasingly those in the low socioeconomic strata. The African milieu/environment is compounded by weak health systems, which are unable to cope with the looming double burden of communicable and chronic non-communicable diseases. This review discusses the economic and developmental challenges posed by CVDs and diabetes in countries in Africa. Using several lines of evidence, we demonstrate that the cost of care for major CVDs and diabetes is beyond the coping capacities of individuals, households, families and governments in most African countries. We have reviewed modeling studies by the International Diabetes Federation (IDF) and other major international agencies on the current and projected impact that CVDs and diabetes have on the economy and development of countries in the region. Locally, appropriate strategies to limit the impact of the conditions on the economies and development of countries in Africa are suggested and discussed. These include monitoring diseases and risk factors, and primordial, primary and secondary preventions implemented following a life-course perspective. Structural, logistic, human capacity and organizational challenges to be surmounted during the implementations of these strategies will be reviewed.     

Rheumatic fever and rheumatic heart disease in Bangladesh: A review

Rheumatic fever (RF) and rheumatic heart disease (RHD) are the most-common cardiovascular disease in young people aged <25 years, globally. They are important contributors to cardiovascular morbidity and mortality in Bangladesh. Classical risk factors, i.e. poverty, overcrowding, ignorance, and insufficient health care services were responsible for the high incidence and prevalence of these diseases over the last century. In concert with the progresses in socioeconomic indicators, advances in health sectors, improved public awareness, and antibiotic prophylaxis, acute RF came into control. However, chronic RHD continues to be prevalent, and the actual disease burden may be much higher. RHD predominantly affects the young adults, seriously incapacitates them, follows a protracted course, gets complicated because of delayed diagnosis and is sometimes maltreated. The treatment is often palliative and expensive. Large-scale epidemiological and clinical researches are needed to formulate evidence-based national policy to tackle this important public health issue in future.     

Epidemiology of Cardiovascular Disease in China and Opportunities for Improvement: JACC International

The burden of cardiovascular (CV) disease is very high in China, due to highly prevalent and poorly controlled risk factors resulting from changing sociodemographic structure and lifestyles in its large population. Rapid economic development and urbanization have been accompanied by changing patterns, expression, and management of CV disease. However, the health care system in China lacks a hierarchical structure, with a focus on treating acute diseases in hospital while ignoring long-term management, and primary health care is too weak to effectively control CV risk factors. To address these challenges, the Chinese central government has ensured health is a national priority and has introduced reforms that include implementing policies for a healthy environment, strengthening primary care, and improving affordability and accessibility within the health system. Turning the inverted pyramid of the health care system is essential in the ongoing battle against CV disease.     

Selenium status and cardiometabolic health: state of the evidence

Use of selenium enriched foods, supplements and fertilizers has increased markedly in recent years in the US and other Western countries because of the perception that the anti-oxidant properties of selenium could potentially reduce the risk of cancer and other chronic diseases. However, concern has been raised recently about possible adverse cardiometabolic effects of high selenium exposure, including an increased risk of diabetes and hyperlipidemia with high selenium intake. Hence, from a public health perspective, the relationship between selenium status and cardiometabolic health should be clarified in order to help guide consumers in their choices of nutritional supplements and enriched food products. Additional experimental evidence is needed to provide new insights into the role of selenium and of specific selenoproteins in human biology, especially to clarify the underlying mechanisms linking selenium to chronic disease endpoints. Further epidemiological studies and randomized clinical trials across populations with different selenium status should be conducted to determine the causal effect of selenium on cardiovascular disease and risk factors. Nevertheless, at the present time the widespread use of selenium supplements or other strategies that artificially increase selenium status above the level required for optimal selenoprotein activity is not justified and should not be encouraged.