Abstract and Introduction
Abstract
Cardiovascular disease (CVD) is the leading cause of mortality worldwide, with more than 80% of CVD deaths occurring in low- and middle-income countries (LMICs). There have been several calls for action to address the global burden of CVD, but there remains insufficient investment in and implementation of CVD prevention and disease management efforts in LMICs. To catalyze the action needed to control global CVD, the Institute of Medicine recently produced a report, Promoting Cardiovascular Health in the Developing World A Critical Challenge to Achieve Global Health. This paper presents a commentary of the Institute of Medicine's report, focusing specifically on the intersectoral nature of intervention approaches required to promote global cardiovascular health. We describe 3 primary domains of intervention to control global CVD: 1) policy approaches; 2) health communication programs; and 3) healthcare delivery interventions. We argue that the intersectoral nature of global CVD interventions should ideally occur at 2 levels: first, all 3 domains of intervention must be activated and engaged simultaneously, rather than only 1 domain at a time; and second, within each domain, a synergistic combination of interventions must be implemented. A diversity of public and private sector actors, representing multiple sectors such as health, agriculture, urban planning, transportation, finance, broadcasting, education, and the food and pharmaceutical industries, will be required to collaborate for policies, programs, and interventions to be optimally aligned. Improved control of global CVD is eminently possible but requires an intersectoral approach involving a diversity of actors and stakeholders.
Introduction
Cardiovascular disease (CVD) is well established as one of the leading causes of death worldwide, with more than 80% of all CVD-related deaths now occurring in low- and middle-income countries (LMICs). There have been several calls for action to address the global burden of CVD, but there remains insufficient investment in and implementation of CVD prevention and disease management efforts in LMICs. To catalyze the action needed to control global CVD, the Institute of Medicine has produced a report entitled Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. A key feature of the committee's report is that the interventions to control global CVD should be intersectoral, extending beyond the direct domain of the health sector to involve multiple sectors of society, both public and private, and at both the population and individual levels. This paper presents a commentary of the Institute of Medicine's report specifically related to the intervention approaches that can be pursued, focusing on the intersectoral nature of these interventions that is required to promote global cardiovascular health. Macro-level, intersectoral interventions are often difficult to implement successfully. Therefore, the challenge will be to adopt innovative and robust implementation approaches that take into account specific characteristics of the sociopolitical environment in different countries to find the optimal opportunities for success.
The determinants of the global CVD epidemic are multifactorial (Fig. 1). Although the proximate risk factors for CVD are biological (hypertension, dyslipidemia, and diabetes) and behavioral (diet, physical activity, and tobacco), these risk factors are influenced by more "upstream" and "structural" factors such as globalization, demographic change, sociopolitical determinants, social inequality, education, and cultural norms. Thus, an intersectoral approach is required to address the multifactorial etiology of CVD.
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Figure 1.
Intersectoral Approach to Control Global Cardiovascular Disease
Multifactorial determinants of global cardiovascular disease and 3 domains of intersectoral intervention.
Figure from Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health by the National Academy of Sciences and used with permission, courtesy of the National Academies Press, Washington, DC.
As shown in Figure 1, the 3 primary domains of intervention to control global CVD are: 1) policy approaches; 2) health communication programs; and 3) healthcare delivery interventions. The intersectoral nature of global CVD interventions should ideally occur at 2 levels: first, all 3 domains of intervention must be activated and engaged simultaneously, rather than only 1 domain at a time; second, within each domain, a synergistic combination of interventions must be implemented. A diversity of public and private sector actors, representing multiple sectors such as health, agriculture, urban planning, transportation, finance, broadcasting, education, and the food and pharmaceutical industries, will be required to collaborate for policies, programs, and interventions to be optimally aligned. This action will provide the foundation for creating and maintaining conditions that promote cardiovascular health.
Policy strategies at the global, national, and local levels have great potential for creating environments that enable individuals to make and maintain healthful choices. Policy tools include financial, legal, regulatory, and trade measures. Tobacco control is a well-established success story of CVD-related policy and demonstrates the impact possible from adopting an intersectoral approach. In particular, the World Health Organization Framework Convention on Tobacco Control, the first international treaty dedicated to a health issue, emphasizes the importance of simultaneous implementation of comprehensive tobacco policies. These include taxation on tobacco products, smoking bans in public places, restrictions on tobacco advertising, counteradvertising, regulations on packaging and labeling of tobacco products, public awareness campaigns, health education initiatives, tobacco cessation services, restrictions on tobacco trade and sales, and support for alternative economic activities for tobacco producers. Similar intersectoral policy approaches can be applied to food and agriculture policy, environmental legislation, and urban planning, all of which have profound impact on the choices available to individuals regarding healthy behaviors. Intersectoral and comprehensive policy approaches are not without their risks and difficulties. Creating collaboration and agreement among different government agencies and institutions is not always straightforward. In addition, developing policy is insufficient: implementation and enforcement is critical and often requires negotiation, compromise, creative financing, and transparent accountability. Despite the successes of the Framework Convention on Tobacco Control, more than 20% of signatory countries have yet to establish a national tobacco-control coordinating mechanism, and implementation of tobacco control policies remains a challenge in many countries.
Health communication programs, which enhance the knowledge, motivation, and skills of individuals and their communities, are by necessity intersectoral, involving multiple partners and stakeholders. Health communication initiatives can involve the mass media and other large-scale public communication strategies as well as communication programs implemented in community settings. Successful communication programs recognize that health behaviors are influenced by socioeconomic, political, and cultural factors, and that interventions are required at multiple interdependent settings and levels. Thus, a combination of mass media, social marketing, community mobilization, empowerment and participatory approaches, enhancement of knowledge and behavior diffusion networks, and access to healthy choices can potentially maximize individuals' capacity to act on increased knowledge and awareness. For instance, community-based health communication interventions related to dietary changes are especially successful when individuals simultaneously have increased access to healthy food choices. Targeted communication strategies that are coordinated and aligned with the implementation of policy strategies have the potential to not only promote healthy behaviors but also build public support for policy changes. However, care must be taken in targeting, designing, and implementing both mass media and community-based health communication initiatives, as the evidence for the effectiveness of targeting multiple risk factors and affecting cardiovascular disease outcomes is not conclusive, and there have been limited evaluations in LMICs. Evaluation of communication efforts in both mass media and community settings, as well as further research using innovative and novel communication strategies, are required to determine the optimal approach in LMICs.
Interventions to improve healthcare delivery—such as strengthening health systems, improving quality of care, optimizing human resources for health, establishing secure supply chains of drugs and technology, and promoting equitable access to care—are crucial to improve the preventive, diagnostic, therapeutic, and rehabilitative services available to the population. Rather than focusing on vertical, disease-specific programs, a "diagonal" approach should be pursued in which CVD-related healthcare delivery should be integrated into a broad-based approach to health systems' strengthening and promotion of primary care services. Involvement of multiple stakeholders, including the private sector such as pharmaceutical and device companies, will be required to work toward equitable access to affordable health services, essential medicines, diagnostics, and technologies for prevention and treatment of CVD. To maximize the effectiveness of interventions to improve healthcare delivery (both clinical and behavioral), they should be implemented in the context of broader population-level policy changes and community-level programs.
In summary, each domain of intervention—policy approaches, health communication programs, and healthcare delivery—is likely to have maximal positive impact when an intersectoral approach is undertaken. In addition, the effectiveness of these 3 domains of intervention can be further enhanced when interventions are synergistically linked across domains and mutually reinforced. Thus, coordination of interventions among these 3 domains is critical to creating enabling environments, maximizing healthy choices, and empowering individuals to adopt health-promoting behaviors. Given the significant and growing burden of CVD in LMICs, and in light of the upcoming United Nations high-level, head-of-state meeting at the General Assembly in September 2011, which will focus on chronic noncommunicable diseases, it is particularly timely and important to recognize the need for intersectoral interventions to promote cardiovascular health as a critical component of global health initiatives in general.