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Public health action programs: past and future
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Monday 10 October 1994: Workshop Abstracts W2 Risk factors, prevention programs and strategies to improve compliance
W2 RISK FACTORS, PREVENTION PROGRAMS AND STRATEGIES TO IMPROVE COMPLIANCE Five-year risk factor trends in MONICA study populations. The WHO-MONICA Project m, Kuulasmaa K, Tuomilehto J. Evans A, Dobson A, Programa Cronicat, Hospital de Sant Pau, Pare Glare 167, 08025 Barcelona, Spain
The WHO-MONICA Project is a ten-year study to measure trends in cardiovascular mortality and coronary heart disease and cerebrovascular disease and relate them to known risk factors, daily living habits, health care or major socioeconomic features measured at the same time in defined communities in different countries. Five-year trends of coronary risk factors were studied for men and women aged 35-64 in all MONICA populations fulfilling quality control criteria, using data from the baseline and second independent random sample surveys carried out between the mid and late 1980s. Measurement methods followed the WHOMONICA manual of operations. Age- and sex-specific annual changes were estimated by regression, and age standardization was calculated using the world standard population weights. Mean systolic blood pressure decreased in most populations; it increased in 7 out of 30 populations in men, but only in 2 populations in women. The change ranged from -13 to +4.4 mmHg over the 5-year period. Mean total cholesterol remained basically unchanged in the 25 populations studied, with only two populations showing a significant upward trend among men. Prevalence of obesity increased in all populations except one, although the increase was statistically significant only in 6 populations. Among men, smoking prevalence declined in the majority of populations, although in women it increased in half of the populations, especially where prevalences were originally low. These data show that continuous monitoring of risk factors is required to evaluate the need for and results of interventions, especially in populations showing increasing trends in risk factors.
Victoria Declaration on Heart Health FarquharJW, Stanford Center for Research in Disease Prevention, Stanford Medical School, Palo Alto, CA 94304-1825,
USA
The Declaration is a policy blueprint and a consensus document for prevention of CVD on a global scale. It was issued by the Advisory Board of the International Heart Health Conference which consisted of representatives of 21 international health organization and agencies (Victoria, B.C., Canada, 1992). The Declaration is addressed, among other, to governments, to the research community, health professionals, voluntary health organizations and the private sector. Its 64 recommendations span population groups, risk factor reduction issues and strategies for prevention. The hallmark of the document is the endorsement of a public health approach as a key strategy. Epidemiological studies suggest th‘atwidespread prevalence of abnormal blood lipid levels is a precondition for the CVD epidemic: 11 recommendations are aimed at correcting abnormal lipid levels and improving dietary practices. The Board recommended decisive actions towards the eradication of smoking habits. One recommendation fosters a ban on advertising and coercive export trade policies for tobacco. Emphasis is placed on international collaboration and assistance to support developing countries in the development of infrastructures for health promotion and disease prevention. The declaration has been translated into 10 languages and it has been widely endorsed. A 35member international Implementation Committee has been created to advocate, establish appropriate partnerships and encourage activities to make the recommendations a reality. A review of accomplishments will take place at the Second International Heart Health Conference (Barcelona, May, 1995). Strategies to improve compliance and quality of life White I-IQ, Cardiol Dept., Green Lane Hosp., Epsom, Auckland 1003, New Zealand
Public health action programs: past and future Muntoni S, Centro per le Malattie Dismetaboliche e [‘Artetiosclerosi, 23/29 Viale Merello, 09123 Cagliari, Italy
Atherosclerotic cardiovascular diseases (CVD) and, in particular, coronary heart disease and stroke are the leading causes of mortality and disability in developed countries. A good international consensus exists on the preventability of CVD, inasmuch as the main risk factors for them have much of their origin determined by powerful cultural forces and, therefore, they can be modified by promoting proper changes in lifestyle at the population level. Development of a strategy for primary prevention of CVD and other chronic diseases has to pass through three phases: phase 1, observational studies on risk factors; phase 2, intervention trials; phase 3, public health action. The latter, based on a combination of the high-risk and population strategy, implies harmonization of not less than five issues: scientific-ethical basis, cost-effectiveness, political authorities’ involvement, public financial support, resort to communication media and techniques. When carried out at the local or regional level, transferability to the national level should also be a feature of the model program. Future public initiatives of CVD prevention and health promotion will have to rely on both the moral and financial support of governments, in order to ensure their institutionalization and replication. Funds needed are not excessive, inasmuch as the community-based approach is the most cost-effective of all categories of medical expenditure, especially as it provides for a simultaneous prevention of disorders, as many chronic diseases share some risk factors.
Despite the development of national guidelines for screening and treatment of dyslipidemia, there appears to be. poor institution of these recommendations by practicing physicians, and some evidence of poor patient compliance. After 1 year, compliance with lipid-modifying drugs may be as low as 20% despite a low incidence of side-effects attributable to stopping the medication. A major factor appears to be lack of awareness by patients that therapy must be lifelong. National guidelines have been shown to increase screening rates, including screening for compliance, but contradictory comment by opinion leaders undermines guidelines’ credibility. Involvement of physicians in transmitting information to their colleagues may negate feelings of outside interference in their practice. Following the publication of the New Zealand guidelines for the management of dyslipidemia which focus on absolute risk, the National Heart Foundation therefore instituted a program of ‘teachers teaching teachers’. Members of the committee which wrote the guidelines discussed with leading physicians how to have interactive session with other physicians, who then had similar sessions with general practitioners. Although further basic and clinical trial evidence is required, a very important factor for improving patient care is to incorporate new knowledge rapidly into routine practice and to ensure that high levels of compliance with the best current advice and treatment are achieved. Approach to improve patient compliance s Dept. of Pharmacol. and Med., Univ. of Minnesota, Minneapolis, MN 55455, USA
Atherosclerosis X, Montreal, October 1994
Monday 10 October 1994: Workshop Abstracts W2 Risk factors, prevention programs and strategies to improve compliance
W2 RISK FACTORS, PREVENTION PROGRAMS AND STRATEGIES TO IMPROVE COMPLIANCE Five-year risk factor trends in MONICA study populations. The WHO-MONICA Project m, Kuulasmaa K, Tuomilehto J. Evans A, Dobson A, Programa Cronicat, Hospital de Sant Pau, Pare Glare 167, 08025 Barcelona, Spain
The WHO-MONICA Project is a ten-year study to measure trends in cardiovascular mortality and coronary heart disease and cerebrovascular disease and relate them to known risk factors, daily living habits, health care or major socioeconomic features measured at the same time in defined communities in different countries. Five-year trends of coronary risk factors were studied for men and women aged 35-64 in all MONICA populations fulfilling quality control criteria, using data from the baseline and second independent random sample surveys carried out between the mid and late 1980s. Measurement methods followed the WHOMONICA manual of operations. Age- and sex-specific annual changes were estimated by regression, and age standardization was calculated using the world standard population weights. Mean systolic blood pressure decreased in most populations; it increased in 7 out of 30 populations in men, but only in 2 populations in women. The change ranged from -13 to +4.4 mmHg over the 5-year period. Mean total cholesterol remained basically unchanged in the 25 populations studied, with only two populations showing a significant upward trend among men. Prevalence of obesity increased in all populations except one, although the increase was statistically significant only in 6 populations. Among men, smoking prevalence declined in the majority of populations, although in women it increased in half of the populations, especially where prevalences were originally low. These data show that continuous monitoring of risk factors is required to evaluate the need for and results of interventions, especially in populations showing increasing trends in risk factors.
Victoria Declaration on Heart Health FarquharJW, Stanford Center for Research in Disease Prevention, Stanford Medical School, Palo Alto, CA 94304-1825,
USA
The Declaration is a policy blueprint and a consensus document for prevention of CVD on a global scale. It was issued by the Advisory Board of the International Heart Health Conference which consisted of representatives of 21 international health organization and agencies (Victoria, B.C., Canada, 1992). The Declaration is addressed, among other, to governments, to the research community, health professionals, voluntary health organizations and the private sector. Its 64 recommendations span population groups, risk factor reduction issues and strategies for prevention. The hallmark of the document is the endorsement of a public health approach as a key strategy. Epidemiological studies suggest th‘atwidespread prevalence of abnormal blood lipid levels is a precondition for the CVD epidemic: 11 recommendations are aimed at correcting abnormal lipid levels and improving dietary practices. The Board recommended decisive actions towards the eradication of smoking habits. One recommendation fosters a ban on advertising and coercive export trade policies for tobacco. Emphasis is placed on international collaboration and assistance to support developing countries in the development of infrastructures for health promotion and disease prevention. The declaration has been translated into 10 languages and it has been widely endorsed. A 35member international Implementation Committee has been created to advocate, establish appropriate partnerships and encourage activities to make the recommendations a reality. A review of accomplishments will take place at the Second International Heart Health Conference (Barcelona, May, 1995). Strategies to improve compliance and quality of life White I-IQ, Cardiol Dept., Green Lane Hosp., Epsom, Auckland 1003, New Zealand
Public health action programs: past and future Muntoni S, Centro per le Malattie Dismetaboliche e [‘Artetiosclerosi, 23/29 Viale Merello, 09123 Cagliari, Italy
Atherosclerotic cardiovascular diseases (CVD) and, in particular, coronary heart disease and stroke are the leading causes of mortality and disability in developed countries. A good international consensus exists on the preventability of CVD, inasmuch as the main risk factors for them have much of their origin determined by powerful cultural forces and, therefore, they can be modified by promoting proper changes in lifestyle at the population level. Development of a strategy for primary prevention of CVD and other chronic diseases has to pass through three phases: phase 1, observational studies on risk factors; phase 2, intervention trials; phase 3, public health action. The latter, based on a combination of the high-risk and population strategy, implies harmonization of not less than five issues: scientific-ethical basis, cost-effectiveness, political authorities’ involvement, public financial support, resort to communication media and techniques. When carried out at the local or regional level, transferability to the national level should also be a feature of the model program. Future public initiatives of CVD prevention and health promotion will have to rely on both the moral and financial support of governments, in order to ensure their institutionalization and replication. Funds needed are not excessive, inasmuch as the community-based approach is the most cost-effective of all categories of medical expenditure, especially as it provides for a simultaneous prevention of disorders, as many chronic diseases share some risk factors.
Despite the development of national guidelines for screening and treatment of dyslipidemia, there appears to be. poor institution of these recommendations by practicing physicians, and some evidence of poor patient compliance. After 1 year, compliance with lipid-modifying drugs may be as low as 20% despite a low incidence of side-effects attributable to stopping the medication. A major factor appears to be lack of awareness by patients that therapy must be lifelong. National guidelines have been shown to increase screening rates, including screening for compliance, but contradictory comment by opinion leaders undermines guidelines’ credibility. Involvement of physicians in transmitting information to their colleagues may negate feelings of outside interference in their practice. Following the publication of the New Zealand guidelines for the management of dyslipidemia which focus on absolute risk, the National Heart Foundation therefore instituted a program of ‘teachers teaching teachers’. Members of the committee which wrote the guidelines discussed with leading physicians how to have interactive session with other physicians, who then had similar sessions with general practitioners. Although further basic and clinical trial evidence is required, a very important factor for improving patient care is to incorporate new knowledge rapidly into routine practice and to ensure that high levels of compliance with the best current advice and treatment are achieved. Approach to improve patient compliance s Dept. of Pharmacol. and Med., Univ. of Minnesota, Minneapolis, MN 55455, USA
Atherosclerosis X, Montreal, October 1994