Global burden of CVD
Non-communicable disease (NCDs) is a major health burden in developing countries and accounts for about 40 million deaths each year. The burden of four main types of NCDs such as cancer, chronic respiratory disease, diabetes and cancer is increasing not only in developing countries but also in low and middle income countries. About 80% of premature NCD death is caused by the above four types of NCDs and among them cardiovascular diseases (CVD) is the leading cause of death (World Health Organization 2017). This report is specifically focused on analyzing global trends related to prevalence and transmission of CVD as it is a great disease burden worldwide. It is a major cause of disability and contributes to escalating health care cost too (Bauer et al. 2014). Hence, to get an insight into ways to reduce disability and death due to CVD, critical examination of the occurrence and management of the condition is necessary. This report provides an insight into incidence rate of disease in developing countries and management of the condition particularly in UK and Ghana. An evaluation of preventive work contributing to assessment of risk and management of the condition and analysis of the health care system is also presented to understand the impact on population change.
CVD is regarded as global health issue because it is the leading cause of death and mortality worldwide. The WHO report suggests that people are mostly dying from CVD than any other disease. 17.7 million people die from CVD every year and among them, 17.4 million were caused due to coronary heart diseases. This accounts to about 31% of all global deaths (World Health Organization 2017). CVD related deaths are seen not only in developed countries but also in low and middle income countries. Hence, from this statistics, it can be said that burden of health care system is the largest due to the epidemic of CVD. It has been the reason for increase in health care cost, increased duration of hospital stay and loss of productivity of countries. It indicates the need for better preventive work and assessment of risk to control the prevalence of the disease condition (Joseph et al. 2017).
CVD is a class of heart disease consisting of coronoray artery disease, stroke, cardiomaypathy and many other disorders causes mainly by selected risk factors. Malambo et al. 2016). The characteristics and attributes of illness mainly involves disruption in the function of heart.. The pathophysiology of CVD involves four characteristics: heart dysfunction, vasculad dysfunction, For instance, in case of coronary heart disease, plaque buildup in the epithelial lining of arteries results in disruption in the supply of oxygen and nutrients to the blood. Lifestyle factors and work characteristics also acts as a major factor contributing to the risk of CVD. Several biological and social factors increase the risk of the disease (Thomas and Power 2009). All these factors create the pathyway for development of heart disorders.
Pathophysiology of CVD
Incidence rate and prevalence of the condition in developed and developing countries:
High incidence of CVD in developed and developing country is a challenge for the health care system because of increase in hospital admission and great burden in the management of the condition (Lackland and Weber 2015). For example in high come country like USA, about 92.1 million adults have at least 1 type of CVD, however the death rate has declined by 25.3% from 2004 to 2014 (Benjamin et al. 2017). According to 2017 heart disease statistics, one in every three deaths in US occur due to CVD and 92.1 million adults are living with some form of the disease. This has increased the direct and indirect cost of the disease considering both health expenditures and productivity lost (American Heart Association 2017). Canada is also one of the developed countries and heart disease is the leading cause of death in the country after cancer. According to the 2012-2013 data, 8.5% Canadian adults are living with hearts disease and 158, 700 adults are newly diagnosed with ischemic heart disease. Young adults between ages 40-60 years are found with hypertension, and blood cholesterol levels (Canada, 2012). Hence, developed countries are coping with increased challenges due to high incidence rate of heart diseases and low incidence rate of the acute, infectious diseases. There is a gradual shift in the mortality with regards to age pattern. There is an epidemiological transition of the cardiovascular disease from young adults to older ages.
There is a need to analyze the difference in prevalence rate in other developing countries too compared to developed countries. In Kenya, CVD is the leading cause of death and contributes to about 6-8% of deaths. This is also linked to high prevalence of hypertension in the last 20 years (Health.go.ke. 2015). UK is one of the developed countries and the updated CVD statistics for the country shows that 26% of deaths in UK occur due to CVD. Compared to US, the prevalence of the disease is much lower in UK (bhf.org.uk. 2018). However, this difference may because of population difference between the two countries too. In UK, about 7 million people are living with the disease and the rise in ageing population may increases the prevalence rate further in the future (bhf.org.uk. 2018). In contrast, Ghana is a less economically developed countries and Ofori-Asenso and Garcia (2016) has shown that compared to other countries, the sub-Saharan region is the only region where the CVD related death has increased. In UK, CVD accounted for 26% of all deaths in 2013 (bhf.org.uk. 2018). In African region, it accounted for 9.2% of all deaths in 2013. More than 50% of the death in Africa occurs in people above 30-69 years of age. It is also estimated that burden of CVD will rise and double by 2020 compared to 1990. Ghana has been identified as the second largest city with high rate of admission due to heart disease and stroke. In 2011, stroke was declared as the third leading cause of death in the city (Ofori-Asenso and Garcia 2016). There is a need to analyze the difference in management of CVD in developed and developing countries to see how treatment outcomes and preventive conditions different in these regions led to epidemiological transition.
CVD in developed and developing countries
Environmental causes:
Many environmental factors is major risk factor CVD. For instance, exposure to tobacco smoke is strongly associated with CVD risk and mortality. Alcohol consumption, tobacco use, and unhealthy diet are some of the environmental risk factors contributing to CVD (World Health Organization. 2017). Such behaviors have an impact on both morbidity and mortality of the disease. Exposure to chemicals like metals and hydrocarbons also affects blood pressure regulation and elevate the risk of CVD. These factors advances disease and the pathophysiological process associated with CVD (Cosselman, Navas-Acien and Kaufman 2015).
Grover et al. (2016) showed that lifestyle factors like excess body weight increases risk of CVD and adapting healthy lifestyle is necessary for such people. Presence of clinical conditions like hypertension and diabetes also increases the risk of CVD (Peters, Huxley and Woodward 2014; Buendia et al. 2017). Human and biological factors like age, gender, ethnicity and race are important determinant increasing the prevalence of the disease (Kumar 2017). Hence, people from different racial groups and those with family history of CVD are two-three times more likely to be affected by the disease. Psychological links to increase in morbidity and mortality risk among CVD patients has also been established as Gallo et al. (2014) showed impact of perceived stress and anxiety on risk of developing CVD. The review of these risk factors suggest that CVD can be prevented by focusing on health education and lifestyle changes and effective implementation of preventable health programs.
In conclusion preventive strategies and not advancement in clinical medicine over years have been found to increase the life expectancy leading to demographic transitions. The transition can be attributed to various extents of the socio-economic development, medical interventions and public health as observed from the late 20th century. In developing countries the epidemics of the non-communicable diseases are the major contributors of the disease burden as infections are decreasing as leading contributors. Genetic predisposition and environmental causes are the factors contributing to the dynamics of CVD epidemic.
Management of the condition in UK and Ghana with reference to primary, secondary and tertiary prevention:
UK:
The global health trends and prevalence of CVD in developed and developing countries were provided in the above sections. This section particularly looks at the way the condition is managed in UKA and Ghana with reference to primary, secondary and tertiary prevention programmes. The primary prevention programs are those which focus on preventing the disease before it occurs or before it is diagnosed in a population group (Goldstein et al. 2010). Some of the main components of primary prevention program include health education, environmental modification and lifestyle and behavioral modification to minimize the risk of developing heart diseases (Drummond et al. 2015). In UK, one of the major preventive health strategies for management of CVD was to reduce the prevalence of smoking. At the national level, the UK Government implemented several programmes to prevent CVD. These included setting national priorities for reducing premature mortality, controlling obesity and tobacco use, decreasing alcohol consumptions and encouraging physical activity in citizens. Many social marketing campaigns like Change4Life were implemented so that people could adapt healthy lifestyles (Department of Health 2013).
Risk factors of CVD
From the analysis of primary prevention programmes implemented in UK, it can be said that a lot of emphasis was paid on controlling obesity and tobacco consumptions in people. This can be regarded as an effective targeted intervention because high BMI and obesity is the reason for development of CVD risk factors like hypertension and diabetes and these conditions consequently increases the risk of CVD (Bastien et al. 2014). Change4Life was the first national social marketing campaign to reduce obesity in England and a three year marketing strategy was implemented to support people at each stage of behavioral change. This campaign was a great success at it covered 99% targeted families in the first year and great response were received from citizens after year of the campaign. It was great social marketing campaign that provided handbooks and web-content to help people change their behavior and collaborated with non-governmental sector to boost behavioral changes in obese people (Dibb 2017). This campaign along with Responsibility Deal framework was also responsible for implementing policies to support industries to produce healthier produces and minimize salt intake (Gillespie et al. 2015). This campaign greatly increased awareness about the health risk associated with obesity, however behavioral changes were not achieved to that extent. This was mainly because of socioeconomic differences in people (Croker, Lucas and Wardle 2012). Hence, targeting people based on their socioeconomic factor was also essential.
The main strength of the primary prevention programmes for CVD in UK was the use of social marketing tool to reach to large group of people. However, since attitudinal changes were not achieved, there was a need for narrow focus to maximize effectiveness of prevention efforts (Croker, Lucas and Wardle 2012). In case of secondary or tertiary prevention for CVD, adequate screening and records regarding case findings is essential for early diagnosis. The main principle of secondary prevention is to control the disease process by identify undiagnosed group and treating them before serious complication arises (Bonow et al. 2011). On the national level, the UK government has developed action plan for cardiovascular disease prevention. The implementation of NHS Health Check national programme is one of the largest prevention programme where the focus is to prevent and detect early signs of heart disease (Gov.uk. 2018). This programme has been effective in identifying undiagnosed people with CVD and those with CVD risk factors such as diabetes and hypertension. The collaboration with local partners to prevent risk behavior will further help to achieve improvements in alleviating risk factors of CVD (Borys et al. 2012). However, there are several challenges in secondary prevention such as convincing health care practitioners regarding the importance of secondary prevention and active engagement of patients in preventive behaviors (Bonow et al. 2011). Hence, designing well-designed pathways for continuity of care is necessary for UK government in the future.
Preventive care strategies for managing CVD
Ghana:
Many policy initiatives like Regenerative Health and Nutrition Programme and Programme of Work (POW) has been implemented in Ghana in the past to control risk of CVD (Bosu 2012). Recent primary prevention program for CVD in Ghana has been directed by the implementation of National Policy for prevention and control of non-communicable disease in 2012. The main priority set by the NCD policy was early detecting and health promotion. Many relevant legislation related to food, tobacco and alcohol policies were also enacted to minimize the risk factors of CVD. Special emphasis was also paid on immunization and physic activity. It was also planned to educate people about limiting intakes of salts, fat, cholesterol and added sugar (Iccp-portal.org. 2012). Although this policy was responsible for many health promotion initiatives in Ghana, however limited success was achieved. This is because of many challenges or limitations like inefficient management of programme, low funding and little political interest to strengthen the health system (Bosu 2012).
In the area of secondary and/or tertiary prevention of early detection and educating people about early signs of the disease was a priority in the NCD policy. Health system strengthening was planned by means of in-service training programmes. Improving access to essential drugs and supplies were also presented. However, limited success has been achieved because of low funds and high cost of drugs. Weak governance can also regarded as one factors that affected the speedy implementation of proposed prevention programs for the citizens. Clinical management of CVD was also challenging because of low compliance rate, high cost of treatment and lack of specialist care (Bosu 2012). Since CVD is a growing burden in Ghana, there is a need for screening and treatment of high risk persons (Kodaman et al. 2016). As the CVD epidemic is in its early stage, life-course approach in preventive strategies is needed so that risk factors can be eliminated from childhood (Ofori-Asenso and Garcia 2016).
Management and treatment outcomes in global context and two countries:
In developed countries like USA, community based approach like community hypertension outreach was arranged to identify CVD risk. The program also targeted racial/ethnic minority groups and socioeconomically disadvantaged groups who are mostly likely to have negative CVD outcpmes. The outcome of such outreach program was that uptake of medications for hypertension in racial groups increased and more number of people were aware about CVD and behavioral changes needed to prevent the disease (Ferdinand et al. 2012). In UK, the Cardiovascular Disease Outcome Strategy identified 10 actions to improve CVD outcomes. This included prevention and risk management of CVD by reduction in smoking prevalence and focus on healthier lifestyle for people. The NHS Health Check Programme was a systematic risk management programmes that provided tailored advice to citizens regarding CVD risk and achieving lifestyle changes (Department of Health 2013). The program was implemented in 2009 and it has been increasing health checks. The evaluation of the progress made by the NHS Health Check in the first four years revealed that the attendance in the programme increased from 5.8% in 2010 to 30.1% in 2012 (Robson et al. 2016). One advantage of the programme that is understood from this outcome is that as the awareness for CVD increase, the attendance by people at high risk of CVD increased. Although the program had achieved some of its target, however more needs to be achieved.
Conclusion
Another important preventive work initiated by UK government included identifying those at high risk of CVD. As inherited cardiac conditions increased the risk of CVD, the British Heart Foundation took the responsible to identify families at risk of cardiac death. The preventive works also emphasized on improving case finding programmes by the development of new tools (Department of Health 2013). Work on case findings was an effective step as this can increase the rate of antihypertensive and statin treatment for high risk group. The evaluation of one of the targeted case finding for CVD compared with usual care in UK revealed increase in number of untreated high risk patients who started statin or antihypertensive treatment. The success of the programme was also possible because these programmes coordinated with primary care service and medical records enhanced the identification of high risk patients (Hemming et al. 2016).
In Ghana, the primary prevention work mainly targeted actions by implementations of policies related to tobacco, alcohol, diet, physical activity and immunization. The advantage of these preventive works was that it targeted risk factors in an comprehensive manner which is essential for the country (Ofori-Asenso and Garcia 2016). Many prevention programmes were also implemented in faith-based organizations after seeing good success rate in developed countries. However, socio-cultural barriers affected the outcome of the programme. Lack of governance is also an issue affecting the outcome of preventive work in Ghana (Abanilla et al. 2011).
Risk assessment, emergency planning and clinical governance in global context and two countries:
The community outreach programs in USA were successful in increasing awareness and health care utilization among racial group, however the limitation in the programs were that it did not controlled risk factors and mortality associated with CVD (Ferdinand et al. 2012). Hence, based on the evaluation of the preventive work in US, it can be said that risk assessment and control can be improved by implementing evidenced based strategies that have been successful in the past (James et al. 2014). In case of UK, it has been found that well structured and systematic risk assessment and risk management programmes are effective in raising awareness and preventing CVD related outcomes. Year-by-year improvement in attendance was found and the NHS Health Checks also led to the identification of new comorbidities (Robson et al. 2016). However, other comprehensive strategy which might improve risk management of the disease includes improving the infrastructure of the programme and regulation evaluation of progress to ensure that desired target is achieved (Lee et al. 2016).
The success of case findings programmes in UK also contributes to the assessment of risk and management of CVD. The evaluation of preventive works in UK in this area gives the lesson that if dedicated staffs are involved and proper coordination with primary care is done, then success of risk assessment process is guaranteed (Hemming et al. 2016). Tools like electronic health records can be used to identify more number of patients with CVD risk (Pike et al. 2016). In addition, the evaluation of preventive works in Ghana gives the insight that proper legal and regulatory governance is critical for the success of prevention efforts. Governance reform is essential to take effective response to the CVD epidemic (Piot et al. 2016). Hence, political parties and several other parties must be involved to implement laws related to prevention of LCD. Development agencies need to identify where maximum assistance is needed for the success of preventive work and incident management for CVD. Educational policies are also needed that starts health promotion in school curriculum too (Magnusson and Patterson 2014).
Evaluation of health promoting capacity of the health care systems:
All prevention efforts and regulatory changes related to CVD can be successful in a country when the health care system of the country is prepared to tackle the epidemic. This would require good infrastructure as well as preparedness of staff to effectively handle the problem (Karwalajtys and Kaczorowski 2010). In case of UK, local health system like Public Health England (PHE) is playing a major role tacking major health related crisis. It is involved in all necessary areas for health promotion and health development. It has health workforce, health financing, good governance, medical products and technologies and good resource to enhance health development in the country (Gov.uk. 2018). This may help overcome system level barriers that may come in the prevention programmes for CVD (Banerjee et al. 2016). In contrast to UK, Ghana has a weak health care system as it is struggling with challenges like poor health infrastructure, poor funding and lack of trained human resource for risk assessment and treatment of chronic disease (Fenenga et al. 2015). Hence, a lot more needs to be done to improve the capacity of Ghana’s health care system to engage in health promotion.
Conclusion:
The report summarized the rise in prevalence of CVD and its growing burden worldwide. Through the statistics on prevalence rate of CVD in developed and developing countries, it is clearly understood that it is the leading cause of mortality. Hence, since the diagnosis of CVD is associated with high health care cost and loss of productivity in countries, the analysis of preventive work in developed and developing countries was essential. The review of preventive programmes implemented in Ghana and UK gave various insight into the strength and weakness of each country in planning preventive actions for reducing the risk of CVD. In case of UK, the implementation of several programs like ‘Change for Life’ and NHS case finding programme was effective in improving awareness of the disease and uptake of treatment in countries. However, certain health care system level limitations remain to be addressed. For instance, in UK poor attityde of health care staff towards secondary prevention was an issue. In case of Ghana, poor governance and health care infrastructure affected the success of preventive work. Hence, it is recommended these countries identifies the flaws in the health care system and correct them to increase their capacity for health promotion and prevention of NCDs like CVD.
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