HEALTH SYSTEMS RESEARCH UNIT

1
HEALTH SYSTEMS RESEARCH UNIT
Report Back from Cardiovascular Disease Working
Group Western Cape Burden of Disease Western
Cape Burden of Disease Volume 6 of 7
2
Operational process of CVD work group

• Develop a conceptual framework based upon a
  literature review to identify the causal factors
  associated with poor diet and lack of physical
  activity.
• 2. Review the epidemiological data of the
  distribution of these risk factors across the
  province.
• 3. Systematicaly review interventions that have
  sought to address these risk factors.
• 4. Further planned that the working group will
  systematically identify the most appropriate and
  feasible interventions that could be considered
  in the Province.
• 5. Finally an analysis of the context of
  policy-making in regard to these interventions
  will be undertaken to include a stakeholder
  analysis.

3
Top twenty leading causes of death across the
Western Cape,2000 (Bradshaw et al.2004)
4
Projected percentage increase in CVD deaths
2000-2040
Taken from Leeder et al 2005
5
Triple burden of disease in the Western Province
6
NCD rates similar across the various communities
7
Increasing numbers of middle age workers
8
Evidence that this epidemic can be reversed
9
Aetiology of chronic non-communicable diseases
fromPreventing Chronic Diseases a vital
investment. Geneva, World Health Organization,
2005.
10
NCD Risk factors in the Western Cape
epidemiological diagnosis
11
Behavioural diagnosis national risk factor
survey in adolescents
12
Smoking

• Important interventions have already been put in
  place
• Surveys suggest that there has been a reversal of
  upward prevalence of smoking especially amongst
  African men
• Important sub-groups still have high levels
• Systematic review of interventions in pregnancy
• Interventions with pregnant women being evaluated
  presently

13
Western Cape school tuck shop survey
14
The potential future of nutritional risks
15
Systematic Review

• Systematic approaches designed to increase levels
  of participation in physical activity,
• Approaches above may have included interventions
  targeting changes in awareness, knowledge and/or
  attitudes toward nutrition and physical activity,
  improving self-efficacy, skill or competency
  concerning these behaviors
• Interventions may also have included programs or
  strategies targeting changes in social norms,
  policy and physical environment, health
  services or consumer behavior etc, leading to,
  for example, increased consumption of fruits and
  vegetables, reduced dietary fat intake, reduced
  obesity prevalence and increased levels of
  health-enhancing physical activity.

16
Various levels of intervention for prevention
health promotion based on McKinlay, 1995
(extracted from Rowland, 2006)
Type of intervention Examples of interventions
1. Downstream interventions 1. Downstream interventions
Interventions that target the individual, usually those at risk Individual counseling Group counseling Education Self-help programmes Pharmacological treatments
2. Midstream interventions 2. Midstream interventions
Interventions that target populations, usually using organisational structures or the natural environment Worksite and community-based health promotion programmes School-based activities Community based activities targeting at-risk populations
3. Upstream interventions 3. Upstream interventions
Interventions that aim to strengthen social norms that promote healthy behaviour and to redirect counter veiling social forces. National and state wide media and social marketing campaigns Economic incentives and disincentives Policies restricting access Policies affecting marketing and sales Policies restricting advertising and promotion
Community/ecological interventions target all
levels structural interventions target either or
both midstream (2) upstream levels (3)
17
Results from review

• A review of more than 300 interventions have
  shown
• that very few studies are from developing
  countries
• and none published were from sub-Saharan Africa.
• Despite this, there have been numerous successful
  interventions which have been sustainable and
  cost-effective and have the potential to be used
  in the South African context.

18
Summary of best practice review by setting (1)
19
Summary of best practice review by setting (2)
20
Summary of best practice review by setting (3)
21
Summary of best practice review by setting (4)
22
Summary of best practice review by setting (5)
23
Summary of best practice review by setting (6)
24
Summary of best practice review by setting (7)
25
School Setting

• Multi-component school programs which include
• a nutrition-based curriculum offered by trained
  teachers, a physical activity component
• a healthy school environment and parental
  involvement.
• The curriculum should preferably run over 3 years
  in grade 4-6 children.
• Two excellent examples in this regard are the
  PATHWAYS study which was developed for American
  Indians and the Know Your Body Program offered to
  primary school children in Crete.
• Both of these studies were adapted to local
  culture, values and norms and showed positive
  outcomes in behavior, clinically and in
  psycho-social aspects.

26
Worksite Setting

• The successful studies were characterized by the
  following
• nutrition and physical activity advice/group
  sessions
• a physical activity program
• changes in the food service canteens
• use of printed materials and use of multi-media
  to promote health messages.
• One of the most important factors in promoting
  successful outcomes was the use of an employee
  committee who participated in planning and
  managing a worksite program.
• A good example of this is the Treatwell -5-a Day
  program.

27
Primary Health Care Setting

• Interventions in primary health care and in the
  community with successful outcomes at the lowest
  level of cost.
• These include using physicians to endorse healthy
  programs, dietitians or nurses to do group
  counseling.
• The use of self-help materials for patients to
  use on their own.
• Brief cholesterol screening programs with a
  minimum time spent on counseling were also
  effective in some studies.
• The use of the media as a means of conveying
  healthy lifestyle messages was also shown to be
  effective in many studies.

28
Modification to improve diet

• Ban advertising of foods during childrens
  programs on radio TV or reduce the market
  pressure on children by regulating advertising
  and obtaining cooperation from the mass media and
  Internet providers
• Introduce advertising and educational campaigns
  (multi-media) to promote increased consumption of
  fruit and vegetables and decreased consumption of
  fat, saturated fats, sugar and salt. Includes
  developing and building-on to the food-based
  dietary guidelines of the DOH.
• Ensure that communities have access to healthy
  and safe foods (food security) such as food
  gardens, food outlets
• Develop and implement a policy for schools on
  foods which are allowed to be sold/provided at
  the schools-including feeding schemes and
  tuckshops

29
Further Recommendations

• Introduce a nutrition healthy lifestyle
  curriculum aimed at schoolchildren for the
  prevention of CVD
• Ensure that all state facilities provide healthy
  foods (high in fruit and vegetables, low in salt,
  sugar and fats to inmates and patients
• Develop a system of incentives for companies who
  introduce healthy canteens and physical activity
  facilities for their staff
• trans fat getting rid of partially hydrogenated
  oils is one of the simplest ways to prevent CVD.
• Cut the sodium content of packaged and restaurant
  foods could make a huge dent in CVD.
• "1 Or Less" switch people in several
  communities from high-fat to low-fat or fat-free
  milk.   

30
Modification methods to improve physical activity

• Ensure that urban development includes access
  to areas for physical activity
• Introduce advertising campaigns (multi-media)
  to promote physical activity
• Introduce a physical activity curriculum aimed
  at schoolchildren for the prevention of CVD
• Ensure that all schools have adequate space and
  facilities for physical activity
• Ensure that all communities have access to safe
  areas where they can be physically active

31
Modification methods to reduce tobacco use and
alcohol

• Increase the price of alcohol and cigarettes
• Ban advertising of alcohol
• Introduce a school policy of a smoke free
  environment

32
Members of the Working Group

• Authors
• Prof Mickey Chopra (HSRU, MRC)
• Dr Nelia Steyn (CDL, MRC)
• Prof Vicky Lambert (UCT)
• Expert Committee
• Prof. Thandi Puoane (SOPH, UWC)
• Prof. Krisela Steyn (University of Cape Town)
• Prof Dinky Levitt (University of Cape Town)
• Dr Yusuf Saloojee (National Council Against
  Smoking)
• Dr Emmanual Deviaud (Health Economist, MRC)
• Dr Sue Parnell (University of Cape Town)
• Prof Vanessa Watson (Planning, UCT)
• Dr Lesley Bourne (Health and Development, MRC)