Postgraduate Training Course in Reproductive Health/Chronic Disease
for Prevention and Control of Cardiovascular Diseases
Department of Preventive
Medicine, School of Public Health, Fudan University, Shanghai, China
National And Community Programmes Noncommunicable Disease Prevention and
World Health Organization
Mark van Ommeren
Department of Mental Health and Substance Dependence, World Health Organization
Cardiovascular diseases (mainly ischaemic heart disease and stroke) has
been the leading cause of death worldwide.The majority of all deaths attributable
to cardiovascular dieases (CVDs) are in developing countries.There is now
a pressing need for developing countries to define and implement preventive
interventions for CVDs. 1
In the early 1950s, CVDs were already an important health issue in developed
countries. On the basis of accumulated scientific evidence from epidemiological
studies and research on preventive medicine showing that cardiovascular
diseases are associated with unhealthy lifestyles and human behaviours,
the concept of community intervention was introduced to the field of cardiovascular
disease prevention in the late 1960s and early 1970s in developed countries2.
Major community-based cardiovascular disease prevention programs have been
conducted in North Karelia, Finland; the state of Minnesota; Pawtucket,
Rhode Island; and in three communities and in five cities near Stanford,California,
USA. Those community-based CVD prevention programs were soon followed by
several other projects of the same kind, in Europe, Israel, South Africa.
A number of projects are also being carried out as demonstration projects
of WHO-related programmes: CINDI (by the WHO Regional Office for Europe(EURO)),
CARMEN (by the WHO Regional Office for the Americas (AMRO)), and Interhealth
(WHO headquarter) 2,3. In conjunction with the WHO Interhealth
Programme, which was started in 1986, many developing countries have been
invloved in the similar activities of community-based CVD prevention and
The mortality of cardiovascular diseases is decreasing in developed countries
as a result of long-term promotion of healthy lifestyles and community prevention
measures. However, with ageing populations and rapidly changing lifestyles
(in particular, tobacco smoking, unhealthy diets, and physical inactivity),
the burden of CVDs is increasing in almost all developing countries4.
The evidence-based, affordable approaches for CVD prevention and control
are needed, especially in low- and medium-resource settings in developing
countries. The successful experiences and scientific evidence for CVD prevetion
and control achieved in the past 30 years in developed countries make it
possible for the developing countries to find the appropriate approaches
to address CVDs.
The objectives of this paper is to identify evidence-based, cost-effective
community-based strategies and intervetions for CVD prevention and control;and
to form recommendations for the appropriate use of the community-based interventions
in the developing countries.
This paper was a literature review.
Criteria for considering studies for this review
A community-based intervention for cardiovascular disease prevention
and control is defined as any primary prevention and secodary prevetion
program that attempted to reduce the population burden of CVDs by modifying
at least one cardiovascular risk factor (ie. blood pressure, smoking, total
blood cholesterol, physical activity, diet) and providing health services
in the community. Intervention studies meeting this definition were included
in this review.
Search strategy for identification of studies
MEDLINE 1966 to March 2003 using medical subject heading “community”,
“intervention*”, “cardiovascular disease*” together with relevant diagnostic
terms(ie. coronary heart disease and stroke)and text word searches for specific
interventions(see below). Searches of reference list of papers, and also
use hand searching.
- cardiovascular disease*
- coronary heart disease
1 and (2 or 3 or 4) and (5 or 6 or 7)
limit to “title/abstract”.
- quality of life
1 and (2 or 3 or 4) and (5 or 6 or 7) and 8
limit to “title/abstract”.
According to the commonly used classification of prevention5,
the studies included in this review were divided into two main types: community-based
primary prevention and community-based secondary prevention. The community-based
primary prevention was classified to more subgroups concerning different
1.Community-based interventions for primary prevention
Since the early 1970s, most of the intervention programs for cardiovascular
disease conducted in the communities were belong to primary prevention,
aiming to reduce the cardiovascular risk factors and reduce morbidity and
mortality from cardiovascular disease in whole communities. Those programs
differ in their settings(rural or urban community, developed or developing
country), methods, components and intensity of the interventions, in the
risk factors targets, and in the evaluation measurements, periods, designs
and effects. Concerning different ways, those community-based intervention
programs can be divided into several different classifications:
(1) According to perspectives to prevention, they can be classified as
High-Risk Approach versus Population Approach.
The traditional epidemiological studies of determinants of cardiovascular
disease offers the opportunity to target those individuals who are likely
to develop CVD and those most likely to benefit from prevention and treatment
efforts and, thus, could play a role in preventing and control CVD. The
results of the programs using high-risk approach(sometime call it individual
approach) proved that they were efficient to reduce incidence of CVD among
the high risk individuals even in less than five years. One example is a
study from China6. In the study in 1987 in 7 cities, a cohort containing
about 2700 subjects(35 yeas and over) free of stroke was sampled in each
community. Screening was administered to the cohort in the intervention
communities for the eligible subjects(hypertension, heart disease, and diabetes)
for intervention. A program of treatment for those subjects was instituted
in the intervention cohort----“every week doctors from collaborating center
hospitals and primary prevention branches went to the local health stations
to see study patients”. Although the intervention included health education
to the full intervention community, but the result only showed the follow-up
of the cohort. The result demonstrated that the 3.5-years cumulative incidence
of total stroke was significantly lower in the intervention cohort than
the control cohort (0.93% versus 1.34%; RR=0.69; 95%CI, 0.57 to 0.84).
Most major large-scale community-based cardiovascular disease intervention
projects use population approach or combination of high-risk approach and
population approach ---- “comprehensive community-based approach” 7-21.
They all use a quasi-experimental design. They all carry out comprehensive
interventions activities, involving innovative media campaigns, local media,
community participation, co-operation with local and national sectors and
policy making. They all carefully planned. Their intervention activities
and process are based on sound theoretical frameworks (such as community
organization, social learning theory, social marketing, ecological health
promotion model). They all use independent cross-sectional randomized sample
of the community to compare the net change of the targeted risk factors.
And also compare the trend of the risk factors and CVD morbidity and mortality
rates in the intervention communities and reference communities. They usually
show a modest effect on the target risk factors or disease rates depending
on the intensity of the intervention in each project2, 22. The
representatives of those major projects included several very famous first
and second generation community-based heart health intervention projects
both in the Europe and in the USA: the North Karelia Project (Finland),
the Stanford Three-Community Study (USA), Stanford Five-City Project (USA),
Minnesota Heart Health Program (USA), the Swiss National Research Programme,
the German Cardiovascular Prevention Study, and the Kilkenny Health Project
(Ireland). Among them, North Karelia Project is the most successful one,
which first conducted as demonstration programme, after the original project
period, their experience has actively been applied for national action2,3.
And as the first major community-based project for CVD prevention, North
Karelia project was soon followed by several other project of the same kind
both on national level and global level. For example, it led to demonstration
projects of WHO-related programmes: Comprehensive Cardiovascular Community
Control Program (CCCCP)(by WHO/the WHO Regional Office for Europe(EURO))
CINDI (by EURO), CARMEN (by the WHO Regional Office for the Americas(AMRO)),
and Interhealth (WHO headquarter). In conjunction with the WHO Interhealth
Programme, which was started in 1986, many developing countries have been
involved in the similar activities of community-based CVD prevention and
control2. Of course, those projects use population approach or
high-risk approach and population approach in combination.
(2) According to how many risk factors targets, the programs can be classified
as Single Cardiovascular Risk-Management versus Comprehensive Cardiovascular
CVD prevention too frequently focuses on single risk factors rather than
on comprehensive cardiovascular risk23. There were many prevention programs
only addressed one risk factors of CVD to test the effect of the targeted
risk factor change or its impact on CVD incidence, morbidity or mortality,
such as high blood pressure control, cholesterol concentration reduction,
changes in nutrition, community-based smoking cessation23-27.
Although single cardiovascular risk-management approach can be effective,
many intervention studies demonstrated that for CVD prevention activities
to achieve the greatest benefits, a paradigm shift is required from the
treatment of risk factors in isolation to a comprehensive cardiovascular
risk-management approach28. Why we should focus on integrated
multifactorial approach in community primary prevention for CVD is also
because two or more cardiovascular risk factors clustering in one person
is very common in the real life, and the clustering of risk factors may
act synergistically increasing the risk more than any one single factor
acting alone23,29. Majority of the major community-based intervention
projects, who use population approach also deal with more than one “classical”
risk factors at the same time, and emphasized both diet and smoking.
(3) According to the components of interventions, the programs can be
classified as Individual behavior Change (educational approach) versus Policy
and Environmental changes.
Community-based CVD prevention projects in the USA, such as Stanford Three-Community
Study, Stanford Five-City Project, Minnesota Heart Health Program, Pawtucket
Heart Health Program, Community Intervention for Smoking Cessation (COMMIT),
are the representatives of individual behavior change approach user24.
Those projects recognize the multifactorial nature of cardiovascular disease
and consistently advocate approaches involving multiple strategies across
multiple channels and across all sectors of the population. However, their
main focus has been on interventions to encourage individual behavior change,
on information and skill building. Environmental and policy approaches have
not received much attention in the projects in the United States. Since
the limited perspectives, the projects could not achieve the greatest impact
comparison of the projects used policy and environmental approaches. For
example, in Stanford Five-City Project, the intervention conducted in the
treatment cities was a 6-year multifactor risk reduction program including
newspapers, television and radio, mass-distributed print media, classes,
contents, and correspondence courses10. The results showed that
changes in risk factors were observed, but no evidence of a treatment-control
difference in terms of combined-event rate of cardiovascular disease between
1979 and 19929,22.
On the contrary, community-based projects to prevent cardiovascular disease
in the Europe, who using approaches focusing on policy and environmental
changes have been more successful than those in the USA. Finland’s North
Karelia Projects is a classic example of a comprehensive public health program
to prevent cardiovascular disease that incorporates policy and environmental
interventions in an effective, community focused manner. The results indicated
that major changes have taken place in the levels of target risk factors
in North Karelia (Table 1) 3. By 1995 the annual mortality rate
of coronary heart disease in the middle age (35-64years) male population
in North Karelia has reduced about 73% form the pre-program years(Graphic
1) 3,11. The risk factors targeted by the program could explain
most of the decline in ischamic heart disease observed over 20 years30.
Another example is Heartbeat Wales project. The important strategy of the
project was “ to achieve environmental, organizational, structural, and
policy changes to support healthy choices by individuals” 31.
Table 1. Risk facotor changes in North Karelia 1972-1997(30-59Years)
(4) Intervention characteristics of the successful community-based primary
prevention programs for CVD prevention and control
Some common intervention and design characteristics can be identified through
summary all of the large-scale comprehensive community-based cardiovascular
disease prevention and control projects (especially North Karelia project):
---carefully planned using sound health promotion model
---interventions and process are based on scientific theories and frameworks.
--comprehensive intervention approach: combination of population approach
and high-risk approach; Multi-components including: mass communication,
specific health education, community organization, policy and environmental
change, co-operation with the other sectors.
---focusing on policy and environmental change intervention strategies and
community diagnosis, community organization and participation.
---quasi-experimental design, long time follow-up and proper evaluation.
2. Community-based Interventions for secondary prevention
The effective community-based secondary prevention programme would prevent
many deaths that occur in middle- and older age and substantially reduce
disability related to CVD. 32
(1) Evidence base
Patients with established CVD constitute one of the highest risk groups.
Secondary prevention involves identifying, treating and rehabilitating these
patients to reduce their risk of recurrence, to decrease their need for
interventional procedures, to improve their quality of life and to extend
their overall survival32. Several studies have demonstrated the
effective-ness of community-based secondary prevention interventions in
the control of CVDs33-35. From the early1980s the WHO-MONICA
study monitored trends in coronary heart disease over 10 years, across 38
populations, in 21 countries. Data from this study indicate that secondary
prevention and changes in coronary care are strongly linked with declining
coronary end-points. It is now clearly evident that lifestyle changes such
as smoking cessation, healthy dietary practices, weight control and regular
moderate physical activity, can significantly contribute to reduction in
cardiovascular mortality in people with established CVD and their recurrence.
(2) Indicators of quality of life for CVD patients
As mentioned above, quality of life should be a key objective of interventions
for patients with CVD, not only to prevent or to retard the progression
of the underlying disease but also to alleviate symptoms and to improve
the patients’ functional capabilities. However, few community-based interventions
for patients with CVD address their impacts on patients’ quality of life.
One reason is that a sensitive and valid tool for assessment of quality
of life for CVD patients may not be available. Lack of assessment instruments
makes it difficult for health service providers to identify the needs of
patients, and less fitted interventions or services provide. Here I will
briefly describe existing quality of life assessment tool and indicators
for testing effectiveness of CVD interventions or treatments.
There is no consensus definition of quality of life until now. Quality of
life has been defined by WHO as “individuals’ perception of their position
in life in the context of the culture and value systems in which they live
and in relation to their goals, expectations, standards and concerns”36.
Different quality of life assessment tools are based on different concepts
and consist of different domains (dimensions) of quality of life. The WHOQOL
instruments (the WHOQOL-100 and the WHOQOL-BREF) are based on the quality
of life concept just described and have six domains36. These
are: (a) physical domain; (b) psychological domain; (c) level of independence;
(d) social relationships; (e) environment; and (f) spirituality/religion/personal
beliefs. There are twenty-four facets (subdomains) are incorporated within
six domains. Quality of life assessment instruments can be classified as
(a) generic instruments to assess quality of life in a variety of situations
and population groups and (b) specific instruments to assess quality of
life of specific populations (e.g. cancer patients, the elderly).
Table 2. Summary of commonly used questionnaires and indicators for assessment
of quality of life in patients with CVD
||State-Trait Anxiety Inventory
||Center for Epidemiologic
||3-item social activity
|General symptom relief
||Health status index
Supplemented Nottingham Health Profile
|Pain (Angina and related)
and specific activities scale
and role activities
Status measures (e.g. ADL)
to illness scale
The sexual symptom distress index
|Return to work/ Personal
||Hospital costs, length
of hospital stay
|Individual economic impact
||Self report, financial
||General health questionnaire
|Perceptions of general
health status or well-being
||GHQ, The psychological
||The sleep dysfunction
||Minor symptom evaluation
Subjective symptom-Assessment profile
The aforementioned WHOQOL instruments, for instance, are generic ones,
which have six uses: in medical practice; improving the doctor-patient relationship;
in assessing the effectiveness and relative merits of different treatments;
in health services evaluation; in research; and in policy making. Although
many studies on quality of life in patients with CVD can be found33,37,
no specific instrument exists. Normally different scales are used together
to assess the quality of life in patients with CVD according to different
concepts and narrow or broad domains covered.
In terms of quality of life assessment for testing effectiveness of CVD
interventions, the studies and practices have been predominantly done in
clinical settings, including assessment of changes in quality of life for
patients receiving coronary artery bypass grafting (CABG), percutaneous
tansluminal coronary angioplasty (PTCA), cardiac transplants, valvular surgeries,
exercise rehabilitation, and so on37 The commonly used questionnaires
(scales), domains (Indicators) are listed in Table 2.
CVD Prevention at the community-level is essential because modifiable
causal risk factors are deeply entrenched in the social and cultural framework
of society. From the limited publications included in this paper, several
experiences and evidence should be completely understood and emphasized.
1. Both community-based primary prevention and secondary
prevention are needed for CVD prevention and control
Primary intervention is directed to susceptiable people before they develop
a cardiovascular disease. The key objective of primary prevention is to
reduce the incidence of disease and consequently, its sequelae5.
But the effects of CVD prevention and control must include not only changes
in the frequency and severity of CVDs but also preventing recurrence of
the established CVD, reducing mortality of those patients and improving
their quality of life. The World Health Organization global strategy for
the prevention and control of noncommunicable disease emphsized that in
addition to reducing the common risk factors in the population, secondary
prevention of major cardiovascular events (fatal and non-fatal myocardial
infarction; fatal and non-fatal stroke; sudden cardiac death, re-vascularization
procedures) should be regarded as a key component of any public health strategy
to reduce the rising burden of CVD in low and middle income countries32.
But we should avoid completely using less cost-effective secondary interventions,
such as high-tech methods to identifying patients, pharmacological methods
to treat patients. The key areas for improving secondary prevention of major
CVD include: community-based approach, patient-oriented delivery system
and support for self-management32.
2. Community-based primary prevention of CVD should target
main cardiovascular risk factors, especially four behavioral risk factors(tobacco,
unhealthy diet, physical inactivity, alcohol) using comprehensive risk-management
World Health Report 2002 showed that, obesity, high blood pressure, high
cholesterol, alcohol and tobacco – independently and often in combination,
are the major causes of CVDs38. The scientific evidence is strong
that a change in dietary habits, physical activity, tobacco control and
alcohol consumption can produce rapid changes in population risk factors
for CVDs. Comprehensive risk-management for community cardiovascular risk
decreasing is because CVD is multifactorial disease process39.
Many people have more than two cardiovascular risk factors at the same time.
3. Community-based primary prevention of CVD need combination
of population approach and high-risk approach
Cardiovascular risks often occur as a continuum throughout the population.
Shifting population distributions of exposure can gain large potential reduction
in CVD morbidity and mortality39. Since most CVD occurs in the
masses of people not at the highest risk level(high-normal to borderline
level), high-risk approach will do little to quell the current epidemic
of CVD, especially in the developing countries, where limited medical resources
can not afford the interventions mainly relying on treatment of high risk
subjects. For example, a high-risk approach can only target 25% of the community
population with elevated blood pressure23. A combination of high-risk
and population-based approach is essential to shift the cardiovascular risk
profile. Prevention through population-wide behavior modification will be
more cost effective than high-risk approach intervention39. The
changes in risk achieved in population-based studies are often small, but
it should be realized that even small changes in the distribution of risk
factors in the population will bring about sizable changes in CVD mortality
as demonstrated among different countries. For instance, for every 1% decrease
in the serum cholesterol level there is an associated 2% reduction in coronary
heart disease(CHD) rates39.
Furthermore, high-risk intervention should more focus on routine health
counseling in primary health system and other evidence-based, cost-effective
measures which have the feasibility of being implemented on a mass scale.
4. A major emphasis and strength of the community interventions
for CVD prevention and control should be attempted to change social and
physical environments in the community
Behavioral psychologist have long recognized that behavior change may
not depend on personal factors, but be more influenced by the social and
physical environmental elements, especially for behaviors like physical
activities, eating habits, stop smoking, which need to maintain day after
day. Since a change in environmental or policy is taken on the societal
level to reduce exposure to health risks or to lead to healthy behavior,
and do not require individuals to take action, it is more likely to be successful
than individual change efforts to promote and maintain individual’s behavior
change. Another rationale for expanding community-based programs to include
more environmental- and policy-level activities comes from behavioral science
theory(e.g., the theory of diffusion of innovations) 39. Individual-centered
efforts are appropriate for the “early adopters” in the community to make
positive health choices based mainly on new information. As for more “later
adopters” in the community, we need the programs focusing more on health-fostering
policies and environments.
5. Using life course perspective to consider community
cardiovascular disease prevention and control
Most of community intervention programs are limited to the community
resident aged 25 years and over. The risk of CVD is influenced by social
and biological exposures not only in adulthood but also in fetal life, infancy,
childhood, adolescence. Some studies confirmed the origin of atherosclerosis
in childhood and showed that the prevalence and extent of fatty streaks
and fibrous plaques increase rapidly during the 15- to 34-year age span39.
The life course perspective carries the potential of identifying the most
appropriate and effective prevention strategies in different populations,
because it considers the factors and processes that act at all stages of
the life-span to affect risk of later disease40. Since the earlier
in the CVD process preventive measures are instituted, the greater the likelihood
for overall effectiveness and benefit, more community-based primary prevention
programs target the youth aged less than 18 years should be advocated in
6. Improving quality of life in patients with CVD
Future community-based intervention for CVD prevention and control, especially
secondary and tertiary prevention, should pay more attention to improve
the quality of life in patients with CVD and related high-risk populations.
The measurement of quality of life should include developing new specific
instruments or identifying more suitable questionnaires both multi-dimensional
ones (e.g. the WHOQOL instruments ) and scales for one specific dimension.
Conclusion and recommendations
Although not including all related publications, this review clearly
show that there are strong evidence base for community-based intervention
for CVD prevention and control. The success of community-based intervention
for CVD prevention and control achieved in the past 30 years and experience
of a few similar projects in developing countries, provide the ideas, approaches,
strategies, models to help the developing countries and low-resource developed
countries to address CVD.
In all, as the WHO advocate: we now have the required base of science and
technology to effectively reduce the public health impact of CVD. Let us
“use what we know”. However, the following recommendations for implementation
of community-based interventions for CVD prevention and control should be
- adapting rather than adopting or copying the existing knowledge
and experience in developed countries because each community is unique.
Community assessment (community diagnosis) should be included in the
first phase of a community intervention program for CVD prevention and
- carefully planning of the program with a good understanding the
community, sound theories, frameworks and health promotion models
- the community-based CVD intervention program should emphasize on
comprehensive approaches, integrated risk management, policy and environmental
changes, community organization, individual empowerment and participation,
collaboration with various sectors
- scientific design and proper evaluation
- the program should be not only a demonstration programme to explore
the best implementation model in the specific setting but also be expand
to national actions
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