Epidemiological transition and novel approaches for cardiovascular disease prevention in rural India

Abstract

Background: Cardiovascular disease (CVD) is a major cause of premature morbidity and mortality globally, and is responsible for 27% of all deaths in India. The rise in CVD burden is largely due to an increase in the prevalence of CVD risk factors and a relative lack of resources devoted for CVD care. Health systems in India face substantial challenges to meet the growing epidemic. Innovative solutions addressing health system challenges and reliable information about the CVD risk factor prevalence and management have the potential to influence strategies for the development of CVD prevention programs in India. Methods: 1. Morbidity data from the SMARThealth India study involving around 62000 participants from 54 villages was analysed to describe the CVD burden and treatment patterns in a rural community of Andhra Pradesh, India 2. The morbidity data from the SMARThealth India study and the Andhra Pradesh Rural Health Initiative (APRHI) study were compared to estimate the trend in blood pressure (BP) distribution and management in the last decade in a rural community of Andhra Pradesh 3. A comprehensive literature review was conducted to describe the role of mHealth in improving healthcare quality for non-communicable diseases in low- and middle-income countries 4. A novel community mHealth intervention model for provision of CVD care to the rural communities was developed and preliminarily evaluated using a mixed methods approach in 11 villages of Andhra Pradesh, India Findings: Approximately 40% of all adults aged 40 years and above in a rural region of Andhra Pradesh, India had hypertension, of which, around 50% were aware of their diagnosis, 48% were on prescribed BP lowering therapy and 26% had their BP controlled. The proportions having low, intermediate and high 10-year CVD risk were 77•7%, 5•4% and 16•9%, respectively. Comparison of two cross-sectional studies, 10 years apart, in the same region showed a 4% increase in the prevalence of hypertension although there was a reduction in mean systolic BP by 1.6 mmHg. Upon comparison of the projected outcomes from current BP treatment patterns with those from an absolute risk approach, it was found that around one-half of those on BP lowering treatment are at low risk and around one half of individuals at high risk are actually taking their BP lowering drugs. Modeling the BP treatment pattern showed that in comparsion to current use of BP lowering medications (20%) in general population, a similar number of people would be treated using an intermediate (22%) or high (17%) risk threshold for instituting BP lowering drug therapy. However, compared to current practice, such risk-based strategies for BP lowering could avert 92% and 65% more CVD events over 10 years, respectively making it an efficient clinical approach to BP lowering. The literature review concluded that though mHealth are currently being used in low-and middle-income countries for patient level behavior change, there is a lack of literature for research on end-to-end healthcare systems where multi-faceted strategies including mHealth are taken to improve patient care. An innovative systems oriented approach using mHealth, task shifting, and risk-based strategies for BP lowering was developed and found to be feasible to implement in a rural setting and acceptable to the rural community, non-physician health workers and primary care physicians. Conclusion: India is undergoing a rapid epidemiological transition. A substantial proportion of a rural Indian population has elevated CVD risk with large gaps in CVD management. An innovative multifaceted mHealth platform for CVD care using efficient clinical approaches is feasible to be implemented in these settings. More research is required to develop an innovative, sustainable and scalable strategy in order to achieve the goals for reducing 25% of CVD by 2025, a target set at the 65th World Health Assembly.