Cardiovascular disease and the changing face of global public health : a focus on low and middle income countries

Eighty percent of the global 17 million deaths due to cardiovascular disease (CVD) occur in low and middle income countries (LMICs). The burden of CVD and other noncommunicable diseases (NCDs) is expected to markedly increase because of the global aging of the population and increasing exposure to detrimental lifestyle-related risk in LMICs. Interventions to reduce four main risks related to modifiable behaviors (tobacco use, unhealthy diet, low physical activity and excess alcohol consumption) are key elements for effective primary prevention of the four main NCDs (CVD, cancer, diabetes and chronic pulmonary disease). These behaviors are best improved through structural interventions (e.g., clean air policy, taxes on cigarettes, new recipes for processed foods with reduced salt and fat, urban shaping to improve mobility, etc.). In addition, health systems in LMICs should be reoriented to deliver integrated cost-effective treatment to persons at high risk at the primary health care level. The full implementation of a small number of highly cost effective, affordable and scalable interventions ("best buys") is likely to be the necessary and sufficient ingredient for curbing NCDs in LMICs. NCDs are both a cause and a consequence of poverty. It is therefore important to frame NCD prevention and control within the broader context of social determinants and development agenda. The recent emphasis on NCDs at a number of health and economic forums (including the September 2011 High Level Meeting on NCDs at the United Nations) provides a new opportunity to move the NCD agenda forward in LMICs

Making Time in Maintenance Work

In engaging technologies and the built environment within the social sci- ences, there increasingly have been appeals to examine the intricacies of time and temporalities in our collective interactions with science and technology more thoroughly. This seems particularly relevant when we consider the rhythms, cycles, rituals, (a)synchronicities, and time horizons of infrastruc- tural configurations. Studying repair and maintenance practices reveals how temporal properties of infrastructure are not only conceptually relevant in understanding socio-material relations, but also of very practical concern to members of society engaging in such relations

Making Time in Maintenance Work

In engaging technologies and the built environment within the social sci- ences, there increasingly have been appeals to examine the intricacies of time and temporalities in our collective interactions with science and technology more thoroughly. This seems particularly relevant when we consider the rhythms, cycles, rituals, (a)synchronicities, and time horizons of infrastruc- tural configurations. Studying repair and maintenance practices reveals how temporal properties of infrastructure are not only conceptually relevant in understanding socio-material relations, but also of very practical concern to members of society engaging in such relations

Screening for cardiovascular disease risk and subsequent management in low and middle income countries : challenges and opportunities

Background: Cardiovascular disease (CVD), mainly heart attack and stroke, is the leading cause of premature mortality in low and middle income countries (LMICs). Identifying and managing individuals at high risk of CVD is an important strategy to prevent and control CVD, in addition to multisectoral population-based interventions to reduce CVD risk factors in the entire population. Methods: We describe key public health considerations in identifying and managing individuals at high risk of CVD in LMICs. Results: A main objective of any strategy to identify individuals at high CVD risk is to maximize the number of CVD events averted while minimizing the numbers of individuals needing treatment. Scores estimating the total risk of CVD (e.g. ten-year risk of fatal and non-fatal CVD) are available for LMICs, and are based on the main CVD risk factors (history of CVD, age, sex, tobacco use, blood pressure, blood cholesterol and diabetes status). Opportunistic screening of CVD risk factors enables identification of persons with high CVD risk, but this strategy can be widely applied in low resource settings only if cost effective interventions are used (e.g. the WHO Package of Essential NCD interventions for primary health care in low resource settings package) and if treatment (generally for years) can be sustained, including continued availability of affordable medications and funding mechanisms that allow people to purchase medications without impoverishing them (e.g. universal access to health care). This also emphasises the need to re-orient health systems in LMICs towards chronic diseases management

Trends in prevalence, awareness, treatment and control of hypertension in the Republic of Seychelles (African region) between 1989 and 2013 [Poster]

Background: Few data exist on secular trends of high blood pressure (HBP) detection and control in low and middle income countries, particularly in the African region. This study examines trends of HBP over 25 years based on 4 independent population surveys. In the Seychelles, heath care is free to all inhabitants within a national health system, inclusive all HBP medications. Previous studies have shown a transition from traditional to cardiometabolic cardiovascular risk factors in Seychelles. Age adjusted cardiovascular disease mortality rates is high but decreasing over the last two decades

Self-reported adherence and associated factors regarding antihypertensive medication in Seychelles

Introduction. Adherence to medication for asymptomatic disease is often low. We assessed factors associated with good adherence to medication for high blood pressure (HBP) in a country of the African region. Methods. A population-based survey of adults aged 25-64 years (N=1240 and participation rate=73%). Information was available in knowledge attitude and practice, SES and other variables. One question assessed adherence. Good adherence to treatment was defined as answering "I forget very rarely" vs "I forget on 1-2 days in a week" or "I forget on 3 or more days in a week". Results. In a univariate model adherence was strongly associated with belief that hypertension is a long-term disease (OR 2.6, p<0.001) and was negatively associated with concomitant use of traditional medicine (OR 0.36, p<0.005). The following variables tended to be associated with good adherence for HBP treatment: age, SES, BMI, belief that HBP is not symptomatic, going to government's clinics, medium stress level, controlled hypertension, taking statins. The following variables were not associated with good adherence for HBP treatment: education, higher BP, knowing people who had a stroke/MI, suffering from another chronic condition. In a multivariate model, pseudo R2 was 0.14. Conclusion. We built a multidimensional model including a wide range of variable. This model only predicted 14% of adherence variability. Variables associated with good adherence were demographics or related to knowledge attitude and practice. The latter one is modifiable by different type of interventions

Building leadership capacity to prevent and control noncommunicable diseases: evaluation of an international short-term training program for program managers from low- and middle-income countries.

To assess the impact of a 1-week training seminar jointly developed and conducted by the World Health Organization and the University Institute of Social and Preventive Medicine of Lausanne targeting senior policy-makers in low- and middle-income countries on public health aspects of noncommunicable diseases (NCDs). A short qualitative questionnaire was emailed to all participants to one of the nine seminars organized between 2010 and 2015. From the 195 participants from 96 different countries, 122 (63%) completed the questionnaire. Among them, 87% reported that the seminar made a positive contribution to their professional development and 48% said it helped strengthening their national NCD program. All respondents remained directly or indirectly involved in NCD work. A frequent suggestion was that similar seminars are developed in their region or country. The evaluation strongly suggests that this short-term seminar had positive impact on both participants' personal development and the organization they worked for. There is a demand for organizing similar seminars at regional/country levels to support NCD prevention and control programs

Network-based indicators of Bitcoin bubbles

The functioning of the cryptocurrency Bitcoin relies on the open availability of the entire history of its transactions. This makes it a particularly interesting socio-economic system to analyse from the point of view of network science. Here we analyse the evolution of the network of Bitcoin transactions between users. We achieve this by using the complete transaction history from December 5th 2011 to December 23rd 2013. This period includes three bubbles experienced by the Bitcoin price. In particular, we focus on the global and local structural properties of the user network and their variation in relation to the different period of price surge and decline. By analysing the temporal variation of the heterogeneity of the connectivity patterns we gain insights on the different mechanisms that take place during bubbles, and find that hubs (i.e., the most connected nodes) had a fundamental role in triggering the burst of the second bubble. Finally, we examine the local topological structures of interactions between users, we discover that the relative frequency of triadic interactions experiences a strong change before, during and after a bubble, and suggest that the importance of the hubs grows during the bubble. These results provide further evidence that the behaviour of the hubs during bubbles significantly increases the systemic risk of the Bitcoin network, and discuss the implications on public policy interventions

Association of socioeconomic status with overall and cause specific mortality in the republic of seychelles : results from a cohort study in the african region

BACKGROUND: Low socioeconomic status (SES) is consistently associated with higher mortality in high income countries. Only few studies have assessed this association in low and middle income countries, mainly because of sparse reliable mortality data. This study explores SES differences in overall and cause-specific mortality in the Seychelles, a rapidly developing small island state in the African region. METHODS: All deaths have been medically certified over more than two decades. SES and other lifestyle-related risk factors were assessed in a total of 3246 participants from three independent population-based surveys conducted in 1989, 1994 and 2004. Vital status was ascertained using linkage with vital statistics. Occupational position was the indicator of SES used in this study and was assessed with the same questions in the three surveys. RESULTS: During a mean follow-up of 15.0 years (range 0-23 years), 523 participants died (overall mortality rate 10.8 per 1000 person-years). The main causes of death were cardiovascular disease (CVD) (219 deaths) and cancer (142 deaths). Participants in the low SES group had a higher mortality risk for overall (HR = 1.80; 95% CI: 1.24-2.62), CVD (HR = 1.95; 1.04-3.65) and non-cancer/non-CVD (HR = 2.14; 1.10-4.16) mortality compared to participants in the high SES group. Cancer mortality also tended to be patterned by SES (HR = 1.44; 0.76-2.75). Major lifestyle-related risk factors (smoking, heavy drinking, obesity, diabetes, hypertension, hypercholesterolemia) explained a small proportion of the associations between low SES and all-cause, CVD, and non-cancer/non-CVD mortality. CONCLUSIONS: In this population-based study assessing social inequalities in mortality in a country of the African region, low SES (as measured by occupational position) was strongly associated with overall, CVD and non-cancer/non-CVD mortality. Our findings support the view that the burden of non-communicable diseases may disproportionally affect people with low SES in low and middle income countries