Online braz j nurs

Abstract. Context. Despite the growing number of CVD in Brazilian general population reported, community-based interventions, which are essential in this context, are scarce and rarely evaluated. Objective. The aim of this study was to carry out a community- and/or practice-based level research intervention, to develop and evaluate a set of CVD prevention actions targeting the vulnerability of Brazilian population. Method. Literature review was done in 2 databases, Scielo and Online Brazilian Journal of Nursing, from 2006 to July 2009. Results. Two hundred and two articles concerning the subject were identified and analyzed, but only 43 were retrieved. The results showed that research in CVDs prevention remains undeveloped compared to other aspects of cardiovascular disease treatment. Mainly of the reports are related to practice-based interventions. Conclusions. There is a pressing need for practice-based interventions to prevent CVD in the population lead by registered nurses and for the executive nurses the pressing need is related to define and implement community-based interventions related to preventive interventions for CVDs.

Keywords. Cardiovascular; nursing; public health; health promotion; disease prevention

Introduction

The cardiovascular diseases (mainly Chagas Disease, ischemic heart disease and stroke) has been an important cause of death in Brazil.

The 2005 Brazilian Government Health Database Report (DATASUS)[1] presented a mortality rate for ischemic heart disease of the 46,12. For cerebral vascular disease the rate was 48,87 while for other cardiovascular diseases, the mortality rate was 59,17.

The estimated directand indirect costs of CVD are significant. Based on government data [2], the annual costs exceed US$ 602 billion in 2004 (8% PIB). The sheer magnitudeof the epidemic CVDs necessitates a strong emphasis on preventionto reduce the burden of CVD in Brazilian society.

Although Brazil has an universal health care system, the access to and utilization of health care are not equal for all population. There are profound differences related to race and gender.

Race and gender are part of the social determinants of health (SDH) that are conditions in which people are born, grow, live, work and age, including the health system. These determinants are mostly responsible for health inequities - the unfair and avoidable differences in health status seen, for example, within Brazilian population.

Obviously, a biased health system is not effective for CVD prevention and health promotion even with universal coverage, focusing on primary health care, because the SDH interfere negatively in the establishment of the policies.

So, as consequence we have that the deaths provoked by cardiovascular diseases are the second cause in the mortality ranking. The first cause of death in Brazil is violence.

The data presented by the Instituto Brasileiro de Geografia e Estatística -IBGE[3] (http://www.ibge.gov.br/english/) revealed that the CVD mortality tax is high for men, but for African-Brazilian men the tax is 359,85 while for white men it is 212,93.

But, the mortality of cardiovascular diseases is increasing also as a result of ageing populations and rapidly changing lifestyles (in particular, tobacco smoking, unhealthy diets, and physical inactivity). Evidence-based, affordable approaches for CVD prevention and control are urgently needed.

The objectives of this study are to identify evidence-based, cost-effective community and practice-based strategies and interventions for CVD prevention; and to form recommendations for the appropriate use of the community and practice-based interventions in Brazil, particularly. We consider that community and practice-based intervention, mainly nursing interventions, must be implemented because they have the potential to reduce the prevalence of cardiovascular disease risk factors and consequently reduce cardiovascular disease incidence, morbidity, and mortality.

- What are the community- and practice-based CVD Prevention Trials; Successful Intervention Strategies and Outcomes for the Brazilian population?

This paper is a literature review. The concepts[4] for considering studies for this review are:

- A community-based intervention for cardiovascular disease prevention is defined as any primary prevention and secondary prevention 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.

- A practice-based intervention for cardiovascular disease prevention is defined as any health professional action that attempted to reduce the population burden of CVDs by implementing at least one intervention (ie, community mobilization, social marketing, school-based health education, worksite health promotion, screening and referral of those at high risk, education of health professionals, direct education of adults, and modification of physical environments).

The search strategy for identification of studies has utilized 2 databases, Scielo and Online Brazilian Journal of Nursing, from 2006 to July 2009, using medical subject heading “cardiovascular disease*” together with relevant diagnostic terms (ie. Chagas Disease, coronary and other atherosclerotic disease, peripheral arterial disease, and stroke). Text word searches were done for specific populations (women, children/adolescents, elderly, and African-Brazilian) and interventions (risk assessment, life style modification, guidelines, clinical tools, education, and advocacy), but they were limited to “title/abstract”.

Two hundred and two articles concerning the subject were identified and analyzed. Brazilian experiences reports about prevention only were retrieved. Forty-three papers were retrieved (none was a randomized controlled trial). The search results showed that research in CVDs prevention remains undeveloped compared to other aspects of cardiovascular disease treatment. Mainly of the reports are related to practice-based interventions.

Most of the papers related to intervention programs for cardiovascular disease risk assessment concluded that is elevated the prevalence of hypertension, diabetes, smoking, overweight or obesity, total cholesterol, sedentary lifestyle, and regular alcohol consumption [5] [6],[7],[8], [9],[10] [11] [12] [13] [14] [15]. The vulnerable people are mainly African-Brazilians[16]. The researchers concluded that is necessary higher public investment on education and orientation of the Brazilian population as regards prevention.

Stroke, Coronary and Other Atherosclerotic Disease, Peripheral Arterial Disease (PAD), and Chagas´Disease

None paper or study related to an intervention program was found for prevention of these health problems at the community level.

The few studies found about CVD prevention for women suggest that misperceptions still exist that CVD is not a real problemfor Brazilian women, in any age. Only one was related to pregnant women[17] and the 3 others to post-menopausal women[18] [19] [20].

Due to an aging Brazilian population and because the risk of CVD increases with age, there is a need for an increased awareness of the importanceof CVD as a major public health issue for older people. But only 4 studies were found about CVD prevention for elderly. One of them is related to primary prevention[21] the others were related to practice-based interventions to secondary prevention [22] [23] [24].

It is important to understand how potential risk factors evolve in childhood for Brazilian population and, especially, how to prevent them. The practice-based interventions reports related to CVD prevention for children and adolescent found hypertension[25] and/or, hyperlipidemia [26] [27], smoking and alcohol[28], and overweight or obesity[29] [30]as important precursors of CVD in Brazilian adults.

The three studies found about life style interventions for CVD prevention suggest that health professionals don’tfocus on life style in the way we should.

One study evaluated a community-based intervention focused on exercise. The authors suggested suggest that exercising should be further promoted with a special focus on sedentary women[31].

The two other studies reported practice-based interventions for special populations: Brazilian-Japanese women[32] and workers[33]. Both focused on physical exercises. Only Santos et al (2008) implemented interventions for stress management, a healthy diet, and the absence of alcohol and smoking.

None paper or study related to a practice-based intervention program was found for prevention of the hypercholesterolemia at the community level.

The IV Brazilian Hypertension Guidelines was published in 2004[34]. The studies found about hypertension guidelines for CVD prevention evidenced that there is only partial compliance with Brazilian Hypertension Guidelines and that certain factors, for example standardization of values for diagnosis and therapeutic target[35] [36].

One study[37] pointed out the Family Health Care Program (a public health care program) as a good strategy for the management of arterial hypertension, although the associated risk factors have remained at higher levels than those recommended and thus needing better management.

Three studies related to overweight and obesity regarding CVD prevention have an adult sample (workers and Brazilian-Japanese) [38] [39]. The other five studied school children and adolescents[40] [41] [42] [43] [44] [45] [46]. In the light of these findings intervention measures all studies recommended to prevent excessive weight gain during childhood, as well provide health education in schools and work places

None paper or study was found related to Diabetes and a practice-based intervention program for CVD prevention at the community level.

None paper or study was found related to smoking cessation and a practice-based intervention program for CVD prevention at the community level.

Only 2 studies examined the social class or race/ethnicity-related health disparities in prevalence of cardiovascular disease risk factors in Brazil.

One of the social determinants that have a great impact on equity in health outcomes is racism whether it is at an individual level or institutionalized. It has been argued that institutional racism (covert or unrecognized) is embedded in Brazilian institutions.

The CVD express the quality of the life style, the healthy or unhealthy habits as well as distress and its management. The study conduced with African-Brazilians treating high blood pressure in the primary level heath care in Rio de Janeiro, Cruz [47] founded in the group a feeling of being discriminated by the health professionals because they were Blacks (p=0,01) and also found differences in the treatment outcomes.

Prejudice related to race, gender, social class create social disadvantaged segments in the Brazilian population, so it must be considered when community based health promotion and disease prevention programs are brought into action [48].

None studies were found related to clinical tools for improvement of the ability of health care providers to care for patients with cardiovascular disease prevention.

All studies related to health education for patients were regarding CVD prevention at a secondary level. The topics were about nutrition and treatment compliance.

Most of the intervention programs for cardiovascular disease conducted in the communities were belong to secondary prevention, aiming to reduce the cardiovascular symptoms and reduce morbidity and mortality from cardiovascular disease in whole communities.

Although the accumulated scientific evidence from epidemiological studies and research on preventive medicine show that cardiovascular diseases are associated with unhealthy lifestyles and human behaviors, the concept of community-based intervention seems to be unknown for Brazilian researchers.

CVD Prevention at the community and practice-based level is essential because modifiable causal risk factors are deeply entrenched in the social and cultural framework of Brazilian society. Although the limited number of publications included in this study, it is necessary to focus research and practice on community-based primary for CVD prevention which target main cardiovascular risk factors, especially three behavioral risk factors(tobacco, unhealthy diet, physical inactivity), as well for improving secondary prevention of major CVD: obesity, high blood pressure, high cholesterol, and tobacco.

Although not including all related publications and cardiovascular problems (as rheumatic heart disease), this review clearly show that there are few Brazilian evidences for community and practice-based intervention for CVD prevention.

So, the following World Health Organization (WHO)[49] recommendations for implementation of community and practice-based interventions for CVD prevention and control should be considered by nurses:

· use several resources to introduce population-wide efforts to reduce risk factors and to adopt a healthy lifestyle through multiple economic and educational policies and programs.

This review shows as consequence for Brazilian registered nurses that there is a pressing need for practice-based interventions to prevent CVD in the population. The recommendations for the executive nurses are related to define and implement community-based interventions related to preventive interventions for CVDs.

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NOTE: This article is my response for participating in the global CVD prevention initiative: a call to action for nursing. The invitation was done by PCNA (Preventive Cardiovascular Nursing Association)’s International Committee to participate in the writing of this paper “Global CVD Prevention: A Call to Action for Nursing” by co-authoring Section IV, Community Based/Public Health Prevention Initiatives. The major mission of the PCNA is to promote nurses as leaders in cardiovascular risk reduction and disease management across the life course of individuals and diverse populations. Toward that goal, PCNA’s International Committee developed a plan to identify and mobilize the international community of nurses in CVD prevention. The first phase of this initiative included concerted efforts to identify nurses and nursing organizations who are involved in science, practice and policy roles in CVD prevention in developed and developing countries. The second phase of this global prevention initiative is the development and dissemination of a state-of-the-art scientific paper that will address the global burden of CVD including the similarities and differences that exist between and within countries and challenges and opportunities for CVD prevention.

Brazilian Research Initiatives for Cardiovascular Disease Prevention at the community- and practice-based level- literature review