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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 4, July/August 2017
AFRICA
253
the region. The following information should then be recorded:
the presence/absence of diabetes mellitus, gender and age of the
patient, history of smoking habits, systolic blood pressure and
total cholesterol level. These charts are very useful tools that can
help non-physician health workers to identify patients with high
cardiovascular risk and motivate them, particularly on lifestyle
changes and when appropriate, to take anti-hypertensive or lipid-
lowering drugs and aspirin.
When using these WHO charts, the non-physician health
worker must realise that risk stratification is not necessary for
making treatment decisions in individuals who belong to the
high-risk category, including patients with established CVD,
those without established CVD who have a total cholesterol ≥ 8
mmol/l, those with low-density lipoprotein (LDL) cholesterol ≥
6 mmol/l, those with total cholesterol/high-density lipoprotein
(HDL) cholesterol ratios > 8, individuals without established
CVDwho have persistently raised blood pressure > 160–170/100–
105 mmHg, those with type 1 or 2 diabetes mellitus with overt
nephropathy or other significant renal disease, and patients with
renal failure and renal impairment.
Cardiovascular risk prevention at the primary
care level
In sub-Saharan Africa, the levels of some risk factors are still
relatively low compared to levels in developed nations. For
example, many people in rural settings have low-fat diets, regular
physical activity and do not smoke.
14
However, the prevalence of
other risk factors such as hypertension and diabetes mellitus is
of concern; for example, up to 35% of adults aged 25 to 64 years
have hypertension.
14
To prevent an explosion of the growing risks of CVD
in sub-Saharan Africa, there must be interventions at the
community level, targeting people who do not have established
CVD, by reducing risk factors such as high blood pressure,
diabetes mellitus and smoking.
15
To prevent an unhealthy diet, the
consumption of local fruit and vegetables should be promoted,
as well as reduction of intake of salt, refined sugars and animal
fat. People should be encouraged to use vegetables and cereals
commonly found in their environment. The promotion of
moderate physical activity should be encouraging and inactivity
discouraged. Control of diet and physical activity will result in
reduction in incidences of obesity, hypertension, high cholesterol
levels and diabetes mellitus.
At the primary care level, hypertension is also preventable
through a proper diet and physical exercise. A well-tailored
hypertension control programme could detect undiagnosed and
unregulated hypertensive individuals and thereby significantly
reduce the incidence of stroke, heart failure, renal failure and
peripheral vascular disease. This could be achieved through
regular awareness campaigns in the media, especially on radio and
television, and through organised lectures at primary healthcare
centres, out-patient departments of secondary and tertiary health
care centres, and in community halls, churches and mosques.
Primary care prevention of CVD: the Seychelles
example
A national programme on the prevention of CVD was initiated
in 1991
16
in the Republic of Seychelles, which consists of 115
islands in the Indian Ocean and had a population of 78 846 in
1998. This programme was initiated following an epidemiological
survey between 1985 and 1987,
17
which showed very high rates
of cerebrovascular disease (higher than in most European
countries) and medium rates of ischaemic heart disease (similar
to those in southern European countries) were prevalent in the
country, especially in young and middle-aged men. There was
also a high prevalence of the classic modifiable risk factors such
as hypertension and diabetes mellitus in the adult population,
and a substantial proportion of the children were overweight.
The epidemiological survey further attributed the high burden
of CVD in Seychelles to dramatic lifestyle changes such as
larger consumption of saturated fatty foods, increased intake
of salt and calories, and increased prevalence of smoking
and sedentary lifestyles.
18
The dramatic changes in lifestyle
were attributed to accelerated socio-economic development and
improved standards of living, with the gross national product
(GNP) per capita multiplying by 10 (from 600 US$ to 6 000 US$)
within 20 years.
Although this programme was started by the Seychelles
Ministry of Health-based Unit for the Prevention and Control
of Cardiovascular Disease (UPCCD), it progressively involved
other sectors such as communities, local parastatals, private
companies, international agencies such as the WHO, and
academia. The programme was community based, involving
non-physician healthcare workers and it was aimed at the
promotion of healthy lifestyles and the control of risk factors in
the population, in an attempt to prevent and control premature
morbidity from CVD, diabetes mellitus and cigarette smoking.
The main approaches used in the Seychelles primary CVD
programme included:
•
Campaigns to raise awareness in the country through the use
of media, especially radio and television.
•
Screening of risk factors in schools through the systematic
assessment of body mass index, blood pressure, smoking and
other lifestyle habits within routine school medical visits
administered to all school children aged five, nine, 12 and 15
years. This screening helped for detection and counselling of
children with abnormal readings.
•
Through the World No Tobacco Day programme in the
Seychelles, high-profile activities were organised involving
large segments of the population, as a main tool for health
education on tobacco control. Such events were organised to
last several weeks or months, thereby exposing the public to
prolonged health education.
Although the Seychelles CVD prevention programme initially
relied mostly on health-promotion activities, additional
emphasis was progressively put on interventions targeting high-
risk individuals, and such measures included the following:
•
Risk-factor screening in public places and work sites were
organised, with a good response. Several companies even
provided financial support, so that plasma cholesterol could
be measured for all their workers, using point-of-care meas-
urements. In order to ensure diagnosis of high blood pressure
and to limit the number of referrals to health centres, screen-
ing procedures were extended to include follow-up visits along
defined protocols for suspected cases of hypertension, diabe-
tes mellitus and dyslipidaemia.
•
Health clubs were organised at the community level for
high-risk individuals, to encourage them to adopt healthy