|Year : 2016 | Volume
| Issue : 4 | Page : 273-278
Feasibility of assessing the awareness of cardiovascular risk through Health Passport approach: A pilot study
Nilamadhab Kar1, Gajendra Kumar Parhi2, Shreyan Kar3, Brajaballav Kar4
1 Black Country Partnership NHS Foundation Trust, Wolverhampton, West Midlands, UK
2 Quality of Life Research and Development Foundation, KIIT University, Bhubaneswar, Odisha, India
3 Quality of Life Research and Development Foundation, KIIT University, Bhubaneswar, Odisha, India; Adams' Grammar School, Newport, Shropshire, UK
4 School of Management, KIIT University, Bhubaneswar, Odisha, India
|Date of Web Publication||14-Sep-2016|
Dr. Nilamadhab Kar
Steps to Health, Showell Circus, Low Hill, Wolverhampton, WV10 9TH
Source of Support: None, Conflict of Interest: None
Background: The risk of cardiovascular disorders is high among the Indian population; however, the awareness about it seems to be a concern. Aim: It was intended to study the feasibility of assessing the awareness of cardiovascular risk at a community level and providing the related information about remedial measures through a Health Passport approach. Methods: Consecutive 38 individuals attending health camp were assessed for specific personal and family history of obesity, hypertension, diabetes, and heart disease. Current risk factors such as exercise, smoking, drug use, stress, and depression were ascertained, and body mass index (BMI), waist circumference (WC), blood pressure were measured to assess the cardiovascular risk based on Framingham criteria. The individualized information along with some key health facts were provided to the participants in a document termed as Health Passport for their reference. Results: There was a general lack of awareness regarding the cardiovascular risk factors in the studied sample. Most participants were above the threshold for blood pressure (65.8%), BMI (71.1%), and WC (73.7%) requiring specific action and more than half (57.9%) had higher cardiovascular risk. The assessment completed in a community set up with basic facilities could provide information regarding the existing risks prompting health actions. The participants considered the Health Passport as a comprehensive initial step toward improving their awareness. Conclusion: It was feasible to assess the awareness about cardiovascular risk and provide individualized health-related information through the Health Passport approach which appears adaptable in health care setups and may improve the awareness.
Keywords: Awareness, cardiovascular, community, health, Health Passport, India, risk
|How to cite this article:|
Kar N, Parhi GK, Kar S, Kar B. Feasibility of assessing the awareness of cardiovascular risk through Health Passport approach: A pilot study. CHRISMED J Health Res 2016;3:273-8
|How to cite this URL:|
Kar N, Parhi GK, Kar S, Kar B. Feasibility of assessing the awareness of cardiovascular risk through Health Passport approach: A pilot study. CHRISMED J Health Res [serial online] 2016 [cited 2021 Sep 18];3:273-8. Available from: https://www.cjhr.org/text.asp?2016/3/4/273/190576
| Introduction|| |
Increased morbidity and mortality secondary to higher prevalence of metabolic disorders in India and other South Asian countries has been a concern.,, The World Health Organization (WHO) attributes 80% of heart disease, strokes, and Type 2 diabetes mellitus to four modifiable risk factors: Smoking, poor diet, physical inactivity, and alcohol. However, it has been found that a considerable proportion of the population is not aware of their risk status. It has been reported that the awareness level is comparatively lower in rural than urban population; however, awareness has also been found to be inadequate even in educated people. It has been suggested to develop strategies that may help improving the awareness. This is, especially important as action on the modifiable risk factors may decrease cardiovascular morbidity and mortality.
Concept of Health Passport has been there since long as a probable method of improving awareness and encouraging healthy life style. However, its utility has been reported to be mixed.,, On the above background, it was intended to find out whether it is feasible to assess awareness about metabolic and cardiovascular risk factors at community level clinics and inform the individuals about these through Health Passports.
| Methods|| |
The Health Passport was designed with five major constructs which included: (i) demographic variables; (ii) existing stable risk factors e.g. family history, already diagnosed long-term illnesses; (iii) current dynamic/modifiable factors e.g. exercise, diet, smoking, alcohol and other substance use, weight, life style, stress, depression, etc.; (iv) current health parameters such as physical measurements (height, weight, waist circumference [WC], blood pressure, pulse) and investigations (blood glucose and lipid profile); and (v) current health action plan. The action plan included specific health-related facts and suggestions for specific action. Health Passport was prepared in a single A4 size card with all the relevant information on both sides.
It was a cross-sectional study in a community set up. The sample included all consenting consecutive adults who were attending a health camp. Demographic variables such as gender, age, education, marital status, work, socioeconomic status (based on self-report), specific personal and family history of obesity, hypertension, diabetes, heart disease along with any other known diseases were recorded. Health parameters (height, weight, WC, blood pressure, pulse) were measured. Specific risk factors such as alcohol and drug use, stress, and depression were checked with specific questions.
Definitions of prehypertension and hypertension were taken from the recommendation of the 7th report of Joint National Committee. Risk related to higher body mass index (BMI) was considered based on the WHO Expert Consultation for Asian population. The cut-off score for WC was used as >90 cm for men and >80 cm for women as suggested for Asians by WHO. Following the assessments, the relevant data were used to find out their 10-year risk for cardiovascular disease using BMI based on the Framingham heart study.
The assessment findings were recorded on the passport and relevant factors were discussed before the passport was handed over to the individuals, along with highlighted personalized action plan. The participants were encouraged to take follow-up actions and investigations as relevant.
The project was approved by the Institutional Ethics Committee of Quality of Life Research and Development Foundation. Data collection for the study were done in Balasore, Odisha, in a health check-up camp organized by a local initiative in February 2014.
| Results|| |
The sample consisted of 15 (39.5%) females and 23 (60.5%) males with a mean age of 47.7 ± 11.4 and 50.9 ± 14.7 years, respectively. Most participants were educated; 39.5% at masters level, 39.5% degree, and 10.5% at college level. There were 31.5% housewives and 18.4% retired while all others were employed; and 42.1% of the sample belonged to upper-middle socioeconomic status followed by 34.2% to lower middle. Most (92.1%) of them were married.
A considerable proportion of participants reported family history of obesity (42.1%), hypertension (57.9%), diabetes (60.5%), heart disease (39.5%), and early (younger than 55 in father or brother or younger than 65 in mother or sister) heart disease (13.1%). Clinical profile of the sample based on their self-report is given in [Table 1]. Physical examination findings as observed during the assessment for Health Passport are given in [Table 2].
Based on the examination, in the total sample, 34.2% had prehypertension, 26.3% hypertension Grade 1, and 5.3% had hypertension Grade 2. Majority of the people (71.1%) felt they did not have hypertension; however, among them only 40.7% had normal recording; 33.3% had prehypertension, 22.2% had Grade 1, and 3.7% had Grade 2 hypertension. This suggests that majority were not aware and considering total sample an additional 59.3% people could be identified who would benefit from interventions related to hypertension.
Considering BMI among the total sample, 23.7% were overweight, 36.8% were obese, and 10.5% were severely obese [Table 2]. Most people (73.7%) reported that they did not have obesity and 7.9% did not know. Based on BMI range, out of these 81.6% participants who reported no obesity or did not know if they had, only 25.8% had BMI at acceptable range; 67.7% had increased risk. Considering total sample, an additional 55.3% people were identified who could benefit from weight reduction. Similarly, considering WC, 73.7% of participants involving 86.7% women and 65.2% men could be identified to have specific risk based on the WHO criteria. According to the Framingham criteria, 10-year cardiovascular risk was higher than normal in 57.9% participants.
| Discussion|| |
This study suggested that a considerable proportion of people in community was not aware of their physical health-related risks. More than half of the participants had increased cardiovascular risks based on Framingham Heart Study criteria. In addition, stress and depression were also highly reported. This approach was helpful in identifying the risk factors in a considerable proportion of participants and providing them with the health-action plans.
Extent of the problem
Results of this study regarding cardiovascular risk factors were comparable to the observations in previous studies in India and elsewhere. It appears that the prevalence figures for hypertension as reported in the community studies in India were considerable: It ranged from 26.5% those without diabetes and 73.1% in those with diabetes; and other reported figures were 41%, (and prehypertension 40%), 43.5%, 51.8%, and 65%. Similarly, in a study of Indians living in Australia, it was found that more than a third under the age of 65 years had high blood pressure; prevalence of diabetes (16%) and obesity (61%) were significantly higher compared with the national average for Australia. In the index study, 34.2% had prehypertension and 31.5% had hypertension; 36.8% were obese and 10.5% were severely obese. Based on WC, 73.7% had heightened risk and 10-year cardiovascular risk was present in 57.9% of participants. Even if these disorders were common, yet the lack of awareness about them was quite high as reported in these studies.
In addition to the physical risk factors, there were concerns of lifestyle factors, stress, and depression. It was interesting to observe that in the studied sample, reported prevalence of smoking, alcohol or drug use was low. However, around one in ten chewed tobacco, an identified risk for oral cancer which is of specific concern in India with highest number of cases in the world., More than half the participants were not having adequate physical exercise. This being a modifiable risk factor needs to be highlighted.
More than one in five participants in this study reported that they felt depressed for 2 weeks or more in the previous year. As depression is a known risk factor for cardiovascular disorders, it needs to be explored, especially in the individuals with higher risk of cardiovascular disorders. A minority of participants (13.1%) reported feeling stressed many times or almost always. It is known that stress affects both mental and physical health in various ways. Although stressful situations and incidences are ubiquitous and individual vulnerability differs; the findings suggested the need for the identification and specific support that may be helpful in decreasing the impact on cardiovascular morbidity.
These observations indicated the gravity of the problem in Indian population and the need for improving public awareness.
Most studies reported sub-optimal level of awareness about cardiovascular risk factors; although the proportion of people who were unaware varied widely in different populations studied.,,,, For example, proportion of people unaware of their hypertensive status ranged from 20.1% in middle-class urban participants, to 54% in a semi-urban population; and rural elderly population were found to be, especially less likely to be aware. In a study of Indians living in Singapore and those in rural India, 27.6% and 74.7% were not aware about their hypertension and while majority with hypertension in Singapore (85%) were receiving treatment, the comparative figure was only 31.6% in rural Indian sample. In a multicenter study in India and Bangladesh, 55% of subjects were not aware about their hypertension. In the index study, 59.3% were not aware about their hypertension and 67.7% were unaware of the increased risk related to their weight. Majority of participants were at risk regarding the truncal obesity based on WC, but were not aware of this.
It has been suggested that increasing awareness of the noncommunicable diseases and ways to prevent them should be the focus of population-wide prevention strategies in South Asian countries. Hypertension and diabetes are already the major public health problems in India with low awareness, which require proactive community-based screening and education. Considering the harm caused by tobacco, it has been urged that cardiologists should take measures to raise patient and community awareness. It has been reported that awareness can be increased by public education.
One of the ways of improving awareness regarding risks and intervention methods is to assess the individual specific risk factors and provide personalized health action plans. In this regard, the Health Passport approach appears appropriate which involves: Focused enquiry of risk factors during assessment, providing information about the abnormal values of clinical examination and investigation, and participatory preparation of person-specific health action plans. It was observed in this study that the participants were interested and engaged in the process.
Often the visits to the hospitals are symptom/illness-specific; and in a highly specialized medical environment, patients receive a specific, specialized attention. There may not be any scope for review of their overall risk-factors or to communicate individualized action plans. Many times, patients do not inform about the risks as they are not aware or they consider them not relevant to the presenting complaints. The findings of this study suggested that it was possible to assess the risk factors and suggest relevant health actions. The whole process of preparing Health Passports including the assessment, documentation, and explanation could be completed within the period of consultation. It can be easily amalgamated within the usual period of patients' visit for specific complaints to any health care setting. As most of this information are anyway collected during usual clinic visits, it may not take considerably more clinician-time to record and provide remaining information. This approach providing information about individualized risk factors and suggesting remedial actions in a Health Passport may be a reference point improving awareness, engagement, and health-promotion actions. Considering life style factors, drug use, exercise, stress, and depression, it can be highlighted that there are much scope for intervention and some of the risk factors can be modified.
Key features for Health Passports should be that they are personalized to the individual, structured, preferably in the first language (mother-tongue), should have specific messages for health-action or change. There should be scope for follow-up through periodic check-up, which can be done face-to-face or in a tele-health approach. Health Passports may be serialized, e.g. following the initial document with general health-related information subsequent ones may cover specific need-based areas.
One of the limitations of the study was the small sample size; however, this was a pilot study evaluating the feasibility of this process. Study findings may be replicated in a larger sample and in different levels of medical set ups. Availability of clinical investigation reports would have been helpful in the risk assessment process; however, it was possible to convey the indications for specific investigations such as glucose and lipids, as a prompt for health actions. The Framingham heart study criteria for 10-year cardiovascular risk was based on Caucasians, so the risk figures for Indians or Asians may not be accurate, but they may be an underestimate considering the known higher vulnerability of Asians than Caucasians. This study assessed the awareness in a sample that were attending a health camp; that amongst general public in the community cannot be commented.
| Conclusion|| |
There was a considerable lack of awareness regarding the health risks in the studied sample. It was feasible to provide specific information regarding the risks and remedial actions in a written, individualized Health Passport, which might help in improving awareness and might act as a reference upon which their future health-actions and changes in risk status can be followed up. Future studies may be conducted to assess the changes in the awareness and health actions through Health Passports and the cost-effectiveness of this approach in changing health-related risks.
Health check-up camps in the community and this study were supported by the Quality of Life Research and Development Foundation and Geriatric Care and Research Organization in Bhubaneswar, India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
ajaj S, Jawad F, Islam N, Mahtab H, Bhattarai J, Shrestha D, et al.
South Asian women with diabetes: Psychosocial challenges and management: Consensus statement. Indian J Endocrinol Metab 2013;17:548-62.
Misra A, Bhardwaj S. Obesity and the metabolic syndrome in developing countries: Focus on South Asians. Nestle Nutr Inst Workshop Ser 2014;78:133-40.
Misra A, Khurana L. The metabolic syndrome in South Asians: Epidemiology, determinants, and prevention. Metab Syndr Relat Disord 2009;7:497-514.
Bansal M, Shrivastava S, Mehrotra R, Agrawal V, Kasliwal RR. Time-trends in prevalence and awareness of cardiovascular risk factors in an asymptomatic North Indian urban population. J Assoc Physicians India 2009;57:568-73.
Yip W, Wong TY, Jonas JB, Zheng Y, Lamoureux EL, Nangia V, et al.
Prevalence, awareness, and control of hypertension among Asian Indians living in urban Singapore and rural India. J Hypertens 2013;31:1539-46.
Williams CL, Wynder EL. Motivating adolescents to reduce risk for chronic disease. Postgrad Med J 1978;54:212-4.
Simmons D, Gamble GD, Foote S, Cole DR, Coster G; New Zealand Diabetes Passport Study. The New Zealand Diabetes Passport Study: A randomized controlled trial of the impact of a diabetes passport on risk factors for diabetes-related complications. Diabet Med 2004;21:214-7.
Völler H, Dovifat C, Schulz T, Lötsch M, Müller-Nordhorn J, Bestehorn K, et al.
Acceptance of a patient passport in secondary prevention of coronary heart disease. Dtsch Med Wochenschr 2004;129:1183-7.
Anderson N, Sridharan S, Megson M, Evans A, Vallance J, Singh S, et al
. Preventing chronic disease in people with mental health problems: The HEALTH passport approach. Psychiatrist 2012;36:208-13.
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, et al
. The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: The JNC 7 report. JAMA 2003;289:2560-72.
WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004;363:157-63.
D'Agostino RB Sr., Vasan RS, Pencina MJ, Wolf PA, Cobain M, Massaro JM, et al.
General cardiovascular risk profile for use in primary care: The Framingham Heart Study. Circulation 2008;117:743-53.
Gupta A, Gupta R, Sharma KK, Lodha S, Achari V, Asirvatham AJ, et al.
Prevalence of diabetes and cardiovascular risk factors in middle-class urban participants in India. BMJ Open Diabetes Res Care 2014;2:e000048.
Adhikari P, Pemminati S, Pathak R, Kotian MS, Ullal S. Prevalence of Hypertension in Boloor Diabetes Study (BDS-II) and its risk factors. J Clin Diagn Res 2015;9:IC01-4.
Farag YM, Mittal BV, Keithi-Reddy SR, Acharya VN, Almeida AF, Anil C, et al.
Burden and predictors of hypertension in India: Results of SEEK (Screening and Early Evaluation of Kidney Disease) study. BMC Nephrol 2014;15:42.
Kalavathy MC, Thankappan KR, Sarma PS, Vasan RS. Prevalence, awareness, treatment and control of hypertension in an elderly community-based sample in Kerala, India. Natl Med J India 2000;13:9-15.
Hypertension Study Group. Prevalence, awareness, treatment and control of hypertension among the elderly in Bangladesh and India: A multicentre study. Bull World Health Organ 2001;79:490-500.
Fernandez R, Rolley JX, Rajaratnam R, Sundar S, Patel NC, Davidson PM. Risk factors for coronary heart disease among Asian Indians living in Australia. J Transcult Nurs 2015;26:57-63.
Gupta B, Ariyawardana A, Johnson NW. Oral cancer in India continues in epidemic proportions: Evidence base and policy initiatives. Int Dent J 2013;63:12-25.
Mishra A, Meherotra R. Head and neck cancer: Global burden and regional trends in India. Asian Pac J Cancer Prev 2014;15:537-50.
Saran RK, Puri A, Agarwal M. Depression and the heart. Indian Heart J 2012;64:397-401.
Ray M, Guha S, Ray M, Kundu A, Ray B, Kundu K, et al.
Cardiovascular health awareness and the effect of an educational intervention on school-aged children in a rural district of India. Indian Heart J 2016;68:43-7.
Divakaran B, Muttapillymyalil J, Sreedharan J, Shalini K. Lifestyle riskfactors of noncommunicable diseases: Awareness among school children. Indian J Cancer 2010;47 Suppl 1:9-13.
Kumar G, Mohan S, Yadav L, Arora M. Global tobacco surveys: Information for action by cardiologists. Glob Heart 2012;7:99-105.
Somannavar S, Lanthorn H, Deepa M, Pradeepa R, Rema M, Mohan V. Increased awareness about diabetes and its complications in a whole city: Effectiveness of the “prevention, awareness, counselling and evaluation” [PACE] Diabetes Project [PACE-6]. J Assoc Physicians India 2008;56:497-502.
[Table 1], [Table 2]