Barriers to prevention

• Cultural, behavioral, and political barriers to non-communicable disease (NCD) prevention exist for public health. Fighting the source of the problem is as important as fighting the risk factor itself.

• Most physicians are trained to treat overt disease with little understanding of the importance of prevention. Many Indians including physicians are willing to accept the disease as Karma, which leaves little room for prevention. The physicians themselves need to be educated about the importance of prevention and the patients should be willing to accept and act on the advice of the physicians.

• As urbanization and globalization bring beneficial changes to low and middle income (LMIC) countries, it also increases the risk factors for cardiovascular disease (CVD) and promotes unhealthy practices. Being mindful of how changes can affect a community’s diet or access to physical activity is an important step in healthy urbanization.

• Increasing awareness amongst patients as well as healthcare professionals about the heightened risk of CVD and diabetes is of paramount importance. Wider efforts need to be taken at national level with input from health care professionals, non-government organizations, diabetes organizations, government authorities, and community leaders to tackle this challenge.

• In the UK, the South Asian Health Foundation (SAHF) in collaboration with Diabetes UK and Department of Health is working in this direction.¹ 

• The notion that antihypertensive medicines are “habit forming” keeps many people from receiving effective treatment. They don’t realize that their lives will actually be shortened by harboring such fears. Hypertension control is as low as 6% in some communities in India. Potential explanations include inadequate communication by the treating physician about the importance of medications and poor adherence by the patients. Adherence to prescribed medications varies inversely with the cost borne by the patient.

• The cost of preventive care is rarely reimbursed by the government or the insurance companies like that of the curative care.

• A major problem with primary and secondary prevention in India is that the health insurance rate is low (<5%). Worse yet, the cost of medications are not covered by any insurance, which covers only the hospitalization costs.

• While much is known about the elements required for effective and safe prevention, little is known about how to deliver these reliably and affordably in new disease epicenters such as India. If this could be achieved on a large scale throughout India, several million people would be saved each year from death or disability during the most economically productive years of their lives. 

• A study in the UK revealed that South Asians have poor knowledge of diabetes and heart disease.² As high as 20-35% not only did not know any preventive measures against heart disease, but also could not identify any risk factors. Many subjects did not even understand the term heart disease. ²

• Despite a higher CAD morbidity and mortality compared with white Caucasians. South Asians are less likely to be prescribed statins and other cardioprotective treatments.³ Therefore, conventional approaches to the testing and treatment of risk factors are not likely to be sufficient in the south Asian population.³

• Reducing excess risk in South Asians requires multilevel, positive, mainstream and targeted measures using multiple approaches. These should address awareness, access, services, discrimination, cultural sensitivity and biologic factors, modified for different countries, situations and contexts. The Indo-US Healthcare Summit provides comprehensive, detailed and practical recommendations, advocating primordial, primary, and secondary prevention by government, medical communities, the public, industry and the media.⁴

• Policy, grass-roots change, and community building should encourage healthy living at all ages, and remove barriers. Population screening, awareness and change should start early and tap community strengths, such as social and cultural occasions. 

Sources 

1. Gholap N, Davies M, Patel K, Sattar N, Khunti K. Type 2 diabetes and cardiovascular disease in South Asians. Prim Care Diabetes. Sep 23 2010.

2. Rankin J, Bhopal R. Understanding of heart disease and diabetes in a South Asian community: cross-sectional study testing the ‘snowball’ sample method. Public Health. 2001;115(4):253-260.

3. Barnett AH, Dixon AN, Bellary S, et al. Type 2 diabetes and cardiovascular risk in the UK south Asian community. Diabetologia. Oct 2006;49(10):2234-2246.

4. Enas  EA, Singh V, Gupta R, Patel R, et al. Recommendations of the Second Indo-US Health Summit for the prevention and control of cardiovascular disease among Asian Indians. Indian heart journal. 2009;61:265-74.