Action research to prevent non-communicable disease
Global organizations are needed to face the rapidly growing challenge in low and middle income countries of research for non-communicable diseases, which are deeply culture and context-dependent. But research on NCDs in developed countries is at least partially relevant, and a new research partnership between developing and developed countries – CAPCoD - is edging open the door.
By Corrie Paeglow, Mahmood Adil, Derek Yach - Global Health Division, Yale School of Epidemiology and Public Health (Sept 05)
Chronic diseases account for 50% of mortality worldwide (see 1). While this is largely seen as a problem of the developed world it is having a devastating effect in the developing world: cardiovascular disease is a leading cause of death in the developing world with nearly three million deaths in India and China each year attributable to CVD. Another 1.7 million deaths are attributable to smoking in these countries, making chronic diseases responsible for more than 7.7 million deaths in just these two developing countries (see 1). However, organizations that fund health research have largely ignored this growing threat and have continued to focus their efforts on infectious diseases.
The small amount of chronic disease research that has been done has been conducted in the developing world. Studies like the North Karelia Program in Finland and the Framingham Heart Study in the United States have outlined both the causes of chronic diseases in developed countries and successful interventions in preventing chronic disease in these countries (see 2 and 3). However, the lessons learned from these programs are not easily applicable in developing countries for two reasons: culture and the differing burden of disease faced by developing and developed countries.
Clearly, public health interventions – especially those that involve matters that are closely linked to culture such as diet and physical activity - need to be both culture-specific and culturally competent. In some countries, women are not allowed to go out alone in public, nor is it acceptable for them to exercise in the presence of men. Promoting physical activity in this population requires more than just a public information campaign – there are other issues that need to be solved creatively.
In addition, the problem of chronic disease is different in developing and developed countries; many developing countries face a double-sided problem of overweight/obesity and underweight/malnutrition while the issues in developed countries are centred exclusively on overweight. Interventions in developed countries can thus narrowly focus on overnutrition and lack of physical activity while developing countries must look at any intervention more holistically.
In the past few years there has been some effort to correct this research imbalance, most notably in Iran and Brazil. The Isfahan Healthy Heart Program (IHHP) was begun in 1999 and will run until later this year. While final data from the program is not yet published, a number of sub-studies have been published that show, for example, that although Iranian teenagers’ fat consumption does not exceed the daily recommended percentage of calories, their intake of saturated fats—which are closely associated with high cholesterol —is still elevated (see 4 and 5). Adolescents’ attitudes towards smoking have also been analyzed; results reveal that having knowledge about the dangers of smoking does not correspond to a lower smoking rate compared to those who are unaware of the dangers (see 4 and 5). Clearly, these results are just a small part of the data and findings that will emerge from the Isfahan project within the next few years. The future data will likely be even more compelling as it will go beyond describing the problem and will indicate whether the interventions the project has used have been effective.
The Agita Sao Paulo program, designed to encourage physical activity among the population of Sao Paulo, Brazil, has proven extremely effective. The program used extensive partnerships, including governmental organizations, non-governmental organizations and the business sector, to implement the intervention. The end result of this collaboration was that the message about physical activity reached 55.7 % of the population, and those who were reached by the intervention were more likely than those who were not reached by the intervention to meet the physical activity standards (see 6).
While the projects in Iran and Brazil vary in many ways, they illustrate two major components that are necessary for research programs to have an impact in the community: the need for partnerships and the need for multisectoral interventions. The Agita Sao Paulo program achieved its results by using large awareness raising events and more personalized health education activities directed toward particular communities (i.e. blue collar workers, students, the elderly). The IHHP has individual, group and community aspects and includes policy interventions, mass media messages and community partnership activities. Both programs also used partnerships to achieve their goals: Agita Sao Paulo collaborated with nearly 160 organizations and IHHP with several governmental and nongovernmental organizations.
If more chronic disease prevention research is to be conducted and the results used to actually improve health, there will be a continuing and expanding need for partnerships. To meet this need the Oxford Heath Alliance - itself a partnership of academics, corporations, NGOs and public health professionals - has created Community Action to Prevent Chronic Disease (CAPCoD), the action research arm of the alliance. There has been a lack of money for researchers from developing countries to develop research proposals and obtain funding with the help of experts in grantsmanship. CAPCoD is making these resources available by connecting researchers in developing countries with grant writing experts, mentors, and teams with similar projects and thus increasing chronic disease research capacity world-wide.
CAPCoD was begun this year with an intensive research workshop from 11-20 May that involved 24 research teams working on chronic disease proposals (click here to see the table of CAPCoD Principal Investigators). The teams represent countries and communities from both the developing and developed world: Brazil, Cameroon, South Africa and Australia, to name a few. In many cases, the target population is a pocket of the developing world in the developed world – such as Aborigines in Australia and Native Alaskans in the United States. Many of the projects involve multiple collaborators including universities, local and national public health bodies, and community organizations.
After the May meeting, these projects have continued in the spirit of partnership by creating two collaborating groups: one for projects with a school-based focus and one for projects with a community-based focus. These groups are working to refine their research proposals and invite other collaborators to fund their projects. The final project proposals will be presented at the Oxford Health Alliance Summit in October 2005 at Yale University.
CAPCoD, however, cannot entirely meet the need for chronic disease research. CAPCoD has a budget of US$400 000 this year for seed funding of the projects, but implementing them would require an investment of US$15-20 million over five years. While the burden of disease due to chronic disease is slated to grow there are no global organizations that focus exclusively on chronic disease research as there are for AIDS, tuberculosis, malaria and vaccines. Now is the time for corporations, governments, and philanthropic organizations to recognized the need for chronic disease research and put their resources towards this major problem.
Statement of interests: The authors are funded by the Oxford Health Alliance and Novo Nordisk.
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