“We don’t worry except when you get sick” — middle aged woman
The epidemiologic transition [1
] describes the shift in population mortality from childhood infectious diseases, nutrient deficiencies, and epidemics at all ages, to degenerative and lifestyle-related diseases at a later age. Many developing countries are undergoing a contemporary version of this transition wherein improved public health measures and medical care help individuals live longer, more productive lives. Concurrently these countries often experience changes in diet (e.g. fewer whole grains, higher fat intake) and reductions in physical activity that lead to higher prevalence of cardiovascular (CVD) risk factors and disease [2
Chronic noncommunicable diseases were estimated to contribute to 59% of global mortality (~32 million deaths) and 43% of the global burden of disease (1998 estimates) [3
]. CVDs accounted for 31% of worldwide deaths and 10% of global disease burden (based on disability-adjusted life years). A dramatic shift will occur by 2025, with low and middle income countries accounting for over 80% of world CVD burden. While demographic shifts will drive much of this change, so too will the dramatic increases in urbanization (projected to exceed 40% by 2021). This trend and its associated lifestyles will contribute to higher rates of diabetes and other important cardiovascular risk factors [2
Population based approaches to reduce CVD have had mixed success in developed and developing countries. Community education, incorporated into the Stanford Three- Community Study, demonstrated a reduced risk of CVD after 2 years among intervention communities relative to control communities [4
]. The Finnish North Karelia Project, a comprehensive community program to reduce CVD risk failed to demonstrate a significant difference between intervention and control communities [5
]. In the Minnesota Heart Health Program, selected intervention components were effective in reducing risk in assigned groups [7
], but overall the program’s effects were only modest and not statistically significant. In the Pawtucket Heart Health Program, early significant differences between a community exposed to an educational, screening, and counseling program and a control community were not sustained [8
]. In the Stanford Five-City Project, after a mass-media educational campaign, the intervention community lowered its short-term relative risk but over time experienced no significant difference in CVD events compared to control cities. The authors concluded that, “[i]t is most likely that some influence affecting all cities, not the intervention, accounted for the observed change” (p. 322) [9
Impact evaluations of similar programs in developing countries are limited. An intervention in Mauritius involving fiscal and legislative measures, the use of mass media, along with school, workplace, and community education, yielded significant 5-year reductions in smoking, hypertension, and hypercholesterolemia prevalence [10
]. Concurrently, diabetes and obesity prevalences, increased by 15% and 56%, respectively.
These studies, although community focused, did not employ research strategies that incorporated the community into the intervention’s design, which may explain the lack of sustained programmatic success while emphasizing the importance of ongoing efforts and the need to tailor programs to the target community. Understanding local norms, beliefs and attitudes is a critical first step in engaging the community and designing an effective sustainable intervention.
The World Heart Federation (WHF) initiated an epidemiologic study based in the three- island country of Grenada to examine effects of the epidemiologic transition on cardiovascular risk. In selecting this Western Hemisphere country, WHF considered several factors. First, Grenada’s geographic isolation made it amenable to public health measures focusing on the modification of local health practices. Second, the traditional Grenadian diet included liberal amounts of seafood, fresh fruit and vegetables, and thus preserving this diet would be expected to help prevent CVD. Third, Grenada was early in the epidemiologic transition, a stage where interventions that mitigate the transition’s negative health consequences would be more likely to have a positive effect. Lastly, its population of 95,000 would allow for a manageable project.
The research reported here was the first part of this multi-stage community-based research project to study heart health in each of the three islands of Grenada. Given the pre-existing differences among the three islands (e.g. infrastructure, industry, access to health-related resources) generalizability of findings from one island to another was not assumed. On each island a similar methodology would be followed: formative research (using qualitative methods); CVD and risk factor surveillance (epidemiologic survey); and programmatic interventions. The latter would be designed to moderate the development (primary prevention) or progression (secondary prevention) of CVD and its risk factors. The formative findings would inform the surveillance methods and processes and the program interventions to assure alignment with the local environment and the community’s beliefs and practices. We report findings from the formative research conducted on one of the islands, Carriacou.