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Journal.pmed.1000320

  1. 1. Policy Forum Will Cardiovascular Disease Prevention Widen Health Inequalities? Simon Capewell1*, Hilary Graham2 1 Department of Public Health, University of Liverpool, Liverpool, United Kingdom, 2 Department of Health Sciences, University of York, Heslington, York, United Kingdom Introduction gap. In this Policy Forum article, we ing then translate into substantial reduc- review this evidence, and consider differ- tions in cardiovascular events and deaths Several high-income countries, includ- ent potential approaches for reducing [17–19]. This evidence suggests that ing the United Kingdom, are tackling inequalities. comprehensive policies can be more ‘‘health inequalities’’ [1]. In 2009, the effective in reducing risk factors and various UK governments announced improving health than a high-risk individ- large-scale programmes to screen and The Whole-Population Approach for Preventing CVD ual approach. Furthermore, identifying treat cardiovascular risk [2]. The respec- individuals with a threshold of a 20% 10- tive health ministers stated that the Some two decades ago, Geoffrey Rose year CVD event risk would then necessi- programmes would reduce health inequal- suggested that a small reduction in risk in a tate multiple preventive treatments for ities, although opposition parties generally large number of people may prevent many one-quarter of the population. In the predicted the opposite [3]. The potential more cases than treating a small number UK, this might decrease UK cardiovascu- effects of any screening policy on health at higher risk [10]. He therefore cautioned lar mortality by approximately 17% (as- inequalities clearly need to be urgently against simply pursuing individual-level suming normal adherence). Conversely, considered, not least in order to inform interventions targeted at changing risk country-wide policies to reduce cholesterol current policy development in the UK profiles in this latter group. Rose instead and smoking population levels by just 5% [4,5] and internationally [6]. advocated a dual strategy, also using a would decrease UK mortality substantially The primary prevention of cardiovas- whole-population approach to change more, by about 26% [15]. Capewell et al. cular disease (CVD) is dependent on the everyone’s exposure. That approach reported similar findings for the US effective reduction of the major risk would support policies that work directly population [18]. factors, particularly by reducing tobacco on what Rose called ‘‘the underlying use and adopting a healthier diet [2]. causes of disease’’; for example, via The Whole-Population However, the substantial excess burden of statutory regulation and environmental Approach for Reducing Social morbidity and mortality due to CVD in controls, rather than indirectly by chang- disadvantaged groups raises major chal- Inequalities in CVD lenges. Social gradients in the major ing risk factors on a person-by-person cardiovascular risk factors can explain basis. Whole-population interventions can There is increasing evidence to support approximately three-quarters of this excess indeed reduce risk factors across entire health equity strategies that take a whole- burden; smoking alone can explain more countries. National legislation and fiscal population approach to CVD risk factors. than half [7,8]. policies can be both effective and cost- This includes simply considering arithmet- Assessing the potential effect of risk saving, whether banning industrial trans- ical principles. Disadvantaged groups experience factor reductions on socioeconomic in- fats (Denmark), halving dietary salt in a greater CVD burden. They are thus likely to gain equalities in health is crucial. McLaren et processed foods (Finland), or promoting extra benefit if a risk factor is uniformly reduced al. usefully distinguish between ‘‘agentic’’ smoke-free public spaces (Scotland, Ire- across the entire population, with a consequent prevention strategies (which rely solely on land, Italy, and elsewhere) [11–14]. reduction in absolute (but not necessarily relative) individuals making and sustaining behav- Growing international evidence now inequalities. This simple arithmetic was spelt iour change) and ‘‘structural’’ strategies supports the Rose hypothesis [15–17]. out by Diederichsen and colleagues [20]. (which work through changes in the wider Small reductions in population cholesterol More recent support came from Kivi- social environment [9]. There is increasing concentrations, blood pressure, or smok- maki et al., who quantified the 15-year evidence to suggest that addressing CVD risk factors using ‘‘structural’’ whole-pop- Citation: Capewell S, Graham H (2010) Will Cardiovascular Disease Prevention Widen Health Inequalities? PLoS ulation approaches generally reduces so- Med 7(8): e1000320. doi:10.1371/journal.pmed.1000320 cial inequalities. There is also worrying Published August 24, 2010 preliminary evidence that screening and Copyright: ß 2010 Capewell, Graham. This is an open-access article distributed under the terms of the treating high-risk individuals (‘‘agentic’’ Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any strategies) might increase the inequalities medium, provided the original author and source are credited. Funding: SC and HG are funded by The Higher Education Funding Council for England (HEFCE). HEFCE had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The Policy Forum allows health policy makers around the world to discuss challenges and Competing Interests: SC was Vice-Chair of the NICE Programme Development Group on Cardiovascular opportunities for improving health care in their Disease Prevention in Populations. HG has long advocated policies to reduce social inequalities. This paper societies. arises from discussions at NICE, but does not necessarily reflect the views of NICE. * E-mail: capewell@liverpool.ac.uk PLoS Medicine | www.plosmedicine.org 1 August 2010 | Volume 7 | Issue 8 | e1000320
  2. 2. Summary Points ‘‘nudge’’ (routinely presenting options to increase the likelihood that people will choose what they would on reflection most N The primary prevention of cardiovascular disease (CVD) is dependent on the prefer) [33]. effective reduction of the major risk factors for CVD, particularly tobacco control and a healthier diet. However, population-based structural approaches to reduce inequalities might N The high-risk approach to prevent CVD typically involves population screening. be difficult to achieve. Such approaches Those exceeding a risk threshold are then given lifestyle advice and/or tablets to reduce blood cholesterol and blood pressure. ideally require concerted cross-sectoral efforts such as universal access to healthy N Evidence suggests this high-risk approach typically widens socioeconomic food, reductions in work place stress, and inequalities. Such inequalities have been reported in screening, healthy diet access to safe environments for physical advice, smoking cessation, statin and anti-hypertensive prescribing, and adherence. activity for all [32]. N The alternative approach is population-wide CVD prevention. For example, The High-Risk Approach for legislating for smoke-free public spaces, banning dietary transfats, or halving daily dietary salt intake. Such strategies are generally effective and cost-saving; Preventing CVD there is also increasing evidence that they can reduce health inequalities. In the UK, the high-risk approach for N We conclude that screening and treating high-risk individuals represents a preventing CVD is typified by the health relatively ineffective CVD prevention approach that typically widens social checks programme Putting Prevention First, inequalities. implemented in England [2]. All adults aged 40–74 years will be invited to be screened for CVD risk. Individuals found to benefits of decreasing risk factors uniform- for the effectiveness of a population-wide exceed a 20% risk of a cardiovascular event ly across a male population (reductions of diet intervention comes from the United in the next 10 years will be treated with a 10 mmHg in blood pressure, 2 mmol/l in States. Folic acid fortification of cereals combination of lifestyle advice plus tablets total cholesterol, and 1 mmol/l in glucose) was introduced in 1996. Absolute social to reduce blood cholesterol and blood [21]. Although relative inequalities would differences in blood folate levels were pressure, as appropriate [2]. remain, such interventions might reduce subsequently reduced by 67% [28]. Fur- This is a controversial area. Manuel et the absolute mortality gap between rich thermore, comparable reductions in in- al. recently ‘‘revisited’’ Rose [34]. Their and poor by approximately 70% [21]. equalities in dental caries followed water influential article advocated the high-risk Smoking rates and exposure to environ- fluoridation [29]. The implications are approach [34]. However, their methodol- mental tobacco smoke are higher in clear. Eradication of dietary transfats, or ogy and conclusions were subsequently poorer groups in Scotland, which is halving the salt content of bread, would criticised by Whincup and others [35]. consistent with other high-income coun- disproportionately benefit deprived groups. The methodological limitations identified tries [22]. However, following the Scottish Of course, the population approach is by these critics meant that firstly, the smoke-free legislation in 2006, there was a unlikely to totally abolish inequalities since Manuel analysis systematically over-esti- substantial fall in hospital admissions for many of the drivers of disadvantage lie mated the likely benefit of individual heart attack and ‘‘acute coronary syn- even further upstream. For instance, strategies (by including patients with drome’’ (involving a 14% reduction in structural interventions in the Ontario established CVD, inflating the numbers smokers and a 21% fall in never smokers). Smoke Free Strategy included smoking in the ‘‘high-risk’’ group, assuming that This drop was uniform across social bans in enclosed public places and en- effectiveness in routine clinical practice groups [13]. closed work places, laws on tobacco sales equalled efficacy in RCTs, and ignoring Strong regulatory policies, particularly to minors, and restrictions on the display under-treatment and poor long-term ad- those including increases in cigarette price, of tobacco products in retail outlets. herence). Secondly, they systematically are also associated with declines in tobacco Overall smoking rates in the province fell. under-estimated the contribution of pop- use of a similar magnitude across socio- However, 40% of aboriginal women and ulation strategies (by conservatively assum- economic groups [23]. This suggests that, men are still smoking, as are 34% of adults ing a 2% reduction in population choles- in the many countries where smoking rates with less than a secondary school educa- terol when falls of 10%–18% have been are higher in poorer groups, the absolute tion compared to 11% who had a observed elsewhere, and by using an benefit will be greater than in affluent bachelor’s degree or higher [30]. unvalidated model and also failing to groups. Indeed, men and women in lower The population approach has a strong mention that population approaches to socioeconomic groups appear more re- ethical base. It is in step with the prevention also reduce the pool of high- sponsive to uniform increases in cigarette ‘‘stewardship’’ model of public health that risk people requiring drug treatment) [35]. price than affluent groups [24,25]. How- places obligations on governments to Likewise, Zulman et al. recently pre- ever, attention needs to be paid to how enable conditions in which everyone can ferred a high-intensity treatment interven- inequalities within disadvantaged groups lead a healthy life [31]. Classic examples tion in the US adult population [36]. can influence responses to population- include legislating for clean drinking However, their mortality estimates were 3- wide interventions and their overall im- water, seatbelts, and food hygiene. Such fold higher than previous publications [36]. pacts [26]. principles have long underpinned broader This over-estimate probably reflected suc- Social differences are observed in diet, policies to protect well-being, by regulat- cessive optimistic assumptions about effec- as in smoking. Thus, low-income families ing market economies and providing for tiveness and long-term adherence [36,37]. consume more saturated fat and fewer basic needs [32]. There is also some Furthermore, critics of the high-risk fruits and vegetables than more affluent support from the political right under the cardiovascular risk screening approach families [27]. Strong supporting evidence banner of ‘‘libertarian paternalism’’ or suggest that this strategy might have low PLoS Medicine | www.plosmedicine.org 2 August 2010 | Volume 7 | Issue 8 | e1000320
  3. 3. effectiveness, leave substantial residual Danish health care system, which aims, care workers, financial incentives, and risk, and achieve a small population like the NHS, to ensure equity in medical availability of low-cost generic ‘‘polypills’’ impact at high cost; as well as result in care [47–49]. [64,65]. Evidence to confirm the effective- the medicalisation of previously healthy Likewise, inequalities in anti-hyperten- ness and cost-effectiveness of such targeted individuals. Furthermore, it does not sive therapy have been reported. A recent strategies in reducing health inequalities is address the root causes of the problem study suggested that social and ethnic currently being gathered [66]. Results are [38–40]. Equally seriously, this high-risk disparities in the detection and manage- eagerly awaited. approach will almost certainly widen ment of hypertension have persisted in the inequalities. UK despite major investment in quality Combining the Population- improvement initiatives, including pay for performance [50]. Long-term adherence Based and High-Risk The High-Risk Approach May (compliance) with primary prevention Approaches? Worsen Social Inequalities in CVD medications barely reaches 50%, and is Might a coordinated approach that often worse in more deprived groups [51– integrates population-based and high-risk There is increasing evidence that in- 53]. Furthermore, inequalities in adher- approaches be more effective? The Norsjo equalities in risk factors can widen when ence have been specifically reported for Community Intervention Program in Swe- effects are mediated through individual- both statins and anti-hypertensive medi- den is an example of a model that level changes in knowledge, motivation, cations [54,55]. combines population health and health and behaviour (for example, national For smoking cessation, greater use and sector interventions. The program created health promotion campaigns and behav- higher quit rates of cessation services by a local health promotion collaboration ioural change programmes) [41,42]. Fur- more advantaged individuals are a real between healthcare providers, grocery thermore, because such interventions do concern [56]. Affluent smokers tend to stores, schools, and municipal authorities. not work directly on population exposure receive more help, and are more likely to Primary care physicians contacted patients to risk factors, they do not address quit [57,58]. Increasing quit rates in more for systematic risk factor screening and inequalities in risk-factor profiles in subse- affluent smokers were also recently report- counselling aimed at CVD risk reduction. quent cohorts. ed in Inter99, the Danish trail of primary Community interventions included chang- ‘‘Agentic’’ interventions, which require prevention in general practice [59]. Sim- es in food labelling to make it easier to mobilisation of an individual’s resources, ilar inequalities have also been reported in adhere to dietary recommendations. The whether material or psychological, gener- workplace smoking interventions [57]. predicted CVD mortality risk was reduced ally favour those with more resources, thus With respect to dietary advice, US by 36% in the intervention area compared tending to increase social inequalities policies traditionally favour individual to 1% in a control community. Socioeco- [9,41,42]. This parallels what Tudor Hart approaches over public health strategies. memorably described as the ‘‘Inverse Care nomically less privileged groups benefited There, Kanjilal and colleagues recently Law’’—the availability of good medical reported bigger declines in CVD risk more from the program [67]. care tends to vary inversely with the need factors in more affluent groups [60]. for it in the population served [43]. Thus, Supporting evidence comes from a recent Specifically Targeting High-Risk the people in the poorest health gain the systematic review of nutritional interven- Populations? lowest net health benefit from the inter- tions in individuals and groups [61]. In ventions [43]. Disadvantage can occur at schools, fruit and vegetable consumption Socioeconomically disadvantaged pop- every stage in the process, from the typically increased more in affluent fami- ulations are susceptible to under-diagnosis person’s beliefs about health and disease, lies; interventions were correspondingly of hypertension, diabetes, and hypercho- and actual health behaviour, to presenta- less effective in disadvantaged areas. lesterolemia and also to suboptimal care tion, screening, risk assessment, negotia- Likewise, in a US primary care setting, for interventions to reduce risk. Risk factor tion, participation, programme persis- interventions to reduce fat intake were less modification through tailored interven- tence, and treatment adherence. Tugwell successful in blacks than in (more affluent) tions in high-risk groups might therefore et al. usefully described this cumulative whites [61]. In Germany, the Cardiovas- produce considerable benefits; however, inequality as the ‘‘staircase effect’’ [44]. cular Prevention Study compared three evaluation is urgently required. Inequalities have also been reported in strategies involving advice from profes- the screening and detection of cancer as sionals and media. After 7 years, hyper- Conclusions well as CVD. For instance, women who cholesterolaemia improved only in upper choose to attend the National Health social groups, thereby increasing the gap Given the ubiquity of social and health Service (NHS) Breast Screening Pro- between the health of rich and poor [62]. inequalities, we should not be surprised if gramme come more from affluent areas In England, a high-risk approach to interventions to reduce CVD have differ- [45]. CVD prevention that specifically priori- ential effects, with advantaged groups In the US, Frohlich’s analysis likewise tises disadvantaged groups and localities is deriving greater benefit than poorer suggested that even when individual-based being actively promoted. The National groups. We have suggested that the interventions are widely applied (such as Institute for Health and Clinical Excel- potential for such unequal effects is greater screening or health information cam- lence recently published public health for high-risk approaches, where change is paigns), they may increase disparities guidelines advising specific approaches contingent on action by individual patients [46]. Furthermore, examples of the inverse for identifying and supporting people most and healthcare providers, compared with care law in CVD primary prevention at risk of dying prematurely [63]. Else- whole population approaches, where prescribing have also been reported. where, more innovative strategies are change is societal and instituted collective- Substantial socioeconomic gradients exist being developed for poor communities— ly by agencies with statutory responsibility in statin use, both in the UK and in the for example, use of non-physician health for public health. PLoS Medicine | www.plosmedicine.org 3 August 2010 | Volume 7 | Issue 8 | e1000320
  4. 4. Operating mainly outside the health that typically widens social inequalities. In head, Robert Beaglehole, Martin Caraher, Sian service, the population approach offers contrast, policy interventions to limit risk- Robinson, Robin Ireland, Klim McPherson, governments the opportunity to act direct- factor exposure across populations appear Margaret Thorogood, and Martin White. ly on population exposure to risk factors. It cheaper and more effective; they could thus addresses the major drivers of health also contribute to levelling health across Author Contributions and health inequalities [68]. Meanwhile, socioeconomic groups. The two approach- ICMJE criteria for authorship read and met: SC evidence that healthcare interventions can es are complementary, and Rose’s advo- HG. Agree with the manuscript’s results and generate and compound risk-factor in- cacy of a dual strategy may prove conclusions: SC HG. Analyzed the data: SC. equalities is steadily accumulating [42]. prophetic [10]. However, all future strat- Collected data/did experiments for the study: We therefore look forward to future egies aimed at improving population SC. Wrote the first draft of the paper: SC. analyses from Tugwell and other col- Contributed to the writing of the paper: HG. health will merit rigorous evaluation of Made substantial contributions to conception, leagues in the Cochrane Health Equity their potential impact on inequities. design, and intellectual content as well as to Field [44]. However, that is no excuse for revisions to drafts of the paper, and approved delay. Acknowledgments the version to be published: HG. In conclusion, there is evidence that CVD prevention strategies for screening We thank many colleagues for their constructive and treating high-risk individuals may comments, particularly Ann Capewell, David represent a relatively ineffective approach Taylor-Robinson, Mike Kelly, Margaret White- References 1. Graham H (2009) Health inequalities, social 14. Levy DT, Chaloupk FJ, Gitchell G (2004) The 25. Main C, Thomas S, Ogilvie D, Stirk L, Petticrew M, determinants and public health policy. Policy effects of tobacco control policies on smoking et al. (2008) Population tobacco control interven- and Politics 37: 463–479. rates: a tobacco control score card. J Public tions and their effects on social inequalities in 2. Department of Health (2009) Putting prevention Health Manag Pract 10: 338–53. smoking: placing an equity lens on existing first. London: Department of Health. Available: 15. Emberson J, Whincup P, Morris R, Walker M, systematic reviews. 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