An international collaboration between Chinese and Indian researchers has developed new, more cost-effective ways to improve primary care and clinical outcomes in regions with limited resources.

The study result was recently published in Circulation with an invited editorial.

The simplified cardiovascular management program, also known as the SimCard study, was a one-year cluster-randomized controlled trial carried out in 47 villages in Tibet, China and Haryana, India where access to basic cardiovascular disease (CVD) management and appropriate medications were extremely limited.

The study enrolled 2086 (1,036 in China, 1,050 in India) individuals with high CVD risks, defined as over 40 years old with a self-reported history of CVD and a measured systolic blood pressure over 160mmHg. Community health workers (CHWs) were deployed and trained to manage those individuals with the assistance of an Android smartphone app consisting of a guideline-based but simplified CVD management program.

The combined results found in the study strongly demonstrated the effectiveness of this program in increasing the use of the anti-hypertensive medications, with the primary outcome being a net-difference of 25.5%. In China, a significant decrease in systolic blood pressure (-4.1mmHg) and increase in the proportion of taking aspirin (24.5%) were also observed. No actual lifestyle changes were found in both countries.

The study was carried out in 2011 by The George Institute for Global Health at Peking University Health Science Center (TGI @ PUHSC) in collaboration with Tibet University in China, and the Public Health Foundation of India (PHFI) in India. Larger and longer context-specific trials are needed to further refine the program and evaluate the hard outcomes.

Customized community-based intervention

As chronic disease burden has been significantly increased over the past decades, delivery of medical care has also changed from individual to population and community-based healthcare.

“Both population-based and high-risk strategies are needed for prevention and control of chronic diseases like CVD,” said Professor Lijing Yan, Principal Investigator of the study and Honorary Professorial Fellow at TGI @ PUHSC. “In resource-limited settings, it would be highly cost-effective if we could adapt the high-risk approach first and then integrate the strategies recommended by guidelines.”

A simplified ‘2+2’ intervention model, which consisted of two medications (blood pressure lowering agents and aspirin) and two lifestyle modifications (smoking cessation and salt reduction), was developed. The model was based on the international and national clinical guidelines for CVD management so that it can be easily implemented and incorporated into the existing local healthcare system as well.

The interventions were carefully tailored to the local cultures with strong support from local governments. For example, in Tibet, special education was carried out to alleviate concerns among Tibetan patients against western medicines.

The role of community health workers (CHWs)

Professor Yan said this study added to evidence demonstrating the potential effectiveness of CHWs in shifting and sharing the tasks of healthcare professionals, which can help reduce the cost of healthcare for individuals.

“Reliance on the overburdened and relatively small number of specialists to target the high-risk people in these areas is not feasible or sustainable. We need to look at models of care which can be inexpensive, accessible and available to everyone,” said Professor Yan. “CHWs are the key components of carrying out such kind of population-based strategies for CVD prevention and control, and can make things available at the doorstep.”

As a result, although no actual lifestyle changes were found, the intervention was effective in changing both the physician and patients’ behaviors in terms of medication prescription and use, as well as a potential to improve clinical outcomes.

The power of mobile technology

Dr. Maoyi Tian, senior research fellow at TGI @ PUHSC, said the smartphone-based electronic decision support system (EDSS) assisted the CHWs to provide standard and prompt care for the first time in these poorer settings.

“Preliminary results from the study have indicated that the EDSS has a large potential to assist the grass-roots level healthcare providers in clinical decisions and patient management in a highly efficient, cost-effective and time/energy-saving way,” said Dr. Tian.

“When implementing the study, it was also very encouraging to see that the CHWs, no matter whether they were young or senior, were willing and able to use the mobile devices.

“For the next steps, we should harness it and implement it on a larger-scale. We will be keen on improving it to a patient-centered design as well as link with local electronic health record system.”

Calling for more south-south collaboration

Despite the differences in the healthcare system, socioeconomic environment and culture, China and India both faced similar challenges in CVD prevention and control such as the rising burden of CVD, large urban-rural health disparities, limited resources and capacity.

Dr. Dorairaj Prabhakaran, Co-Investigator of the study in India and Vice President of PHFI, said that perception was one of the biggest challenges in combating chronic diseases like CVD and needed to be overcome. “People think chronic diseases are only problems for the rich, but we now know, having done this study in poorer settings that hypertension is a big problem. It’s affecting everyone in the population.”

“The study was the first dual-country trial of its kind worldwide and presented a good example for other collaborations between the developing countries in view of the huge synergy recognized and its inexpensiveness and sustainability. We should pool our resources together and collaborate more on areas of common interests in the future.”

Experts say more action is needed to reduce worldwide salt consumption after new research by The George Institute for Global Health found many countries are not meeting targets.

Dr Jacqui Webster, from the World Health Organisation Collaborating Centre on Salt Reduction at the Institute, said. The public health benefits of salt reduction could not be stated strongly enough..

“Simply put, reducing salt intake to the World Health Organisation target of 5 grams per person per day, will save tens of thousands of lives at the same time as saving governments hundreds of millions of dollars in health costs,” Dr Webster said.

“Excess sodium is a significant cause of high blood pressure, which is a major risk factor for cardiovascular disease (CVD), and this includes stroke and coronary heart disease.

“CVD is the world’s leading cause of death, killing 17 million people every year and around 2 million of these deaths are attributable to eating too much salt.

“In Australia if average salt intake was reduced by just three grams per day, an estimated 3,500 lives would be saved each year along with $200 million in health care costs.

“Australia has previously introduced some measures, but these results show that more can be done to help reduce that sodium content.

“We know that reducing salt takes more than just asking people to stop putting salt on their food at the dinner table, because around 70% of the salt we eat is hidden in processed foods.”

The global review assessed the progress of countries towards the World Health Organisation’s target of a 30% reduction by 2025, with the aim of achieving less than 5 grams per person per day.

Based on existing published data and country reports, it found:

• Countries not meeting the WHO target of 5g of salt per person per day include United Kingdom (8.1g), Canada (8.5g), New Zealand (8.57g), the United States (8.8g) and Australia (8.9g)
• A total of 75 countries now have a national salt reduction strategy
• Only 12 countries have so far reported a reduction in population salt intake

“Salt reduction strategies can include work with the industry, labelling and consumer education programs,” Dr Webster said.

“We have the targets set for reducing salt in foods set but progress in some countries seems to have slowed in recent years.

“An effective salt reduction strategy requires an improved determination and co-ordination from the government and food industry as well as more funding.

“The results will be immediate and real, saving many lives and millions of dollars every year.”

An Australian delegation has gone to Hyderabad, India for trade mission talks with Indian officials and business leaders, accompanied by Chief Operating Officer of The George Institute for Global Health, Tim Regan.

The trade mission sought to identify opportunities for greater cooperation and economic partnership between Indian and Australian businesses. It involved several high level round tables with delegates including Chief Minister of Andhra Pradesh, Mr. Chandrababu Naidu, and Secretary of Industries, Commerce & Power of Telangana, Mr. Arvind Kumar. The delegation was led by the Parliamentary Secretary to the Minister for Foreign Affairs and the Minister for Trade and Investment, the Hon Steven Ciobo MP.

The trade mission also met with CEO  Ms. Sangita Reddy from Apollo Hospitals and senior executives from Tech Mahindra and the LV Prasad Eye Institute.

Mr. Regan used the opportunity to discuss the importance of enhancing collaboration between Australian and Indian clinical research industries and health professionals, in order to leverage off the expertise of both countries to improve health in the region.  Topics of mutual interest included mHealth and road safety.

“International collaboration is essential to the George Institute mission of improving the health of millions around the world. Trade missions such as these allow for an open dialogue between government, not for profits and businesses to begin to work on these important collaborations,” said Mr. Regan.  

In an important step towards understanding how to prevent childhood cancer, new research from the International Childhood Cancer Cohort Consortium (I4C) confirms the occurrence of childhood cancer rises as birthweight increases. However the research also found this is unlikely to be primarily due to the mother’s weight gain during pregnancy, a major contributor to the size of the baby. The study was recently published in the journal Paediatric and Perinatal Epidemiology.

The study was the first designed to specifically collect data before the children developed cancer. It includes pooled data on infant and parental characteristics and cancer incidence, covered 380,000 live births. It was collected from studies going back more than 50 years from six geographically diverse regions, including the UK, USA, Denmark, Israel, Norway and Australia. The total analysis included 377 children with cancer, including 115 with leukaemia and 262 with non-leukaemia-type cancers.

“We have been able to compile a significant amount of evidence that effectively shows that childhood cancer incidence rises with increasing birthweight,” said Professor Terry Dwyer, the Executive Director for The George Institute for Global Health. “While we observed a correlation between increased birthweight and higher risk of cancer incidence in children, there were no significant interactions with maternal pre-pregnancy overweight or pregnancy weight gain.”

The study showed that after adjusting for gestational age and sex an increased risk of 26 percent for every kilogram increase in birthweight was observed for all cancers. In older children (diagnosed at or after three years of age), cancers other than leukaemia are particularly related to high birthweight.

“At The George Institute we are focused on the prevention, treatment and care of noncommunicable diseases, like cancer,” said Professor Dwyer. “I am more optimistic that we’ll find ways of preventing childhood cancer than I was when we started this study 10 years ago. We know that there are no easy answers, but we are assembling more clues, like this piece of evidence, which will help us fill in the puzzle. Additional research into childhood cancer is needed so that we can provide actionable solutions to improve outcomes for future generations.”

I4C researchers plan to follow this study up with several lines of inquiry, including: looking at data in new cohorts such as in Japan and China to see whether this association exists there as well; investigating other factors that have some relationship to birth weight, such as birth order, to see whether the association is similar in infants of different birth order; and making cord blood measurements from infants in the cohorts to determine whether growth hormones of various types explain what we have found.

Dwyer, a Professor of Epidemiology at the Oxford Martin School and the Nuffield Dept. of Population Health, also leads the I4C, an international alliance of longitudinal studies of children. The I4C aims to make major contributions in advancing understanding of the role of early-life exposures in childhood cancers.

While previous studies have posited on the connection between childhood cancers and high birthweights, the collaboration of the six cohorts has allowed the examination of a wider range of potential factors measured prospectively including maternal age, marital status, education level, smoking propensity, previous live births, diabetes, pre-pregnancy BMI and total pregnancy weight gain.

Researchers used state-of-the-art statistical techniques to analyse the complex data set. The final dataset excluded multiple births due to higher rates of low birthweight and children with Down syndrome due to previously observed higher risks of childhood leukaemia. 

This week is International Men’s Health Week and it’s a great opportunity for individuals and families to reflect on the state of men’s health in their local community. 

Some of the leading causes of death for men around the world include heart disease, stroke and Chronic Obstructive Pulmonary Disease (COPD).

Here are some simple tips for men to help improve their health and reduce the risks.

1. COPD: Quit smoking

While there are many factors that cause COPD, the best course of treatment is prevention. Not taking up smoking and avoiding second hand smoke greatly reduces your chances of developing COPD.

2. Stroke: Reduce your salt

There are the obvious high salt foods like chips, soft drinks and fast foods, but salt has a way of sneaking into many of our staple foods too, with bread, cheese, breakfast cereals and soups and sauces, containing relatively high levels of salt. The World Health Organisation guidelines for adult salt intake is five grams per day, about one small teaspoon, so opt for low sodium options instead to reduce your risk of stroke.

3. Heart Disease: Regular exercise

Our heart is a muscle, and needs regular exercise to stay in form. Those who spend most of their working life sitting at a desk should take a walk on their lunch break, or do a lap of the office when they go to the bathroom.