Heart of Soweto moves to primary health care

Rationale: Thirty years ago, the Declaration of Alma-Ata recognised the role of social and environmental factors in illness and identified the importance of primary health care as the key to achieving the WHO goal of “Health for All”.

Dr M Chan, Director of the WHO, reaffirmed the primary health care approach as the most efficient and cost-effective way to organise a health system. She also pointed out that international evidence overwhelmingly demonstrated that health systems orientated towards primary health care produce better outcomes at lower costs and with higher user satisfaction [Chan M. Return to Alma-Ata. Lancet 2008;372:865-866.]. She reported that money alone would not buy better health outcomes in the absence of efficient systems for delivery and that continued poor health in many countries reflected failure to invest in fundamental primary health care infrastructure, services and staff.

A recent report from the 2008 G8 summit also highlighted the need for major efforts to strengthen health systems in developing countries, particularly the provision of effective primary care [WHO. The World Health Report 2008 – Primary Health Care: Now More Than Ever. Geneva: World Health Organization].

In this context we recognise that our initial attempt to describe the spectrum of heart disease within Soweto has been limited, focusing only on advanced cases presenting to the Chris Hani Baragwanath Hospital. We started to address this limitation by piloting a series of Heart Awareness Days during which we undertook community screening for cardiovascular disease (CVD) and risk factors (> 1 500 voluntary participants in total). We found that only 22% of participants had no risk factor for CVD. Moreover, awareness rates of heart disease and risk factors were extremely low.

The specific results of these days were:

By far the most prevalent risk factor was obesity (43%), with up to 70% of subjects overweight. Importantly, the prevalence of obesity was significantly lower in men than in women (23% versus 55%: OR 0.24 95% CI 0.19 to 0.30: p < 0.001). A further 33% of subjects had high blood pressures (systolic or diastolic) and 13% an elevated (non-fasting) total blood cholesterol level: no statistically significant differences between the sexes were found. Being either overweight or obese was associated with elevated blood pressure and raised cholesterol levels. Overall, only 22% of participants were found to have no risk factor for the future development of cardiovascular disease.

Clearly, there is a large potential burden of CVD and risk factors within Soweto. However, we are unable to place this into context relevant to other common disease states.

Our aim, therefore, is to extend the Heart of Soweto study into the primary health clinics of Soweto to provide information on the pattern of diseases and risk factors in this community in epidemiological transition.

In this way we will establish the Soweto Primary Care Registry. This will document the spectrum, burden and management of CV risk factors and milder forms of heart disease in the community setting. Information on overall disease burden and specifically cardiovascular disease, including diabetes and stroke, will facilitate effective primary health care planning.

Study participants: Each year the study will include 2 000 patients, randomly selected regardless of the nature of their complaint, who present to two participating primary care clinics in Soweto on dedicated screening days.

Study data: In collaboration with Dr Maureen Joffe, Wits Health Consortium, University of the Witwatersrand, we have developed an abbreviated Soweto Primary Care Registry data collection form to quantify the prevalence and spectrum of known CVD already diagnosed in the primary care setting. This mirrors the more detailed registry developed in the initial phases of the Heart of Soweto study. In addition we will discover the burden of undetected CVD based on screening for symptoms and signs and use of specific study investigations.

Case definitions: The Primary Care Registry will employ the disease categories used by Lopez and colleagues [Lopez AD, Mathers CD, Ezzati M, Murray CJL. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 2006;367:1747-57], that is, the 10 leading causes of burden of illness in low- and middle-income countries, including 1) perinatal conditions, 2) lower respiratory conditions, 3) hypertension, heart failure and ischaemic heart disease, 4) HIV/AIDS, 5) cerebrovascular disease, 6) diarrhoeal disease, 7) mental disorders, 8) malaria, 9) tuberculosis and 10) chronic obstructive pulmonary disease.

In addition we plan to assess the following: Self-reported cultural, socio-economic information such as education status Medical history and potential cardiovascular symptoms Blood pressure and heart rate Body mass index and anthropometric measurements Detailed lipid profile Patients with symptoms or signs suggestive of CVD will have an ECG recorded and will be referred to the Cardiology Unit at Chris Hani Baragwanath Hospital for definitive assessment.