Post on 26-Feb-2023
Cardiovascular Disease (CVDs) and Non-Communicable Diseases
The emergence of CVD and other NCD’s is a major global
health challenge. Control of the dual burden of CVD and other
NCD's are primarily through effective health promotion
interventions aimed at reducing the four common behavioural risk
factors (tobacco use, unhealthy diet, low physical activity and
excess consumption of alcohol). Critically discuss examples and
relevant literature, how these behaviours can be improved using
structural interventions (e.g., taxes on unhealthy products,
reformulation of manufactured food, shaping urban environments to
encourage physical activity).
The Use of Structural Interventions in Improving Predisposing
Behaviours for Non-Communicable Diseases
(A Critical Analysis of Available Evidence)
Introduction
The rapid increase in the prevalence of Non-communicable
disease in every region of the world is possibly the most
important public health problem of the 21st Century. Non-
Communicable Diseases (NCDs), mainly cardiovascular diseases,
diabetes, cancers and chronic respiratory diseases are the
leading cause of death and disability globally accounting for 63%
of the 57 million deaths in 2008 (WHO, 2010). The 2010 WHO Global
Report on Non-Communicable Diseases projects over a 15% increase
in the mortality and morbidity from NCDs in the coming decade,
especially in low and middle income countries where the impact of
NCDS is currently the highest, accounting for 80% of global
mortality from NCDs (Galambos, Sturchio, & Whitehead, 2013).
Numerous studies show that tobacco use, physical inactivity,
excessive intake of alcohol and unhealthy diet are the main
preventable behavioural lifestyles that put individuals at risk
of NCDS (Desvarieux et al., 2012). Therefore interventions that
address these four risk factors (tobacco use, physical
inactivity, excessive intake of alcohol and unhealthy diet, have
the potential to significantly reduce the burden of NCDs
(Beaglehole et al., 2011).
Over the years, focus on improving these lifestyle factors
aiming at reducing NCDs have moved from health promotion
interventions that leave decision making solely to the
individual, to more structural population wide interventions like
taxes on unhealthy products, reformulation of manufactured food,
reshaping urban environments to encourage physical activity
(McQueen, 2013). This essay aims to describe how these risky
behaviours are being improved using structural interventions.
Why Structural Interventions?
According to Sommer and Parker (2013), structural
interventions refer to interventions that aim to alter the
context within which health is produced by modifying the social,
environmental economic and political source of public health
problems that determines individual, community and societal
outcomes. Its uses an indirect approach in influencing risk of
disease. Rather than merely providing individuals withinformation
to make informed choices about their health like most traditional
health promotion interventions, structural interventions
acknowledge that most risky behaviours occur as a result of the
individual’s immediate environment and tries to shape the
environment in such a way to reduce risk (McQueen, 2013).
Structural interventions are not aimed directly at the risky
behaviour but larger conditions within which these risky
behaviours are embedded, and usually take the form of
legislation, economic incentives, etc (Sommer & Parker, 2013).
Tobacco use, physical inactivity, excessive intake of
alcohol and unhealthy diet are behavioural lifestyle habits that
are influenced by forces outside the control of individuals
(McQueen, 2013) which is difficult to improve through the use of
information led health promotion strategies alone and usually
fail to produce long term outcomes (Galambos, Sturchio, &
Whitehead, 2013). Hence the need to alter the environment that
fuel or influence these risky behaviours, a large body of
evidence support the notion that providing health information
alone does not lead to the desired change in behaviour (Sommer &
Parker, 2013)
Additionally, structural interventions are very cost
effective, but require strong political will/enforcement, and
multi-sectoral partnerships. As a consequence, these
interventions selected for pressing attention need to satisfy a
rigorous, evidence based criteria; a considerableoutcome on
health (lessening of theuntimely deaths and disabilities);
sturdyfacts for cost efficiency; reduced costs of execution; and
the political and fiscalpracticability for scale-up (McQueen,
2013). There are numerousprobable intercessions for Non-
Communicable Diseases.Nonetheless, the most robust
obtainableproof for the efficiency and outcome of interventions
is to reduce the pervasiveness of the main risk aspects via
population-wide approaches that are directed at all and sundry,
and to aimat treatment of individuals who are at a higher risk of
contracting Non-Communicable Diseases, especially cardiovascular
conditions (Galambos, Sturchio, & Whitehead, 2013). Not all
intercessions are cost effectual or inexpensivewith regards to
equity and resources; the practicability of execution and scale-
up of intercessions in everynation must, therefore, be reflected
on (Galambos, Sturchio, & Whitehead, 2013).
Evidence for Using Structural Interventions in Improving:
Unhealthy Diets
Unhealthy diets have been acknowledged as some of the key
sources of NCDs. For examples, some cardiovascular diseases such
as stroke, hypertension and left-ventricular hypertrophy have
been linked directly to poor diets such as too much ingestion of
dietary salt and the intake of unhealthy or saturated fats. While
observing the effects of dietary salt intake on cardiovascular
activities, Bochud et al. (p.530) observed that experts have
brought forth stronger evidence linking dietary salt intake to
cardiovascular conditions that have resulted in morbidity and
mortality, and as such have called for the reduction of salt
intake to 5g per day. The reduction of salt intake is meant to
curb the unprecedented increase in cardiovascular diseases
throughout the world. In a bid to control the intake of dietary
salt, the WHO(2010) has proposed structural interventions that
have been widely adopted by countries such as New Zealand, France
and Japan among others (Bochud et al p. 531). While it is not
possible to control individual intake of diet salt and unhealthy
and saturated fats, one of the interventions that has been
propped up by the World Health Organization (2012) is the
behavior change. Behavior change on diets is mainly attainable
through teaching the populace on the effects of poor diets and
also through individual and societal assessment of diets
ingested.
A notable example of places where structural interventions
have led to reduced mortality rates includes Japan and Finland
(Desvarieux et al., 2012). According to Desvarieux et al. (2012),
in Finland, both societal and national interventions that were
directed at changing behaviors led to the lessening of coronary
related deaths by almost 85 percent in addition to the decrease
in all-cause deaths.Desvrieux (2012), further observes that
exclusive of Finland and Japan, there is no up to date data from
nations that have employed population-based structural
interventions to reduce dietary salt ingestion like the United
Kingdom that gave a pointer that they were moving from the
initial 10g per day to the recommended 5g per day.
However, it is important to observe that, In Finland, while
the decrease (-96%) was much greater in the younger generations
(35-44 years), the reduction was also considerable in the older
age groups too. That is, the reduction was -69 percent among
individuals of 65-79 years, the immense reduction indicated that
it was never too late for prevention and change (Desvarieux et
al., 2012).
With regards to the intake of other unhealthy diets such as
saturated fats and meats, one of the structural interventions
that have been proposed by experts is the reduction of subsidies
that are placed on such foods by the different governments. The
reduction of subsidies is likely to result in the increase in the
prices of such food stuffs thereby making them unaffordable to
many people. As a consequence, individuals will be forced to
reconsider other available but cheaper food options which will,
in effect, result in reduction in the intake of saturated fats
and meats. Consequently, this is likely to increase the number of
healthy individuals. A good example of where the removal of
subsidies on unhealthy foods has been effective in reducing NCDs
that are associated with such foods is in Poland. According to
Desvarieux, after the removal of the subsidy on extremely
saturated fats and meats by the Polish government and the
subsequent promotion of the inclusion of vegetables in diets, the
mortality rates that were linked to coronary heart diseases were
cut down by 25 percent within a period of 5 years, even though
there was no perceptible advancement in the polish health care
system (Desvarieux et al., 2012).
Other notable structural interventions that can be
effectively employed in the reduction of the consumption of
unhealthy diets are the increase of taxes on such foods. The
increase in taxes will have a similar effect are the reduction of
subsidies in that they will increases the prices of such foods
thereby making them inaccessible to many people.
However, despite the above stated interventions on the
consumption of unhealthy diets being successful in given
countries, equal success rates may not be realized among certain
spheres of the populace, for instance, wealthier individuals and
families. Wealthier individuals may still have access to the
unhealthy diets despite the increase in taxes and the reduction
in subsidies. Thus they will still be able to consume unhealthy
diets. As a consequence, the most successful structural
intervention that can be applied and success realized equally
throughout the population remains education and the assessment of
individual diets.
Low Physical Activity
The World Health Organization observes that apart from being
the number one cause of death universally, CVDs killed
approximately 17.3 million individuals during the year 2008. Of
these deaths, nearly 7.3 million were as a result of coronary
heart conditions while 6.2 million deaths were attributable to
stroke (WHO Media centre , 2013). The report further opines that
both the mid-income and low-income nations were disproportionally
affected by the conditions as more than 80 percent of CVD related
deaths happened took place in these countries and the rates of
deaths in men and women were equal (WHO Media centre , 2013). The
report further projects that the number of individuals who are
likely to succumb to CVDs, stroke and heart conditions, will
increase to approximately 23.3 million people by the year 2030
while CVDs will remain to be the sole leading cause of death
globally (WHO Media centre , 2013).
Alwan et al. (2010) draw a direct link between coronary
heart conditions, diabetes and stroke and physical inactivity.
Alwan et al. (2010) opine that there is also a close response
association for both diabetes and cardiovascular with risk
reductions that occur regularly at a degree of 150 minutes every
week. Evidence also indicates that taking part in 30 to 60
minutes of physical activity every day considerably lowers the
risk of colon and breast cancers (Oxford Health Alliance
Programme, 2014). A number of structural interventions aimed at
the promotion of physical activities that comprise the best buy
have been proposed. For instance, the promotion of physical
activity alongside the ingestion of healthy diet through the use
of media has been observed as a more cost-effective, inexpensive
and exceedingly practicable alternative (Alwan et al., 2010). The
WHO assembly (2004) endorsed Global Strategy on Diet, Physical Activity and
Health and the subsequent Action Plan for the Global Strategy for the Prevention
and Control of Non-Communicable Diseases 2008–2013 (Alwan et al, 2010).
These are some of the universal structural interventions meant to
push the member states towards the execution of the outlined
programs and actions with the objective of amplifying the levels
of physical activities amongst the world populaces. The
structural interventions require children and young adults (5-17
years) to take part in a one hour in intensive physical activity
each day. On the other hand, adults (18-65 years) are required to
involve in 75 to 150 minutes of intensive physical activities
each day (Alwan et al, 2010).
Other structural interventions that are prone to boost
physical activities amongst the populace includes ensuring
execution of policies that ensure sports, walking and cycling are
accessible and safe in order to promote physical activities
(Oxford Health Alliance Programme, 2014). The effectiveness of
physical activities was demonstrated in both the United States
and Cuba during the 1991-1995 economic crises (Desvarieux et al.,
2012). The economic crisis led to amplified physical activities
(walking) because of the fuel shortage by between 30-60 percent.
In effect, the increased physical activity in the two nations
resulted in 14% to 7% decrease in obesity and a further reduction
in coronary related deaths in a year and a 39% reduction by the
year 2002 (Desvarieux et al., 2012).
Lastly, another remarkable structural intervention that may
be useful in ensuring increased physical activities within
populations is through urban reshaping. This involves the
construction of sidewalks in towns and cities to ensure that
pedestrians have paths that they can use to access the urban
centres. Likewise, by-laws are also effective in ensuring
increased physical activities within urban settings. For
instance, laws that do not allow people to drive to town on given
days will increase physical activities among population as people
will be forced to walk and use bicycles to access cities (Oxford
Health Alliance Programme, 2014).
However, despite the benefits that can be attained from
involvement in vigorous physical activities, the advantages can
only be attained if the individual is willing to take part in the
activities (Oxford Health Alliance Programme, 2014). This is
because taking part in such activities is considered as a
behavior that individuals are required to learn. Attaining the
desired outcome may, therefore, require that the above
recommended structural interventions are conducted in school or
work based environments in which it is compulsory for individuals
to take part. This may lead to development of the habit of taking
part in routine physical activity. Nevertheless, the best
structural intervention with regards to low physical activities
is to reach out to the populations and teach them the negative
effects of low physical activity through the media (Oxford Health
Alliance Programme, 2014).
Excessive Consumption of Alcohol
According to Statistics (2014), over 2.5 million the annual
global deaths are attributable tothe unwarranted and detrimental
consumption of alcohol. England and Wales reports over 5000
alcohol related deaths annually (Statistics, 2014). Unwarranted
alcohol use is, therefore, a key source of avoidable premature
death that gave an explanation for nearly 1.4% of the total
deaths registered in England and Wales during the year
2012(Statistics, 2014).
In relation to the unwarranted use of alcohol, Alwan et al.
(2010) assert that efficient structural interventions for alcohol
related liver conditions; cancers and other CVDs should be aimed
at the diverse patterns and levels of alcohol use.
Well-known proof of efficiency and cost-effectiveness of the
structural interventions to decrease the detrimental consumption
of alcohol comprising instances from nations like Mexico, Russia,
Brazil, Viet Nam and China have propped up the execution of the
following effective structural interventions(Alwan et al., 2010):
A widely acknowledged structural intervention that may be
employed in curbing excessive use of alcohol is the increase in
taxes levied on the alcoholic beverages. The increase in taxes
will, in effect, lead to the increment in prices of the alcoholic
beverages. As a consequence, the increment will ensure lower
consumption of alcohol among the user as they will not be able to
afford more alcohol as before (Alwan et al., 2010).
Another notable structural intervention that can be successfully
applied in order to regulate and decrease the unwarranted
consumption of alcohol is the regulation of the availability and
accessibility of alcoholic drinks including the recommended
purchase age limit. The structural intervention has been widely
used internationally and as been successful in decreasing alcohol
consumptions among the underage (Alwan et al., 2010).
Nevertheless, one of the key setbacks of the wide
population-founded structural interventions stated above is due
to their lack of ability to distinguish between people whose
consumption of alcohol is linked with detrimental results and
those whose consumption arenot(International Center for Alcohol
Policies, 2014). Thus, by their nature, these interventions
tackle the lowest general denominator and are short of the
flexibility to act in response to the requirements of groups and
individuals whose drinking may be predominantly problematical
(International Center for Alcohol Policies, 2014).
Also, another disadvantage of the aforementioned structural
interventions is that they may neither be uniformly cultural
significant nor apposite in every setting. This is because the
interventions have normally failed to consider the important role
that is played by alcohol in various communities throughout the
globe and the rationale that alcohol consumption is strongly
embedded into the foundation of the normal social life in
numerous communities (International Center for Alcohol Policies,
2014). That is to say, every part of the globe has its own
distinctiverange of viewpoints, approaches, and customs around
alcohol consumption and the perceptions on thesuitable place
within the daily life. Therefore, a one-size-fits-all
intervention may not be applicable in each setting as
theefficiency is likely to fluctuate (International Center for
Alcohol Policies, 2014).
Tobacco Use
According to WHO (2010), more that 6 million universal
deaths are attributable to the use of tobacco that includes both
smoking and exposure to tobacco smoke. The statistics further
observes that this rate is anticipated to amplify by an extra 1.5
million cases in the year 2020 unlesseffectual interventions and
approaches are put in place in order to curtailthe increase.
(WHO, 2010).It is approximated that smoking is responsible for 71
percent of deaths from lung cancer, 42 percent of all persistent
respiratory conditions and 10 percent of the CVDs (WHO 2010).
While close to 1.2 billion people in the world are smokers, a
higher percentage of this people are found in both middle and low
income economies.
Beaglehole et al, observe that precedence for urgent action
aimed at realizing the proposed universal goal of a world that is
free from tobacco and in which less than 5 percent of the
populace consumes tobacco by the year 2040 (2011). By
implementing 4 of the proposed strategies found in the Framework
on Tobacco Control (FCTC), above 5.5 million deaths are likely to
be prevented over a period of 10 years. The reduction in
mortality rates resulting from tobacco use will mainly affect
middle-income nations and a total of 23 low-income nations that
are experience an increased burden of Non Communicable Diseases
(Beaglehole et al. 2011).
Notable structural interventions that have been put in place
to prevent and reduce tobacco use throughout the world includes
the placing of warning signs on tobacco packets with the
objective of warning users of the consequences of smoking
(Hammond et al., 2006). Sommer and Parker (2013) observe that
even though this structural intervention has been successfully
applied, there is still a need to ensure that smokers are aware
of the dangers that smoking poses to them and people around them.
A study on the “effectiveness of cigarette warning labels in
informing smokers about the risks of smoking”, carried out in
four nations (Canada, USA, Australia and United Kingdom)
disclosed that although it isfrequently presumed and repeatedly
asserted by the tobacco industry that tobacco users are
sufficiently informed on the risks that smoking poses to them,
this notion is false (McQueen, 2013). The outcomes of the study
indicated that there were considerable gaps in the comprehension
of the smoking risks. That is to say, most of the smokers
indicated that heart conditions and lung cancers were
attributable to smoking while a quarter of the smokers
(interviewees) did not deem the vice as a major cause of strokes.
Still, slightly above half the number of smokers interviewed
deemed smoking as a cause of impotence. Lastly, the study
disclosedthat the knowledge of the harmful constituents of
tobacco among the users was incongruously low (Hammond et al.,
2006).
Another remarkable structural intervention that has been
frequently used to curtail the use of tobacco is the increase of
taxes on tobacco products. According to Hammond et al. (2006),
increases in taxes normally produceas a minimum proportionate
increase in cigarette price, which, in turn, diminishes cigarette
use. Hammond et al. (2006) further assertsthat approximates of
price elasticity of demand for tobacco in the United
Statescharacteristicallyvary between −0.3 and −0.5. This implies
that a 10 percent increase in the prices of cigarettes will in
turn result in a 3-5 percent decrease in demand for cigarettes
for every adult smoker. The addictive nature of smoking,
therefore, implies that the long-standingreactions to
undeviatingincrease in prices will be almost twofold as large as
short-term impacts.
Even thoughapproximationsdiffer, numerous researches have
pointed out that both the youth and the young adults are more
responsive to price compared to the adultsmokers. As such,a 10
percentrise in tobacco prices would diminish the number of
youthful tobacco users by virtually 7 percent and
thestandardamount smoked by over 6 percent.Elevated prices will,
therefore, negatively impact theheadway to established smoking.
Hammond et al. (2006) also observe that prices have
sturdyoutcomes on the smoker of 18–24 years, the age bracket in
whichsmoking lifestylefrequently becomesresolutely established.
Clean indoor air laws are also structural interventions that
have been executed successfully in a bid to reduce tobacco use.
The laws are mainly meant to ban smoking in a varietyof public
places that include public parks, restaurants, transport systems,
bars, and private offices (Hammond et al., 2006). The purpose of
clean indoor air laws is to make sure that smoking is viewed as
less strikingthrough thereductionof smoking opportunities by
holding up the social standards against tobacco use. The
execution of the clean indoor air laws has been aggravated by
considerableproof of the harms resulting from tobacco smoke (ETS)
to the nonsmokers.
According to Hammond et al. (2006), widespread clear indoor
air laws have been connected with reduced rates of tobacco use
within the United States. Researches have disclosed that 5-20
percent reducedper persontobacco use in states with wide-ranging
clean indoor air laws. Hammond et al. (2006) additionally note
that fewer researches have looked atthe pervasiveness and
termination rates, and that states with widespread clean air laws
have recorded a 10 percent lower incidence rates compared to
other states. This is in concurrence to the study conducted by
Emont et al that noted 12 percent increased rates of previousto
current tobacco users and Moskowitz’s revelation of 38 percent
increased 6-month termination rates in regions that had stronger
worksite laws.
However, despite the gains made through structural
interventions such as clean indoor air laws and price increments,
many smokers are still not aware of the danger smoking pose to
them and people around them. As a result, teaching as a
structural intervention should be implemented in order to create
awareness on the risks of smoking. Furthermore, in concurrence to
the above statement, Macqueen (2013) opines that the degree to
which tobacco users comprehend the enormity of the health risks
has a sturdy effect on their smoking attitude. That is, smokers
who recognize greater health risks as a consequence of smoking
are more prone to intend to relinquish and to renounce smoking
effectively. Lastly, Hammond et al. (2006) note that the health
risks that are associated with smoking are also the most
widespreadinspiration to give upthat is cited by present and
pastsmokers. It is also the best indicator of long-standingself-
restraintamongstgrounds for quitting.
Conclusion
Reducing the universal burden of NCDs will necessitate a whole-
of-society reaction at the international, national, and personal
levels. There is a need for formation of a matrix of NCD
partnerships that is linked through World Health Organization and
other United Nations and bilateral agencies, NGOs, private
sectors and foundations (Galambos, Sturchio, & Whitehead, 2013).
The United Nations meeting can generate some degree of
international commitment to this novel charge; nonetheless,
member countries will also berequired to commit to establishing
and strengthening countrywide plans that are aptly financed and
executed. Focusmust, therefore, be concentrated on avoidance
across the lifespan and reallocateavailable resources towards the
support of superior quality and healthy lifestyles, and
timelydetection and management of the risk aspects and symptoms
as opposed to last minute treatment of chronic illnesses (Sommer
& Parker, 2013).
The United Nations High-level Meeting on Non-communicable
Diseases is, therefore, only the initialstage in what must be a
lasting and progressingassociationbetweennumerous partakers to
enhanceuniversal health. The next stages necessitate theexecution
of the proposed structural interventions, investment in ground-
breakingstudies on preventative health approaches, advancements
in examination, concurrence on targets, and establishment
ofpractical timelines. This key public health challenge can be
efficiently tackled in order to save millions of upcoming lives
(Galambos, Sturchio, & Whitehead, 2013). It, therefore, calls for
timely response and involvement in universal NCD associations for
deterrence and promotion of personal and professional cost-
effective strategies that are practical (Sommer & Parker, 2013).
References
Alwan, A. et al. (2010). Global status report on Noncommunicable Diseases
2010. Geneva: World Health Organization.
Bochud, M., Marques-Vidal, P., Burnier, M., & Paccaud, F. (2012).
Dietary Salt Intake and Cardiovascular Disease:Summarizing the
Evidence. Public Health Reviews, Vol. 33, No 2. , 530-552.
Desvarieux, M., & Paccaud, F. (2012). Editorial:Addressing
Cardiovascular Disease Globally:Yes We Can. Public Health Reviews,
Vol. 33, No 2. , 346-350.
Galambos, L., Sturchio, J. L., & Whitehead, R. C. (2013).
Noncommunicable Diseases in the Developing World: Addressing Gaps in Global
Policy and Research. Baltimore, Maryland: JHU Press.
Hammond, D. et al. (2006). Effectiveness of cigarette warning labels in
informing smokers about the risks of smoking:findings from the International Tobacco
Control (ITC) Four Country Survey. London: group.bmj.com.
International Center for Alcohol Policies. (2014). Introduction: An
Integrative Approach to Alcohol Policies. Retrieved April 13, 2014, from
http://icap.org:
http://icap.org/PolicyTools/ICAPBlueBook/IntroAnIntegrativeApproa
chtoAlcoholPolicie s/tabid/187/Default.aspx
McQueen, D. V. (2013). Global Handbook on Noncommunicable Diseases and
Health Promotion. Berlin, Heidelberg: Springer Science &
Business.
Oxford Health Alliance Programme. (2014). Physical Activity Interventions.
Retrieved April 13, 2014, from oxha.org:
http://www.oxha.org/cih_manual/index.php/physical-activity-
intervention-evidence-evidence.
Sommer, M., & Parker, R. (2013). Structural Approaches in Public Health.
London: Routledge.
Statistics, O. f. (2014, February 19). Liver disease biggest cause of
alcohol-related deaths in England and Wales. Retrieved April 13, 2014,
from Office for National Statistics:
http://www.ons.gov.uk/ons/rel/subnational-health4/alcohol-
related-deaths-in-the-united- kingdom/2012/sty-alcohol-releated-
deaths.html.