Deprivation represents the "elephant in the room" with regard to cardiovascular disease (CVD), and health care professionals have an important role to play in tackling the problem, delegates heard at a special plenary session opening the EuroHeart Care Congress in Glasgow, Scotland, 22 March to 23 March 2013. The session heard how Scotland, a country considered to have the highest rates of heart disease in Western Europe, has recently taken action to address the CVD health inequalities that exist between affluent and deprived communities.
Mr Michael Matheson, the Public Health Minister in the Scottish Government, told the meeting, "We are continuing to make significant cuts in the number of deaths from heart disease and stroke, with an 8.1% drop in deaths from coronary heart disease between 2010 and 2011. I am also pleased that we're cutting coronary heart disease mortality rates fastest in the most deprived areas, which is vital if we are to successfully improve health equality in Scotland." Recent statistics show that between 2002 and 2011, reduction in the age-sex standardised mortality rate for CHD among the most deprived category was 38.7%, compared with 25.1% in the least deprived category¹.
"There is however more to do. For example, more people are surviving heart attacks and living with heart disease, so they need access to high quality rehabilitation and support. Our Heart Disease and Stroke Action Plan focuses not just on providing the best possible care, but in helping people's longer-term recovery in their own communities. Future improvements will largely depend on people's lifestyles - eating better, being more active, stopping smoking and drinking sensibly - and we are also taking firm action in all these areas to support people to live healthier lives," said Mr Matheson.
Scotland targets deprived areas for health checks
Dr Barry Vallance, the lead clinician for Heart Disease in Scotland, stressed there was no room for complacency. "Death rates from heart disease have fallen in Scotland, but it still remains the second highest cause of death after cancer. In Scotland, as in other parts of the world, there's still a significant gap between the rich and poorest, with those living in deprived communities more likely to die prematurely."
Statistics for Scotland have shown a big difference for the richest and poorest members of society, with those in the top 10% having a standardized mortality ratio for CHD of 65 compared to 140 for those in the bottom 10%².
No one, said Dr Vallance, fully understands why people from deprived areas are more prone to CVD. "The reasons are likely to be multi factorial. Health is low on their list of priorities because they've so many other issues to contend with, and they consider vices like cigarette smoking and excess alcohol as pleasures. Furthermore, they're less likely to be able to afford healthy activities like gym memberships and fruit and vegetables," he said. With regard to unhealthy activities, taking the example of smoking, in 2005 smoking rates in Scotland ranged from 11% in people from the 10% most affluent areas to 44% in people from the 10% least affluent areas³.
People from deprived areas in Scotland also appear to be accessing less treatment for CVD. Data from the National Records of Scotland, showed that in 2008/9 over 20% fewer treatments than expected for angioplasty and CABG surgery were carried out for people in the 10% most deprived areas, compared to around 60% more treatments than expected in people from the 10% least deprived areas⁴.
"The overall result is that people from deprived areas often present to health professional with more advanced disease, leading to their having higher morbidity and mortality rates," said Vallance. "In a National Health System it's not that we're denying people from deprived areas health care, but that they don't seek it out," he said.
Since March 2009as part of the "Keep Well" programme of inequalities targeted health checks, the NHS in Scotland has delivered over 180,000 health checks to people living in the most deprived areas. The health checks, which are carried out in general practice and offered to all 40 to 64 years olds living in deprived communities, focus on CVD and wider life style issues, such as mental health and social needs. People identified to be at risk are referred for services including smoking cessation, alcohol interventions and diet/weight management or are prescribed appropriate medication. "Our next step is to take a bottoms-up approach, educating children about CVD. We want people to start taking responsibility for their own health from an early age," said Dr Vallance.
Health care professionals urged to be proactive
In order to increase access to health care for marginalized groups, Professor Christi Deaton, from The University of Manchester, UK, told the meeting that health care professionals need to become more proactive and go out into communities. "Just because you are holding clinics there's a tendency to think that people will come to them. To be really effective you need to seek out your most deprived or under-served patients," said Professor Deaton.
The first step, she said, was to identify "pockets" of deprivation and identify vulnerable groups within your own community. "Many councils have statistics on morbidity and mortality for different conditions according to area, and also information about deprivation," said Professor Deaton.
It is helpful, she added, to collect information about ethnicity for your area. "If you only see 1% of people of a certain ethnicity in your clinic, but statistics tell you that the local area has 15% you know you're not reaching that part of the population," she said.
One effective strategy for targeting different populations is to recruit lay community health workers. "They can act as service brokers persuading people to come in for screening. Their activities may involve speaking in churches, mosques or other community centres, or even just knocking on people's doors to tell them about screening," said Professor Deaton. Where there are language barriers community workers can be employed from different ethnicities. "It appears people much prefer health prevention messages to come from within their own communities, rather that outsiders telling them what to do," said Professor Deaton.
Health care professionals, said Professor Deaton, can tackle the problem of deprivation on all sorts of different levels. "There's a lot we can do to help influence Government policy and improve the infrastructure for healthy living. This might be campaigning for increased access to recreational areas and cycle lanes, so that people can exercise more, and encouraging Government subsidies for healthy foods like fruit and veg," she said. "Health professionals should also be encouraged to undertake research looking at the best ways to persuade individuals and populations to adopt healthy behaviours, like exercising more, quitting smoking and reducing alcohol intake. Nurses are very good at talking to people and developing interventions that are culturally relevant and that incorporate patient perspectives and ideas."