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CARDIOVASCULAR DISEASE PREVENTION IN LOW RESOURCE SETTINGS:LESSONS FROM THE HEARTFILE EXPERIENCE IN

This paper outlines activities of the Heartfile Sania Nishtar, MRCP, PhD Program in Pakistan (http://heartfile.org). The program focuses on cardiovascular disease pre- vention and health promotion, and includes several initiatives that encompass building pol- icy, reorienting health services, and developing BACKGROUND changes shifting the focus from com- grass-roots community interventions that uti- municable diseases and reproductive lize the print and electronic media by incor- health to also include the prevention Heartfile was created in Pakistan for porating social marketing approaches. and control of NCDs. This shift will Initiated by the nonprofit private sector, use among a population of 140 million, require defining public health models the program now links with major public sec- against the backdrop of the high prev- that focus on the population approach tor primary healthcare programs, and is cur- alence rates of cardiovascular disease rently spearheading formulation of the Nation- to NCDs, and are suited to low resource (CVD), which affects more than 30% al Action Plan on Noncommunicable Disease situations. of the adult population, therefore war- Prevention and Control in Pakistan. In addi- Heartfile, a private sector, donor- tion, the program is being refined, validated, ranting aggressive preventive strategies.1 funded organization based in Pakistan, and packaged as a replicable model for other The need to address these issues is made used this approach in a developing developing countries and in low resource set- more urgent by the serious health and tings, which utilizes utilizing appropriate prin- economic challenges posed by Pakistan’s country and developed several relevant ciples of franchising with inbuilt components average per capita income of US $500, models for targeting different segments sensitive to cultural and social adaptations. of the population, as well as healthcare A review of the planning process, imple- and its total health expenditure of 0.8% providers throughout the nation. The mentation strategy, and fund-raising experi- of the GNP. The delineation of the ep- ence is presented. Strategies unique to low re- idemiological transition highlighting the organization optimized its meager re- source settings, such as the development of changing global trends of disease, which sources through partnerships that en- cost- and time-efficient strategic alliances and brought the burden of noncommuni- abled it to draw support from the me- partnerships, have also been highlighted. In dia, distribution channels, and social de- addition, specific caveats are identified as be- cable diseases (NCD) to the forefront as ing helpful to private sector development of a major health challenge for developing velopment organizations, and provided chronic disease prevention programs in re- countries, has lent additional gravity to the opportunity to include its interven- source-constrained settings, and a road map to the situation.2–5 tions in National Primary Healthcare a sustainable public-private sector partnership Further, the recently published programs. The organization was subse- is provided. (Ethn Dis. 2003;13[suppl2]:S2- quently successful, not only in initiating 135–S2-144) World Health Report 2002 Reducing Risks, Promoting Healthy Life6 provides a policy change that led to the inclusion powerful reasons for greater investment of CVD on the country’s health agenda, in CVD prevention and management. but also in spearheading the formula- The report concludes that 6 of the top tion of the National Action Plan and 10 health risks in developing countries Policy for its government, thus allowing are directly relating to CVD, and high- advancement toward the goal of reduc- lights the magnitude of benefit that pos- ing morbidity and mortality due to car- sible reductions in risk could achieve in diovascular diseases in Pakistan. The various cost-effective ways. In this con- program can also be viewed in its broad- text, successful experiences from com- er context and its practical relevance to munity-based interventions in the set- other developing countries in the pro- ting of developed countries,7–10 and in cess of designing heart health programs, countries with economies in transi- thereby broadening its goals to encom- tion,11 provide useful insights into the pass the overarching objective of devel- dynamics of addressing these diseases at oping a model for use in other devel- a population level, translating into a de- oping countries and low resource set- From Heartfile, Pakistan. cline in incidence of cardiovascular dis- tings. eases. Similar trends can be expected for Founded by the author in 1998 with Address correspondence to Sania Nish- the developing world. an initial grant from the Canadian De- tar, MRCP, PhD; 1-Park Road, Chak Sha- zad; , Pakistan; 0092-51- Reaching this goal will necessitate a velopment International Agency to sup- 2243580; 0092-51-2240773 (fax); san- reorganization of priorities in develop- port the publication of public awareness ia@heartfile.org; http://heartfile.org ing countries to incorporate policy leaflets, Heartfile has since expanded to

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posters. Later, specific programs in al- ticles. As part of the NEWS campaign, The report concludes that 6 located districts focused on encouraging articles appear on the inside front page the participation of all categories of of the newspaper; in JANG, the articles of the top 10 health risks in healthcare providers through dedicated appear on the health page of the Sunday developing countries are training and provision of signage. In ad- newspaper, and are printed on half the dition, publication of the South Asian back page of the US magazine every Fri- directly relating to CVD, Association for Regional Cooperation day. In the former 2 newspapers, the 12,13 and highlights the magnitude (SAARC) prevention guidelines rep- word count ranges from 300–800 resented the initial step in developing words; whereas articles in the US mag- of benefit that possible customized guidelines for the preven- azine for adolescents are in the form of tion and control of cardiovascular dis- large graphics with the message con- reductions in risk could eases in Pakistan. In conjunction with tained in a caption of 100–150 words achieve in various cost- these activities, a research wing was also (Figure 2). Boxes are inserted in the ar- set up at Heartfile to fill gaps in knowl- ticles promoting questions via email, effective ways. edge that were relevant to addressing while a checklist repeatedly advocates CVD prevention in Pakistan. An over- healthier lifestyles. The style of the ar- view of the individual projects follows. ticles varies from being a topic-oriented discussion on a specific aspect of a risk include 4 dimensions: community in- factor to an informative piece respond- terventions, reorientation of health ser- COMMUNITY ing to a particular question; in addition, vices, research, and advocacy. An over- INTERVENTIONS stories and checklists are also published. view of the individual projects follows. Assessment of the intermediate mea- Community interventions needed to Tier 1: Print Media Campaigns sures of community impact of the En- cater to the information needs of differ- glish newspaper campaign has recently ent segments within the native Pakistani Newspaper Campaign (http:// been conducted through a telephone population, as categorized by literacy heartfile.org/news.htm) survey.14 Results indicate that an esti- rates, place of residence, and economic An overview of Heartfile’s newspaper mated 0.66 million individuals read status. Based on these considerations, a campaigns is presented in Table 1. The three tier model was designed. The first ‘‘NEWS-Heartfile public awareness these articles regularly, while 0.79 mil- tier constituted the Print Media cam- campaign’’ was the opening intervention lion read them occasionally. For the paigns targeted to the urban and rural for the Heartfile project in Pakistan, sample interviewed, the articles signifi- literate populations; the newspaper cam- with the target group being the English cantly supplemented the knowledge of paigns are the highlight in this category, literate elite, a minority of the urban 86.7%, 77.3%, and 85.3% with respect drawing support from the largest pub- population. The campaign’s intent was to diet, exercise, and smoking, respec- lication house in the country. Subse- to change behaviors within this segment tively, and were the sole source of in- quently, second tier programs evolved of the population, which usually proves formation for 5.3%, 9.3%, and 4%, that drew on a partnership with state- to be trend setting for other social again with respect to diet, exercise, and owned electronic media, and expanded groups. Tier 1 (print media campaigns) smoking, respectively. With respect to the scope of community interventions includes similar interventions that are the practical impact of these articles, to areas in which the print media has currently ongoing though a newspaper 40.4% of those interviewed had made limited penetration. In addition, other in the local language and a US magazine some dietary changes, 38.7% had made novel projects were launched at the targeted to adolescents. This campaign some changes in their exercise patterns, grass-roots level as part of the third tier has been launched through space do- and 7.6% had reduced their tobacco projects, in partnership with social de- nated by the newspaper group ‘‘JANG’’ consumption. velopment organizations, that incorpo- (http://jang-group.com), which has the Even after taking the limitations of rated social marketing approaches to ex- largest circulation in the country. a telephone survey into account, results pand the scope of the program in the Along with articles, colored illustra- indicate that the program has had a sig- underprivileged and remote rural areas. tions of the Heartfile mascot and the nificant impact on the knowledge, per- As part of this program, health pro- logo lettering are posted on a weekly ba- ceptions, and practices of the English fessionals were initially sensitized to the sis in each of the 2 daily newspapers and newspaper reading elite in Pakistan. The concept by the circulation of a regular the weekly magazine (Figure 1). One ar- key element of this campaign, however, newsletter, frequent updates on activi- ticle in each category appears each week, is the donated newspaper space, which ties, and through the distribution of with a total weekly appearance of 3 ar- helped not only to significantly optimize

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Overview of the newspaper campaigns*

Number of Campaign News Copies Outreach to Profile of the Duration of Articles WEEKLY Paper per Day Individuals Population the Campaign Appeared NEWS† Heartfile public NEWS daily 450,000 2.7 million English literate February 1999 182 awareness campaign (nation wide) urban and ongoing JANG† Heartfile public JANG daily 1 million 6–7 million literate urban January 2000 82 awareness campaign (nation wide) and rural US‡ Heartfile public US 450,000 2.7 million Urdu literate urban February 2001 91 awareness campaign (nation wide) and rural * As of January 2003. † Daily newspaper. ‡ Weekly adolescent’s magazine accompanying THE NEWS.

resources, but also, more importantly, Public Information Leaflets (http:// and How’’; ‘‘Smoking and Your Heart’’; ensured nationwide dissemination of the heartfile.org/pamphlet.htm) ‘‘Food and Your Heart’’; ‘‘Prevent a information. Survey responses also re- A set of 6 public information leaflets Heart Attack’’; ‘‘Symptoms of Heart vealed that the use of an identifiable have been developed in English and Disease’’ and ‘‘Cholesterol and Your logo and mascot were critical to the ef- Urdu (a local Pakistani language) and Heart.’’ A local consumer distribution fective penetration of these messages. entitled: ‘‘High Blood Pressure: Why network distributes these to pharmacy stores in 16 cities nationwide where they are sold on a cost recovery basis. The pamphlets have also been used by a hos- pital in Manchester, England for its Urdu-speaking population.

Posters (http://heartfile.org/ posters.htm) Posters have been developed for dif- ferent target audiences. An example of this involved an illustrated poster en- couraging individuals to have their blood pressure checked and displayed in facilities throughout the country. This intervention was found to be effective in prompting 36.6% of those viewing the posters in waiting rooms of clinics to have their blood pressure checked for the first time.15 Using pharmaceutical field staff to distribute the posters great- ly reduced the cost of distribution. As a follow up to this activity, another inter- vention is being designed to give indi- viduals a more comprehensive overview of high blood pressure. This approach employs posters and take-away leaflets as tools of intervention. Posters are also be- ing used to pilot the school system’s anti-passive smoking campaign in the capital city of the country. Other posters are discussed as part of the specific in- Fig. 1. Caption ??? terventions.

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provides an overview of the organiza- tions activities and the text of the public information material.

Tier 3 Campaigns The 3rd tier campaigns are designed on a grass roots level to reach a popu- lation with little penetration by print media and to supplement the electronic media (televison and radio) campaigns. Two models are currently being imple- mented in separate districts. The first model focuses on communities, includ- ing the health professional component, and is being conducted in partnership with social development organizations. The other model focuses on the training of health professionals, who then be- come responsible for engaging the com- munity.

Model 1: Heartfile Lodhran CVD Prevention Project (http:// heartfile.org/lodhran.htm) The project in Lodhran has been Fig. 2. Caption ??? initiated in one of the poorest areas of Pakistan targeting a predominantly rural population of one million, in partner- Tier 2: Electronic Media spots focused on creating awareness ship with the National Rural Support Campaigns about high blood pressure and promot- Program (NRSP). The NRSP is a na- ed opportunistic screening while the an- Radio tionwide network of rural, grass-roots other emphasized the principles of car- A one year campaign concluded in community organizations (CO) to en- diovascular disease prevention. The October 2002 featured a daily 60-sec- able rural communities to plan, imple- spots ended with the Heartfile and Min- ond spot on network radio, as part of ment, and manage development activi- istry of Health logos appearing together, the only hour-long program that is ties and programs for the purpose of en- the first time the ministry has shared its broadcast throughout the country, suring productive employment, allevi- logo with a private sector nongovern- reaching 90% of the population with ating poverty, and improving in the mental organization. Currently, this access to radio. Eight spots were broad- quality of life. In the District of South campaign is undergoing impact evalua- cast in rotation. Placement in the na- Punjab, NRSP has 534 organizations tion, the results of which will be the ba- tionwide air time was negotiated at sub- with an average of 30 members per CO sis of a joint strategy to air future spots sidized rates. Currently, this campaign, representing their villages. The project over an extended period of time. along with the television campaign de- was initially designed with 3 compo- scribed below, is being undergoing eval- nents: community-wide health educa- uation. Internet Campaign tion, village activist training, and train- Heartfile has posted the largest bilin- ing of health professionals. Television gual Web site dealing with preventive The first 2 components are linked As part of piloting the electronic cardiovascular care with English and with the NRSP program. Community- media intervention, Heartfile, in part- Urdu versions; the Urdu version is the wide health education is packaged with nerships with the ministry of health, ran only site of substantial size that uses the CO sessions of NRSP and involves 30 television spots (on national televi- Urdu to post public awareness material dedicated cardiovascular health educa- sion during prime time, which reaches relevant to preventive cardiovascular tion sessions for community groups uti- 80% of the population. One of these care in Pakistan. In addition, the site lizing customized training materials, in-

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cluding overheads, posters, and pam- which obviated the need to develop an Model 2: The Jhelum and Chakwal phlets. The village activist training com- independent vertical program in the Project ponent is linked to the NRSP short-to-medium term. In addition, This project is an example of the community management and skills LHWs were thought to be ideal catalysts second approach in the tier 3 commu- training; sessions are scheduled on a for promoting healthy behaviors in their nity interventions, and focuses on uti- quarterly basis for village activists select- communities, as they exercised local in- lizing health professionals to advance ed from the COs. In these sessions, the fluence in the domain of health. The the cardiovascular prevention agenda. activists are subjected to further training launching of the ‘‘LHW Heart Health The health professional component of to enable them to act as effective cata- Program’’ in the district of Lodhran was this project, which forms the main bulk lysts for their communities; approxi- therefore treated as the pilot phase of of the intervention, is described in detail mately 50 activists receive training mod- this program at the national level, and under the health professional compo- ules every 3 months. The health profes- was conducted in collaboration with the nent. The community intervention sional component has been launched in district health department under a for- component is linked to the health pro- fessional component and focuses on in- partnership with the district health de- mal agreement with the federal ministry troducing communities to the program partment and will use training to en- of health, which included a provision through opportunistic screenings of courage all categories of healthcare pro- for future expansion on a national level. high blood pressure. The communica- viders to participate in health promo- As part of the pilot phase, process tion interventions, and will link the tions campaign directs the public to evaluation and validation of the training health professional component with the look for the Heartfile logo to get a curriculum and the intervention tools community and activist components. blood pressure check and accurate in- were conducted. A training package was The health professional component also formation on lifestyle changes that pro- developed that focused on including focuses on increasing the rates of screen- mote cardiovascular disease prevention cardiovascular disease prevention as part ing for high blood pressure by including and control. Heartfile print and elec- of the LHW work-plan. Training was health professionals into the Facility- tronic media campaigns also target this organized following the cascade ap- Based High Blood Pressure Screening community, using the logo and the mas- proach, which included a ‘‘train the Program and by organizing screening cot to reinforce the message, a critical LHW trainers’’ component for 38 train- camps throughout the district. Interven- part of the social marketing approach. ers in the district, followed by training tion tools include workshops, district The community component is further for 700 LHWs in Lodhran. based high blood pressure screening reinforced by the school health compo- camps and distribution of educational The restructuring plan also incor- nent of the project, which draws sup- and support materials. porated a school health component port from a close collaboration with the The need to restructure the imple- composed of interactive lecture sessions, district health department and uses mentation strategy was identified bu in- extensively piloted visual intervention packaged formats and tools utilized for termediate impact evaluations, highligh- tools including posters, pamphlets, and the Lodhran project. The processes and ing the program’s need to include health take-home materials. The project has tools of the school health project are be- professionals at the grass-roots level, built-in assessment components for ing validated and pilot tested in these children, and other local activists. In evaluation. Support from the local de- districts; results could form the basis of this context, Lady Health Workers partment of education ensured the ac- expansion of the school health plan at a (LHWs), of the National Program for tive and consistent participation of national level. Family Planning of the Ministry of state-owned schools, which provide the Health, were identified as a useful re- majority of primary and secondary level ‘‘Eat Healthy’’ Promotional source. LHWs are the work force of schooling in the district. In addition, re- Campaigns more than 100,000 locally hired young structuring introduced several other cat- In addition to the core projects, women with at least an 8th grade edu- egories of village activists and locally in- which target significant segments of the cation and who participate in the Lady fluential individuals, such as counselors population, other projects have been Health Worker Program (LHWP) of the and the clergy, to the program. launched for selected target groups; the . The LHWP is Results from the midterm evaluation objective of these campaigns is to key to the government’s effort to raise of the Lodhran project have guided the change behaviors, which may set trends, the health status of women and children incorporation of changes in the imple- thus having a ‘‘trickle-down’’ effect. The in Pakistan’s poor rural areas. Therefore, mentation strategy; refining this experi- ‘‘Eat Healthy’’ campaign is an example the inclusion of LHWs represented the ence will help in developing a replicable of this approach and was launched in 2 desired reorientation of health services, model. settings. A heart-friendly menu was en-

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dorsed by a Marriott Hotel restaurant, diovascular disease prevention and con- turally appropriate and practical, rele- one of the few 5-star hotels in the coun- trol. The health professional education vant guidelines have been developed try. In addition, low cholesterol items component is supplemented by the through a broad-based consensus among were promoted in a leading chain pastry community interventions through the various stakeholders in 7 South Asian shop. print and the electronic media. countries. These guidelines were offi- cially released by the World Heart Fed- Other Support Projects KSM Collaboration eration at the Second SAARC Biennial A women’s awareness campaign has Heartfiles collaboration with the Congress of the SAARC Cardiac Society been packaged with the ongoing com- family planning organization, Key So- in Delhi in February 2002. Publication munity health promotion projects by cial Marketing (KSM), has resulted in of the SAARC was reported in interna- incorporating women’s cardiovascular the development of a training module tional journals, and received extensive health issues in print and electronic me- on prevention and management of hy- media attention in SAARC countries; an dia campaigns. A similar strategy is be- pertension. KSM works with a network abbreviated version was published as an ing used for the anti-tobacco awareness of about 4,000 private doctors and para- article in a peer-reviewed journal.13 campaign. Other support projects fea- medics throughout Pakistan who are ex- ture events to mark special occasions, pected to take refresher training over the Newsletter such as World Heart Day, helping to en- next 2 years; this training will include The quarterly Heartfile Newsletter is hance media coverage of the issue, and the new module on hypertension. While posted to more than 3000 physicians thereby acting as effective advocacy the normal focus of KSM’s training ac- throughout the country, with a focus on tools. tivities is the provision of high-quality those without access to academic op- family planning services, the relevance portunities. In addition to activity high- of blood pressure screening for clients lights of the quarter, the newsletter car- REORIENTATION OF intending to use hormonal methods ries a regular feature, named ‘‘Bill- HEALTH SERVICES make this module a useful addition to board,’’ which is a pull-out section in- the curricula. The collaboration be- tended for use as an easy reference in Jhelum and Chakwal Project tween KSM and Heartfile is intended to clinical situations and containing cus- (http://heartfile.org/jc.htm) utilize private sector providers to pro- tomized guidelines and management al- The focus of this project is on train- mote wider health goals. gorithms for common diseases. In ad- ing both physician and non-physician dition, a section on ProCORb posts se- health service provider who provide the SAARC Region Prevention lected items of interest that have been bulk of health care at the grass-roots lev- Guidelines recently posted on the ProCOR web el, but do not benefit from the academic In 2002, Heartfile published Guide- site, while another site collates clippings opportunities that focus on larger lines and Recommendations for Coronary from the bulletin of the World Heart towns. Health providers are sensitized Heart Disease Prevention in the SAARCa Federation, HeartBeat in an attempt to and trained in opportunistic blood pres- Region in collaboration with the SAARC raise awareness of the need to address sure screening with the help of custom- Cardiac Society which is a representative the prevention paradigm of diseases on ized training curricula developed for dif- scientific body of South Asian countries. a global scale. ferent categories of healthcare providers. These guidelines are partly dedicated to The curricula are participatory in nature policy recommendations and also sum- and suitable for adult learning, focusing marize practical and relevant public RESEARCH on quality of care to clients, good com- health and clinical recommendations munication techniques, and rational use addressing primary and secondary pre- Implementation research is an im- of drugs in the context of CVD preven- vention of coronary heart disease. The portant component of the Heartfile pro- tion. Short, one-day courses are provid- guidelines represent the first time cul- gram. Though several of the initial pro- ed to health service providers on rele- jects lacked a true experimental design, vant issues and practical steps that pro- such as control groups or baseline as- viders can take. Following training, each a South Asian Association for Regional sessments, many of the projects initiated provider receives a signboard with the Cooperation is made up of participants from subsequently have sound evaluation and Heartfile logo. The public are then di- Bangladesh, Bhutan, India, Maldives, Ne- rected by the communications cam- pal, Pakistan, and . The main goal of SAARC is to accelerate economic and so- paign to look for this logo to get blood cial development in member states through b ProCOR is a global electronic confer- pressure checks and accurate informa- joint action in certain agreed areas of co- ence on heart health (http://www.procor tion on lifestyle changes to promote car- operation. .org).

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assessment components. First-genera- sues. These studies will help to uncover stan. Work is currently underway to re- tion Heartfile projects (eg, newspaper current gaps in knowledge and practices fine and package this experience in or- campaign) were evaluated through post- in Pakistan, which can then be specific der to replicate it in other similar set- intervention, self-reported changes in targets for interventions to expand sec- tings utilizing appropriate principles of practice and perceptions. Later, second- ondary prevention practices. franchising. The package will incorpo- generation projects (eg, the Lodhran rate sound evaluation components and project), established baselines and con- will have built-in mechanisms to cater trol communities for comparison, but ADVOCACY to local situations. This first Heartfile evaluated knowledge and attitudes initiative will incorporate approaches to about risk factors exclusively and, as Noncommunicable diseases, includ- advance cardiovascular health in the de- part of the post-intervention analysis, ing cardiovascular diseases, were not fea- veloping world. Several international will examine changes in these. Third- tured prominently as part of the health- health organizations have already ex- generation projects, (eg, the Jhelum and care agenda in Pakistan at the time of pressed interest in facilitating the trans- Chakwal project) are establishing prev- Heartfile’s inception; therefore one com- fer of this methodology to other devel- alence of risk factors, in addition to de- ponent of the Heartfile program focused oping countries. In addition, formal termining baseline levels for knowledge on advocacy. This was greatly enhanced agreements have been reached with in- and practices; this will enable evaluation by media visibility, a natural conse- stitutions in Sri Lanka, Bangladesh, of outcomes as part of the post-inter- quence of Heartfile’s information dis- Iran, Nepal, and Tunisia. vention assessment. semination strategy. Several achieve- Heartfile is also working to define ments indicate significant progress in the risk factor profile of the Pakistani this direction, initially evidenced by the DISCUSSION population, in order to set precise goals initiation of the collaborative television campaign and representation of Heart- for preventive initiatives. Ideally, this The Heartfile Program has not been should have been undertaken in a well- file in national committees on related is- sues. Three years of Heartfile’s advocacy fully evaluated for impact; however its designed, multi-center prospective co- individual components are in varying hort design; however, logistic issues pre- efforts culminated in signing of a Mem- orandum of Understanding (MOU) be- phases of evaluation and reporting. In- cluded that, so a case-control study was tween Heartfile and the ministry of termediate measures of community im- conducted. Prospective cases of CAD, health in January 2003; the MOU en- pact, and the proven economic feasibil- documented by coronary angiography ables Heartfile to take a lead role in for- ity of one of the projects, have yielded were recruited in a hospital-based set- 14 mulating the National Action Plan on positive and encouraging results. ting, with controls being those from the NCD Prevention and Control for Pak- In ideal situations, public health in- study population with normal coronary istan through a consultative process. In terventions begin after initial situational angiograms, matched for age and sex. addition, the MOU binds the ministry assessments and baseline surveys. Such The key advantage to this approach lies of health to incorporate the National programs have long-term implementa- in using the ‘‘gold standard’’ for the di- Action Plan as part of its new health tion strategies, which are executed by agnosis of CAD, thereby avoiding prob- policy. dedicated resource personnel with spe- lems of misdiagnosis associated with the cific adequate funding allocations over a use of less specific diagnostic modalities period of time. In addition, these pro- such as ECG. The study was completed REPLICATION OF THE grams are often tested in an experimen- in February 2002, and is currently in HEARTFILE PROGRAM tal design, with control communities for press. tangible comparisons and are also usu- Heartfile’s role as principal investi- In the wake of the present urgency ally under-taken with public sector in- gator from Pakistan in WHO studies to address CVD through a prevention stitutional support, linked with a long- such as the PREMISE Study and Vali- approach, it is also necessary to develop term strategic plan. Heartfile on the dation of the CVD Risk Assessment and effective implementation methodologies other hand, has evolved as an initiative Management Package expands the con- that are suited to low resource situa- in the private sector with no initial long- tributions of research beyond risk factor tions, cater to cultural and social re- term funding allocation. Its various definition and community-based imple- quirements in under-privileged com- components and programs evolved and mentation to include studies examining munities and are adaptable for resource- developed in the context of locally rel- the treatment gap in secondary preven- constrained healthcare practices. In this evant circumstances as need was iden- tion of CVD and validation of programs context, useful lessons can be learned tified and as strategic alliances became that are developed to address these is- from the Heartfile experience in Paki- available that would maximize the mea-

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ger resources drawn from international to integrate and strengthen relevant pro- addressed by the commercial domain in donor support and personal funding. grams, and to disseminate these to other the context of health education. During Therefore, several weaknesses may be low resource settings. Links with inter- such dialogue, it is necessary specify the identified in this program, compared national research institutes have been prolonged duration of the campaign, as with programs developed in ideal situ- the backbone of ongoing epidemiologi- such campaigns need to be of a sus- ations. Along with these weaknesses, cal research. In addition, Heartfiles’ em- tained duration to have an impact.18,19 however, the program has several inher- inent international advisory board The success of this intervention has ent strengths and the experience gained brings a broad-based international per- been based largely on the visibility of from the program is relevant to other spective to this program. the message, and its cost effectiveness developing countries reflecting both the Several local examples of this pro- due to donated newspaper space. As this problems encountered in such settings, gram merit further elaboration in an at- strategy has proven to be largely useful as well as the opportunities that exist to tempt to highlight their relevance for in Pakistan, it seems prudent to rec- counter these. similar private-sector based initiatives to ommend exploration of the feasibility of From its inception to the time it af- take place in the future. The print me- the replicating this module in other low fected policy change, Heartfile has dia campaigns using newspapers, dem- resource settings. spanned a period of 4 years, a tight onstrate the potential to develop a Heartfile’s nationwide dissemination timeline that would have made achiev- health education campaign with mini- of pamphlets to pharmacy counters ing the desired results difficult in even mal resources, producing low-cost, ef- could be achieved by considering the the best of circumstances. Factors that fective messages in a public health set- pamphlets a ‘‘product’’ on the distribu- have contributed to the program’s suc- ting, as opposed to commercial adver- tion list of a consumer distribution cess relate to human factors, and the de- tising. These messages can be carried by agency, with an extensive national net- velopment of strategic partnerships at a premier media product, not only as a work. The agency distributed pamphlets the local, regional, and international lev- public service, but also as a valuable ad- free of cost, and included an incentive els, which, together, have helped opti- dition to the quality of the media’s for the retailer. Since commercial item mize time and resources. product. In resource-constrained set- distribution channels exist in most At a national level, effective links tings, newspapers can be identified as a countries, the feasibility of this approach with the media, social sector develop- readily available tool for health educa- can be explored in other situations. ment organizations, social marketing tion messages, and an important com- As part of Heartfile’s tier 3 com- agencies, consumer distribution net- ponent of CVD prevention strategies. munity interventions, the Lodhran pro- works, the public sector and the com- In addition to providing health infor- ject outlines a novel partnership, initi- mercial sector have helped in achieving mation, such messages can provide prac- ated at a district level with a social de- program objectives. At the local district tical skills and social support for change, velopment organization, and eventually level, public sector partnerships with the and can promote policy change. In ad- expanded to encompass links to both departments of health and education dition, these messages can help shape the private and public sectors, providing have resulted in effective penetration at the public discussion agenda, and in- a guide for affecting policy change. the grass-roots level. At the regional lev- creased media coverage of an issue has Links with social development organi- el, Heartfile’s partnership with the been demonstrated to increase the pub- zations helped to optimize administra- SAARC Cardiac Society in publishing lic perceptions of the issue’s impor- tive costs, and allowed the CVD pre- the SAARC Guidelines on the Prevention tance.16,17 However, it is necessary to vention agenda to penetrate a commu- of Coronary Heart Disease established a make a distinction between health ed- nity in partnership with a well-respected regional initiative, which provided the ucation relayed by newspapers and social sector development network. Sev- impetus for relevant activities at a na- through advertising with important cost eral components of this project are be- tional level. Another example of suc- implications. The success of social mar- ing refined and evaluated in order to cessful regional collaboration is high- keting approaches in health education make them replicable both within and lighted by the initiation of the Heartfile warrants the use of visual aids such as a outside the country. This model out- program’s replication in other South logo and mascot. These intervention lines an opportunity and provides useful Asian countries, an initiative currently tools, while identified as being essential approaches within this paradigm for in the planning stage. On the other to social marketing strategies, had not other low resource settings, which are hand, strong ties to global international previously been identified as being ef- certain to have initiatives in place at the organizations such as the World Health fective for CVD prevention campaigns grass-roots level aimed at social devel- Organization (WHO) and the World in the developing world. These an other opment and improvement of the quality Heart Federation (WHF) have helped social marketing approaches should be of life.

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The Lodhran experience represented sionals from the private and public sec- cause it represents the first public-pri- one approach to engaging in heart tors. The project format represents a vate partnership in health initiated at health activities at a district level where- replicable methodology, which is suited the policy development level, and will as the approach adopted as part of the to similar situations, and can be initi- encompass common program imple- Jhelum and Chakwal project exemplifies ated locally with seed funds; subsequent mentation elements. another. This latter approach used incorporation of the training module Several difficulties were also encoun- health professionals, rather than the with formal health sector capacity build- tered throughout the course of this pro- community, as an entry point. The pro- ing training ensures long-term sustain- gram. Initial attempts at placing CVD ject design focused heavily on the prin- ability. on the national health agenda were un- ciples of social marketing, involving Other links have enabled Heartfile successful and despite the delineation of training of health professionals, provi- to reach out to health service providers several opportunities to incorporate sion of signage, and engaging the al- in an attempt to engage them in the heart health into primary health care, ready sensitized community in the pro- project. Collaborative initiatives under a the governent was resistant to making a ject through the opportunistic screening formal agreement with a multi-national policy change. However, subsequent ef- of blood pressure. Social marketing ap- pharmaceutical company have helped to forts were fruitful in prompting the proaches are known to being effective as circulate the quarterly newsletter, sup- ministry of health to stage joint televi- part of health promotion in the devel- ported publication of the SAARC sion spots with Heartfile. In addition, oping countries20 and have been utilized guideline13 and helped in disseminating collaboration with the LHWP involved in Pakistan in the domain of reproduc- posters developed for health facilities. training the work force of more than tive health.21 While incorporating such Indeed opportunities to develop such al- 100,000 LHWs, thereby expanding the approaches, however, extreme caution liances exist in most situations; however scope of the Heartfile program. The must be exercised; over-enthusiasm in extreme caution must be exercised in process and tools of this intervention are promoting a range of products not only doing so. The organizations name, in- of particular relevance to other low re- casts doubt in the minds of officials and tellectual property, and reputation must source settings utilizing grass-roots net- donors but also narrows the range at the be safeguarded at all costs. The princi- works of primary healthcare providers cost of excluding other non-controver- ples of transparency, avoidance of con- with limited education and training. sial elements that resonate with the flict of interest and compliance with Initial failed attempts at engaging principles of health education.22 There- laws and regulations must also guide re- the government in this approach can be fore the Heartfile approach to social lationships. In addition, the contribut- attributed to bureaucratic, cultural, and marketing did not involve product pro- ing organization must be of high repute. policy constraints; a similar resistance motion in any way. The concept of so- This program has also highlighted can be expected in similar settings. In cial marketing has not been previously several opportunities that exist for pri- this context, the role of international utilized on a mass scale in projects re- vate sector organizations with similar health organizations such as WHO lated to CVD prevention. Heartfile rep- goals and objectives to link with govern- should be fully appreciated. Such orga- resents the first such use of the ap- ment programs. Examples include the nizations play a major role in shaping proach. Utilizing opportunistic blood electronic media collaborative initiative, health agendas of developing countries. pressure screenings as the focal point in the LHW Heart Health Project in the Therefore, it is imperative for private- the program presents additional advan- district of Lodhran, with provision for sector-based initiatives to foster an ac- tages, since high blood pressure screen- national expansion, and links with the tive collaboration with the country’s op- ing and control is ideally suited to be department of education. The most sig- erational arm of WHO so that advocacy the initial component of an integrated nificant collaboration with the public targeted at local policy makers will also cardiovascular disease prevention and sector however relates to the formal have active support of WHO. control program particularly for a poor agreement (MOU) with the ministry of The Heartfile program also encoun- country. High blood pressure screening health, which empowers Heartfile to tered several funding constraints. is perceived as a ‘clinical’ need and is a take a lead in the development of the Healthcare needs of developing coun- vehicle for dietary, tobacco, diabetes, National Action Plan on CVD Preven- tries are traditionally thought to be syn- and obesity control; the program is also tion and Control, expanding the CVD onymous with reproductive health issues unlikely to encounter the powerful re- issue to encompass an NCD approach. and communicable disease control; sistance of organized vested interests, The signing of this MOU represents a NCDs do not resonate with these pri- such as the tobacco industry.23 This pro- major breakthrough, not only in terms orities. Therefore, significant effort was ject has been undertaken with donor of prioritizing NCDs on the health required to highlight the importance of funding and has involved health profes- agenda of the government, but also be- the rising CVD burden. To this end,

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much broader context in the domain of papers as a tool for a cardiovascular preven- development. Heartfile represents a pri- tion program in a developing country. J . . . it is imperative for Health Commun. In press. vate sector experience, which has now 15. Nishtar S, Jehan J, Khan SY, Badar A, Mirza private-sector-based initiatives expanded to assist national development YA. Posters can prompt people to have their to foster an active through improved health. The degree to blood pressure checked. J Health Promot which this provides a model for other Educ. In press. 16. Smith KA. Effects of newspaper coverage on collaboration with the developing countries remains to be de- community issue concerns and local govern- termined. ment evaluations. Commun Res. 1987;14: country’s operational arm of 379–395. WHO so that advocacy REFERENCES 17. Newman IM, Fitzsimmons ML. Newspapers 1. National Health Survey of Pakistan. 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J Am Dietary Assoc. 1994;94:1284– 1290. the economic impact of these diseases, national Heart Health Conference. Victoria, Canada; 1992. 20. Janowitz B, Suazo M, Fried DB, Bratt JH, both at the macroeconomic level and as Bailey PE. Impact of social marketing on con- 5. World Bank. Human Development and Net- traceptive prevalence and cost in Honduras. it related to households. The argument work Strategy. Washington, DC: World Bank, Stud Fam Plann. 1992;23(2):110–117. was also made stronger by highlighting Health Nutrition and Population Division; 21. Social marketing approaches and health pro- 1997. the inability of health systems to face motion. Available at: http://www.key.org.pk 6. World Health Report 2002. Reducing Risks, the challenge of the rising burden, 22. Davies J. Social marketers’ lack of success in Promoting Healthy Life. Geneva: World using CSM discipline to harness commercial thereby strengthening the case for in- Health Organization; 2002. resources and increase contraceptive preva- vesting in CVD prevention and control. 7. Pushka P, Tuomilehto J, Nissinen A, Vartiai- lence. Soc Markers Forum. 1984;1(2):2. nen E, eds. The North Karelia Project: 20 year Data from the World Bank, WHO, and 23. Reddy KS. Hypertension control in develop- results and experiences. The National Public Murray and Lopez were of significance ing countries: generic issues. J Hum Hyper- Health Institute (KTL), in collabo- importance in highlighting the issue, tens. 1996;10(suppl 1):S33–S38. ration with the WHO Regional Office for 24. SAARC Coronary Heart Disease Prevention while local cost-based data from the re- Europe and the North Karelia Project Re- Guidelines. Available at: http://heartfile.org/ search Foundation; 1995. cent SAARC Coronary Heart Disease Pre- apend.htm vention Guidelines,24 which emphasized 8. Carleton RA, Lasater TM, Assaf A, Lefevre the inability of individuals to access RC, Mckinlay SM. Pawtucket Heart Health Program: I. An experiment in population care, further enhanced the relevance of based disease prevention. RIMedJ.Dec investment in CVD prevention and 1987;70(12):533–538. controls programs. Therefore, Heartfile 9. Farquhar JW, Fortmann SP, Flora JA, et al. was successful in generating funding Effects of community-wide education on car- diovascular disease risk factors: The Stanford from international donor sources, in- Five-City Project. JAMA. 1990;264(3):359– cluding: the UK’s Department of Inter- 365. national Development (DFID), the Ca- 10. Brownson RC, Smith CA, Pratt M, et al. Pre- nadian International Development venting cardiovascular disease through com- munity based risk reduction: The Bootheel Agency (CIDA), and the European Heart Health Project. Am J Public Health. Union funded Trust for Voluntary Or- 1996;86(2):206–213. ganizations in Pakistan (TVO). 11. Zatonski WA, McMichael J, Powles JW. Eco- These organizations provided fund- logical study of reasons for sharp decline in mortality from ischemic heart disease in Po- ing support for the Heartfile program at land since 1991. BMJ. 1998;316:1047–1051. a critical point during the course of the 12. South Asian Association for Regional Coop- cardiovascular disease epidemic in de- eration (SAARC) prevention guidelines. veloping countries. This enabled Heart- Available at: http://heartfile.org/saarc.htm file to plan and implement projects ad- 13. Nishtar S. Prevention of coronary heart dis- ease in south Asia. Lancet. 2002;360:1015– dressing CVD issues in the native Pak- 1018. istani setting and had implications for a 14. Nishtar S, Mirza YA, Jehan S, et al. News-

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