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Cardiovascular Risk Factors in Cochabamba, Bolivia Estimating Its Distribution and Assessing Social Inequalities

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Cardiovascular Risk Factors in Cochabamba, Bolivia Estimating Its Distribution and Assessing Social Inequalities Department of Epidemiology and Global Health Umeå Universitet, 901 87 Umeå www.phmed.umu.se/english Cardiovascular Risk Factors in Cochabamba, Bolivia Estimating its distribution and assessing social inequalities Usama Boles YERCIN MAMANI ORTIZ UMEÅ UNIVERSITY Cardiovascular Risk Factors in Cochabamba, Bolivia Estimating its distribution and assessing social inequalities Yercin Mamani Ortiz Department of Epidemiology and Global Health Umeå 2019 This work is protected by the Swedish Copyright Legislation (Act 1960:729) Dissertation for PhD licentiate in Medical Science with an orientation towards Public Health ISBN: 978-91-7855-099-9 Cover design by: Yercin Mamani and Lenar Mamani. Electronic version available at: http://umu.diva-portal.org/ Printed by: CityPrint i Norr AB Umeå, Sweden 2019 This thesis is dedicated to my parents for their love, endless support and encouragement. Table of Contents Abstract ..................................................................................................... i Abbreviations ......................................................................................... iii Prologue .................................................................................................... v Background............................................................................................... 1 CVD: a worldwide public health problem .............................................................................1 The CVD epidemic in LMIC ................................................................................................... 2 Cardiovascular risk factors: concept and distribution in LMIC........................................ 2 CVRF in Latin America ........................................................................................................... 3 CVRF in Bolivia and Cochabamba ........................................................................................ 4 Surveillance of preventable cardiovascular risk factors..................................................... 5 The Bolivian health system and the NCD/CVD policy.......................... 8 The national health system .................................................................................................... 8 NCD and CVD in the Bolivian health system .................................................................... 10 Rationale of the study ............................................................................ 13 Aims ......................................................................................................... 15 Specific objectives:..................................................................................................................15 Conceptual framework .......................................................................... 16 Methods.................................................................................................. 20 Study setting:..........................................................................................................................20 Bolivia ...............................................................................................................................20 Cochabamba .................................................................................................................... 21 Data collection........................................................................................................................24 The research team and my role on it........................................................................... 25 Adaptation of the WHO-STEPs approach in Cochabamba ..................................... 25 Training of the interviewers and health service networks......................................26 Sampling .......................................................................................................................... 27 Instruments and measures............................................................................................ 31 Variables .......................................................................................................................... 31 Data analysis ..........................................................................................................................33 Sub-study 1.......................................................................................................................34 Sub-study 2 ......................................................................................................................34 Ethical considerations........................................................................................................... 35 Findings...................................................................................................36 Characteristics of the participants in the study.................................................................36 Social determinants associated to CVDs ............................................................................36 Prevalence and risk of CVRF................................................................................................ 37 Behavioural risk factors by socioeconomic characteristics ....................................39 Smoking ............................................................................................................................ 41 Alcohol consumption ......................................................................................................42 Low fruit and vegetable consumption ..........................................................................43 Low level of physical activity .........................................................................................44 Metabolic risk factors by socioeconomic characteristics......................................... 45 Raised blood pressure.....................................................................................................46 Overweight and obesity .................................................................................................. 47 Abdominal obesity...........................................................................................................48 Abdominal obesity inequalities from an intersectional perspective .............................. 50 Discussion ...............................................................................................56 The current situation of CVRFs in Cochabamba............................................................... 56 Where are the CVRFs concentrated? .................................................................................. 58 Gaps in the abdominal obesity prevalence in the intersectional space between gender and ethnicity...........................................................................................................................60 What explains the joint and referent disparities............................................................... 61 Methodological considerations .............................................................63 Conclusions.............................................................................................64 Implications for practice .......................................................................65 Dissemination and impact..................................................................... 67 Acknowledgements ................................................................................ 71 References............................................................................................... 72 Appendix ................................................................................................. 85 Abstract Background: The increase in the prevalence of cardiovascular risk factors (CVRFs) is considered one of the most important public health problems worldwide and especially in Latin American (LA) countries. Although the systematic surveillance of chronic diseases and their risk factors has been recommended, Bolivia has not yet implemented a national strategy to collect and monitor CVRF information. Evidence from previous studies in Bolivia and other Latin American countries has suggested that CVRFs affect women more than men and mestizos more than indigenous people. However, a more accurate and comprehensive picture of the CVRF situation and how ethnicity and gender intersect to affect CVRFs is dearly needed to support the development of health policies to improve population health and reduce inequalities. Objective: to estimate the distribution of CVRFs and to examine intersectional inequalities in Cochabamba – Bolivia in order to provide useful information for public health practice and decision making. The specific objectives are: i) to estimate the prevalence of preventable risk factors associated with CVDs and ii) to assess and explain obesity inequalities in the intersectional spaces of ethnicity and gender. Methods: The data collection procedure was based on the Pan-American version (V2.0) of the WHO STEPS approach adapted to the Bolivian context. Between 2015 and 2016, 10,754 individuals aged over 18 years old were surveyed. The two first stages of the STEPS approach were conducted: a) Step 1 consisted of the application of a questionnaire to collect demographic and lifestyle data; b) Step 2 involved taking measurements of height, weight, blood pressure, and waist circumference of the participants. To achieve objective 1, the prevalence of relevant behavioural risk factors and anthropometric
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