Jerry Allison, Jennifer
Florendo, Rebecca Martillan, Cynthia Perez, Irma Sedanto
BCCM Year Level II
Dr. Violeta Abear and Dr.
Reynaldo O. Joson
Legazpi City, Albay,
According to the World Health Organization, cardiovascular and pulmonary diseases account for six of the top ten causes of mortality in the world, and six of the top 15 causes of mortality in Asia. They also account for three of the top seven causes of morbidity throughout the world and three of the top 15 causes of morbidity in Asia. Although it is proven that certain behaviors can reduce the risk of cardiovascular and pulmonary diseases, there is no absolute way to guarantee a disease free life. However, by recognizing and modifying our behavior as individuals and as a group we may be able to reduce the morbidity and mortality from cardiovascular and pulmonary diseases for our families, our communities, and ourselves.
The purpose of Community Health Management is to develop a primary health care approach that will use community involvement, linkages, indigenous resources, and local support systems to provide primary and secondary cardiovascular and pulmonary disease prevention programs. Such programs will incorporate individual awareness, behavior modification, and environmental change strategies to achieve their goals.
The goals in a Community Health Management program should:
Specific Cardiovascular Disease Risk Factors:
Risk factors to cardiovascular diseases have been well studied and documented. Organizations such as the World Health Organization and the American Heart Association provide immense literature on the control of cardiovascular diseases. Although there are numerous contributing factors, three risk factors have been shown to significantly increase a persons risk of cardiovascular disease: cigarette smoking, hypertension, and hyperlipidemia. These risk factors alone, or in combination with each other increase a persons risk of cardiovascular disease greater than two-fold. Furthermore, these risk factors when combined have been shown to have a synergistic effect on cardiovascular disease. It has also been shown that reducing or eliminating these factors can lower the risk of cardiovascular disease to the rates of those persons without risk factors. Finally, a significant contributing factor to the development of cardiovascular disease is lack of exercise, or a sedentary lifestyle.
Specific Pulmonary Disease Risk Factors:
Risk factors to pulmonary diseases have also been well studied and documented. The World Health Association has dedicated an entire chapter in the 1999 annual report to the effects of tobacco, benefits of eliminating tobacco use, and strategies for countries. The American Lung Society and numerous other government and non-profit organizations have taken pulmonary diseases on as a mission. The most significant risk factor to the development of long-term pulmonary disease is tobacco smoke. Tobacco smoke leads to chronic obstructive pulmonary disease, cancers, it may exacerbate asthma, and increases the risk of respiratory infections. As with cardiovascular risk factors, the elimination of smoking can return a patient to their pre-risk factor states if eliminated earlier enough in the course of disease. Other risk factors to pulmonary disease include chronic pulmonary infections, exposure to toxic agents and carcinogens, and genetic factors.
Smoking Cessation Programs:
Diseases related to cigarette smoking represent a twentieth-century epidemic, now spreading globally. Smoking is the primary cause of cancer of the lungs, larynx, oral cavity, and esophagus (approximately 10-20 times the risk compared with non-smokers) and contributory to cancers of the pancreas, bladder, kidney, stomach, and cervix and to leukemia (about 2 times the risk). Smoking acts synergistically with chemical and radiation carcinogens in the lung and with alcohol in the esophagus and in the oral cavity. Former smokers, after a lag of up to four years, show a progressively lower relative risk compared with continuing smokers and even compared with the slowly rising rate as never-smokers age. However, the absolute risk of lung cancer probably never declines, in sharp contrast to coronary heart disease endpoints. Low-tar, low-nicotine, and filtered cigarettes have had little or no protective effect, because the smokers tend to inhale more deeply and more frequently.
A huge literature attests to the difficulty of helping smokers quit. About 5% "quit" by themselves (for at least a six-month period) each year, but others relapse. Physicians play a key role in urging smokers to quit and in guiding them to self-help materials, classes, or pharmacologic quitting aids. Worksite, family, and community reinforcement are essential; increased taxes on tobacco products reinforce as well. Prevention of smoking, especially in young people, minorities, and women, can be enhanced by organized community and school programs as well as regulatory actions.
The reduction of cardiovascular and pulmonary diseases through tobacco elimination is a primary prevention effort. Therefore, efforts must include:
Awareness programs are the easiest to implement. However, public health experts agree that awareness programs have the least impact on behavior change. Awareness programs must be provided simultaneously with behavior modification and changes in the environment. Awareness can be conducted in a variety of ways and to different target groups based on the need of the community. Some of these programs have targeted school, media, workplaces, and other establishments. Awareness programs to be effective should include the information previously provided, and information that relates to users and potential users that cigarette smoking is the most important cause of preventable morbidity and early demise. Cigarette smoking increases the risk of fatal heart disease by two-fold. It can also increase the risk of lung cancer by ten-fold. Cigarette smoking by mothers during pregnancy leads to lower birthweight children. However, cessation of smoking lessens the risk for myocardial infarction and stroke. Quitting smoking can slow the rate of coronary artery disease, and can reverse the effects leading to chronic obstructive pulmonary disease. Patients who quit smoking have a decreased incidence of respiratory infection.
Behavior modification is the most difficult objective to achieve, yet is the most effective in reducing the risk of cardiovascular and pulmonary diseases. Individuals have a variety of reasons for their specific behavioral patterns. Physicians must understand these reasons and address patients on an individual level. It is the responsibility of the physician to offer and assist the patient in modifying behavior that can alter the healthy state or lead to disease that will affect the individual, the family, and the community. The physician can take specific steps. Such steps include:
Alternatives for pharmacologic therapy include nicotine gum and transdermal nicotine patch. The physician should also offer or refer the patient and family for counseling if indicated. Most importantly, the physician must set an example if they expect the patient to take them seriously and to modify their behavior.
Although behavior change is the most effective, and awareness provides the incentive for behavior change, it is the environment that provides the long-term support. Physicians must be aware and prepared to address situations such as visual stimulus that stimulates a person to smoke. Such stimuli include the morning cup of coffee, drinking alcoholic beverages, and even pictures or friends can stimulate the urge to smoke. The removal of these stimuli in some cases may be necessary to help the patient to quit. Another means of addressing the environment is the availability of cigarettes. This may require a community approach, but reducing or eliminating the availability of cigarettes will provide a barrier for those periodic urges while one is abstaining. The legislative process can be effective in taxing tobacco so it is unaffordable, restricting the sale of tobacco products, or in extreme cases, providing funding for health services when efforts to control tobacco use are insufficient. Physicians can do their part by volunteering with groups and by participating in community public education campaigns
Primary prevention programs are the ideal mechanism to prevent morbidity and mortality from cardiovascular and pulmonary diseases. These types of programs may be extremely difficult because they require awareness, which is the easiest to provide but the least effective; behavior modification which is the most effective and most difficult to achieve; and environmental change which is effective but generally costly. Behavior modification may be difficult to achieve because of denial of the risk of the problem. Environmental change may be difficult because of the economic impact.
Secondary programs do not prevent cardiovascular or pulmonary diseases. These programs are designed to detect the diseases at their earliest stages so that effective treatment may reduce long term morbidity and mortality. Most secondary prevention programs are accessible, available, and affordable. However, this still requires cooperation from the community and the health care system.
Tertiary prevention programs are very critical for cardiovascular and pulmonary diseases. These diseases often do no kill patients immediately. Often, these diseases are insidious and progress over years. During this time the patients suffer from decreased physical tolerance, increased difficulty in breathing, economic crisis due to high cost of medical care. Patients may suffer long before they die. Tertiary programs are important to provide rehabilitation to avoid these long-term sequelae.
In many of the communities in the Philippines, even if we were able to implement successful secondary prevention programs, many of the patients would not be able to afford the healthcare cost associated with treating their diseases. Without a doubt, primary prevention is the best approach for reducing morbidity and mortality and lessening the economic burden on the health care system. In addressing cardiovascular and pulmonary diseases, primary prevention is without a doubt the most logical and cost effective strategy to reduce the long term morbidity and mortality.
Primary prevention must be implemented at the community level and the community must take responsibility for its success. It is the responsibility of the community, In cooperation with the health care system, to assess the disease situation, identify goals, implement programs, and evaluate the results of the programs. This process must be done through community involvement, use of existing and new linkages, use of indigenous resources, and use of existing and new support systems. It is not until we embrace this concept that we will truly see a decline in the morbidity and mortality of cardiovascular and pulmonary diseases, and other community diseases.
BCCM Directory of Community Health Management Plans