Primary prevention of cardiovascular disease through population-wide motivational strategies: insights from using smartphones in stroke prevention

Valery L Feigin, Bo Norrving, George A Mensah, Valery L Feigin, Bo Norrving, George A Mensah

Abstract

The fast increasing stroke burden across all countries of the world suggests that currently used primary stroke and cardiovascular disease (CVD) prevention strategies are not sufficiently effective. In this article, we overview the gaps in, and pros and cons of, population-wide and high-risk prevention strategies. We suggest that motivating and empowering people to reduce their risk of having a stroke/CVD by using increasingly used smartphone technologies would bridge the gap in the population-wide and high-risk prevention strategies and reduce stroke/CVD burden worldwide. We emphasise that for primary stroke prevention to be effective, the focus should be shifted from high-risk prevention to prevention at any level of CVD risk, with the focus on behavioural risk factors. Such a motivational population-wide strategy could open a new page in primary prevention of not only stroke/CVD but also other non-communicable disorders worldwide.

Conflict of interest statement

Competing interests: VLF is a principal investigator of the RIBURST study and a randomised controlled trial testing efficacy of Stroke Riskometer app for primary stroke prevention; he has served as a speaker for AstraZeneca and Bristol-Myers Squibb. VLF declares that the not-for-profit Stroke Riskometer app is copyrighted by the Auckland University of Technology (New Zealand), and any possible revenue from sales of Stroke Riskometer Pro version of the app will be used for research and educational purposes. The other authors declare no competing interests and have no conflicts to disclose.

Figures

Figure 1
Figure 1
Comparison of conventional population-based, high-risk and motivational population-wide cardiovascular disease (CVD) prevention strategies. Modified from WHO ‘Cardiovascular disease prevention and control. Translating evidence into action’. (A) Population-based prevention strategy aimed at shifting the distribution of risk factors and associated CVD risk in the whole population towards optimal distribution of CVD risk (shadowed in grey area shows a theoretically possible proportion of the population that could benefit from this strategy); (B) high-risk prevention strategy aimed at treating the individuals at high absolute risk of CVD (shadowed in grey area shows a theoretically possible proportion of the population that could benefit from this strategy; with the 20% cut-off for 10-year high CVD risk, only about 13% of the population could benefit from this strategy); (C) motivational population-wide CVD prevention strategy aimed at managing CVD risk factors in the individuals at the high relative risk of CVD (shadowed in grey area shows a theoretically possible proportion of the population that could benefit from this strategy; with two CVD risk factors, almost 80% of the population could benefit from this strategy).
Figure 2
Figure 2
Integrating mobile technology with patient management systems.

References

    1. Vos T, Allen C, Arora M et al. . Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016;388:1545–602. 10.1016/S0140-6736(16)31678-6
    1. Feigin VL, Krishnamurthi RV, Parmar P et al. . Update on the global burden of ischemic and hemorrhagic stroke in 1990–2013: the GBD 2013 study. Neuroepidemiology 2015;45:161–76. 10.1159/000441085
    1. Kassebaum NJ, Arora M, Barber RM et al. . Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016;388:1603–58. 10.1016/S0140-6736(16)31460-X
    1. Wang H, Naghavi M, Allen C et al. . Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016;388:1459–544. 10.1016/S0140-6736(16)31012-1
    1. Feigin VL, Norrving B, George MG et al. . Prevention of stroke: a strategic global imperative. Nat Rev Neurol 2016;12:501–12. 10.1038/nrneurol.2016.107
    1. Roth GA, Forouzanfar MH, Moran AE et al. . Demographic and epidemiologic drivers of global cardiovascular mortality. N Engl J Med 2015;372:1333–41. 10.1056/NEJMoa1406656
    1. Feigin VL, Forouzanfar MH, Krishnamurthi R et al. . Global and regional burden of stroke during 1990–2010: findings from the Global Burden of Disease Study 2010. Lancet 2014;383:245–55. 10.1016/S0140-6736(13)61953-4
    1. Krishnamurthi RV, Feigin VL, Forouzanfar MH et al. . Global and regional burden of first-ever ischaemic and haemorrhagic stroke during 1990–2010: findings from the Global Burden of Disease Study 2010. Lancet Glob Health 2013;1:e259–81. 10.1016/S2214-109X(13)70089-5
    1. Feigin VL, Roth GA, Naghavi M et al. . Global burden of stroke and risk factors in 188 countries, during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet Neurol 2016;15:913–24. 10.1016/S1474-4422(16)30073-4
    1. Forouzanfar MH, Alexander L, Anderson HR et al. . Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015;386:2287–323. 10.1016/S0140-6736(15)00128-2
    1. United Nations General Assembly. Resolution adopted by the General Assembly: 66/2: Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. Adopted 19 September 2011. Published 24 January 2012.
    1. World Health Organization. Global action plan for the prevention and control of noncommunicable diseases 2013–2020. Geneva: WHO, 2013. (4 Dec).
    1. Chestnov O, Obermeyer W, St John J et al. . Towards the world we want. Bull World Health Organ 2014;92:623 10.2471/BLT.14.144808
    1. Lim SS, Allen K, Bhutta ZA et al. . Measuring the health-related Sustainable Development Goals in 188 countries: a baseline analysis from the Global Burden if Disease Study 2015. Lancet 2016;388:1813–50.
    1. Das P, Horton R. Physical activity—time to take it seriously and regularly. Lancet 2016;388:1254–5. 10.1016/S0140-6736(16)31070-4
    1. Yusuf S, Hawken S, Ounpuu S et al. . Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004;364:937–52. 10.1016/S0140-6736(04)17018-9
    1. O'Donnell MJ, Chin SL, Rangarajan S et al. . Global and regional effect of potentially modifiable risk factors associated with acute stroke in 13,447 cases and 13,472 controls in 32 countries: INTERSTROKE case-control study. Lancet 2016;388:761–75.
    1. Rose G. Strategy of prevention: lessons from cardiovascular disease. Br Med J (Clin Res Ed) 1981;282:1847–51.
    1. McLaren L, McIntyre L, Kirkpatrick S. Rose's population strategy of prevention need not increase social inequalities in health. Int J Epidemiol 2010;39:372–7. 10.1093/ije/dyp315
    1. Alliance NVDP. Guidelines for the management of absolute cardiovascular disease risk. Canberra: National Health and Medical Research Council of Australia, 2012.
    1. Heuschmann PU, Grieve AP, Toschke AM et al. . Ethnic group disparities in 10-year trends in stroke incidence and vascular risk factors: the South London Stroke Register (SLSR). Stroke 2008;39:2204–10. 10.1161/STROKEAHA.107.507285
    1. Jackson R, Wells S, Rodgers A. Will screening individuals at high risk of cardiovascular events deliver large benefits? Yes. BMJ 2008;337:a1371
    1. Capewell S. Will screening individuals at high risk of cardiovascular events deliver large benefits? No. BMJ 2008;337:a1395.
    1. World Health Organization. Prevention of cardiovascular disease: guidelines for assessment and management of cardiovascular risk. Geneva: WHO, 2007.
    1. Emberson J, Whincup P, Morris R et al. . Evaluating the impact of population and high-risk strategies for the primary prevention of cardiovascular disease. Eur Heart J 2004;25:484–91. 10.1016/j.ehj.2003.11.012
    1. Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C et al. . General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ 2012;345:e7191.
    1. Jørgensen T, Jacobsen RK, Toft U et al. . Effect of screening and lifestyle counselling on incidence of ischaemic heart disease in general population: Inter99 randomised trial. BMJ 2014;348:g3617.
    1. Puska P. Successful prevention of non-communicable diseases: 25 year experiences with North Karelia project in Finland. Public Health Med 2002;4:5–7.
    1. Miura K. Epidemiology and prevention of hypertension in Japanese: how could Japan get longevity? EPMA J 2011;2:59–64. 10.1007/s13167-011-0069-y
    1. Record NB, Onion DK, Prior RE et al. . Community-wide cardiovascular disease prevention programs and health outcomes in a rural county, 1970–2010. JAMA 2015;313:147–55. 10.1001/jama.2014.16969
    1. Ebrahim S, Taylor F, Ward K et al. . Multiple risk factor interventions for primary prevention of coronary heart disease. Cochrane Database Syst Rev 2011;(1):CD001561 10.1002/14651858.CD001561.pub3
    1. Spring B, Ockene JK, Gidding SS et al. . Better population health through behavior change in adults: a call to action. Circulation 2013;128:2169–76. 10.1161/01.cir.0000435173.25936.e1
    1. Jones SP, Jenkinson AJ, Leathley MJ et al. . Stroke knowledge and awareness: an integrative review of the evidence. Age Ageing 2010;39:11–22. 10.1093/ageing/afp196
    1. Group NZG, editor. New Zealand primary care handbook. 3rd edn Wellington: New Zealand Guidelines Group, 2012.
    1. Dalton ARH, Soljak M, Samarasundera E et al. . Prevalence of cardiovascular disease risk amongst the population eligible for the NHS Health Check Programme. Eur J Prev Cardiol 2013;20:142–50. 10.1177/1741826711428797
    1. Chiolero A, Paradis G, Paccaud F. The pseudo-high-risk prevention strategy. Int J Epidemiol 2015;44:1469–73. 10.1093/ije/dyv102
    1. Goff DC Jr, Lloyd-Jones DM, Bennett G et al. . 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice guidelines. J Am Coll Cardiol 2014;63(25 Part B):2935–59. 10.1016/j.jacc.2013.11.005
    1. James PA, Oparil S, Carter BL et al. . 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014;311:507–20.
    1. McLean RM, Williams S, Mann JI et al. . Blood pressure and hypertension in New Zealand: results from the 2008/09 Adult Nutrition Survey. N Z Med J 2013;126:66–79.
    1. Pew Research Center. Global Attitudes & Trends. Smartphone Ownership and Internet Usage Continues to Climb in Emerging Economies 2016.
    1. Nasser FB, Trevena L. There's an app for that: a guide for healthcare practitioners and researchers on smartphone technology. Online J Public Health Inform 2015;7:e218 10.5210/ojphi.v7i2.5522
    1. Burke LE, Ma J, Azar KMJ et al. . Current science on consumer use of mobile health for cardiovascular disease prevention: a scientific statement from the American Heart Association. Circulation 2015;132:1157–213. 10.1161/CIR.0000000000000232
    1. BE HE@LTHY, BE MOBILE 2014. .
    1. Buller DB, Borland R, Bettinghaus EP et al. . Randomized trial of a smartphone mobile application compared to text messaging to support smoking cessation. Telemed J E Health 2013;20:206–14.
    1. Carter MC, Burley VJ, Nykjaer C et al. . Adherence to a smartphone application for weight loss compared to website and paper diary: pilot randomized controlled trial. J Med Internet Res 2013;15:e32 10.2196/jmir.2283
    1. Chow CK, Redfern J, Hillis GS et al. . Effect of lifestyle-focused text messaging on risk factor modification in patients with coronary heart disease: a randomized clinical trial. JAMA 2015;314:1255–63. 10.1001/jama.2015.10945
    1. Ganesan AN, Louise J, Horsfall M et al. . International mobile-health intervention on physical activity, sitting, and weight: the Stepathlon Cardiovascular Health Study. J Am Coll Cardiol 2016;67:2453–63. 10.1016/j.jacc.2016.03.472
    1. Urrea B, Misra S, Plante TB et al. . Mobile health initiatives to improve outcomes in primary prevention of cardiovascular disease. Curr Treat Options Cardiovasc Med 2015;17 10.1007/s11936-015-0417-7
    1. Piette JD, List J, Rana GK et al. . Mobile health devices as tools for worldwide cardiovascular risk reduction and disease management. Circulation 2015;132:2012–27. 10.1161/CIRCULATIONAHA.114.008723
    1. Pfaeffli Dale L, Dobson R, Whittaker R et al. . The effectiveness of mobile-health behaviour change interventions for cardiovascular disease self-management: a systematic review. Eur J Prev Cardiol 2015;23:801–17. 10.1177/2047487315613462
    1. Surka S, Edirippulige S, Steyn K et al. . Evaluating the use of mobile phone technology to enhance cardiovascular disease screening by community health workers. Int J Med Inform 2014;83:648–54. 10.1016/j.ijmedinf.2014.06.008
    1. Chan CV, Kaufman DR. Mobile phones as mediators of health behavior change in cardiovascular disease in developing countries. Stud Health Technol Inform 2009;143:453–8.
    1. Digital Trends. The number of smartphone users in the world is expected to reach a giant 6.1 billion by 2020. . 2016.
    1. Cooney MT, Dudina A, D'Agostino R et al. . Cardiovascular risk-estimation systems in primary prevention: do they differ? Do they make a difference? Can we see the future? Circulation 2010;122:300–10.
    1. Feigin VL, Krishnamurthi R, Bhattacharjee R et al. . New strategy to reduce the global burden of stroke. Stroke 2015;46:1740–7. 10.1161/STROKEAHA.115.008222
    1. Mancia G, Fagard R, Narkiewicz K et al. . 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2013;31:1281–357. 10.1097/
    1. Gluckman TJ, Kovacs RJ, Stone NJ et al. . The ASCVD risk estimator app: from concept to the current state. J Am Coll Cardiol 2016;67:350–2. 10.1016/j.jacc.2015.10.068
    1. Riddell T, Wells S, Jackson R et al. . Performance of Framingham cardiovascular risk scores by ethnic groups in New Zealand: PREDICT CVD-10. N Z Med J 2010;123:50–61.
    1. Hill S, Spink J, Cadilhac D et al. . Absolute risk representation in cardiovascular disease prevention: comprehension and preferences of health care consumers and general practitioners involved in a focus group study. BMC Public Health 2010;10:108 10.1186/1471-2458-10-108
    1. Fagerlin A, Zikmund-Fisher BJ, Ubel PA. Helping patients decide: ten steps to better risk communication. J Natl Cancer Inst 2011;103:1436–43. 10.1093/jnci/djr318
    1. African Health Observatory World Health Organization [Internet]. (cited 10 March 2015). .
    1. Licskai C, Sands TW, Ferrone M. Development and pilot testing of a mobile health solution for asthma self-management: asthma action plan smartphone application pilot study. Can Respir J 2013;20:301–6. 10.1155/2013/906710
    1. Ly KH, Carlbring P, Andersson G. Behavioral activation-based guided self-help treatment administered through a smartphone application: study protocol for a randomized controlled trial. Trials 2012;13:62.
    1. Jenkins C, Burkett N-S, Ovbiagele B et al. . Stroke patients and their attitudes toward mHealth monitoring to support blood pressure control and medication adherence. mHealth 2016;2:24.
    1. Feigin VL, Norrving B. A new paradigm for primary prevention strategy in people with elevated risk of stroke. Int J Stroke 2014;9:624–6. 10.1111/ijs.12300
    1. Norrving B, Davis SM, Feigin VL et al. . Stroke prevention worldwide—what could make it work. Neuroepidemiology 2015;45:215–20. 10.1159/000441104
    1. Parmar P, Krishnamurthi R, Ikram MA et al. . The Stroke Riskometer™ app: validation of a data collection tool and stroke risk predictor. Int J Stroke 2015;10:231–44. 10.1111/ijs.12411
    1. Morgan J. The power of the App: can mobile-technology save lives? Lancet Neurol 2015;15:668 10.1016/S1474-4422(15)00297-5
    1. Doctors Choose the Best Health Apps of 2014. HealthTap.
    1. Ordúñez P, Tajer C. Disseminating cardiovascular disease risk assessment with a PAHO mobile app: a public eHealth intervention. Rev Panam Salud Publica 2015;38:82–5.
    1. Kulshreshtha A, Vaccarino V, Judd SE et al. . Life's simple 7 and risk of incident stroke: the reasons for geographic and racial differences in stroke study. Stroke 2013;44:1909–14. 10.1161/STROKEAHA.111.000352
    1. Cardiovascular disease prevention and control. Translating evidence into practice. Geneva: World Health Organization, 2005.
    1. Neil HAW, Perera R, Armitage JM et al. . Estimated 10-year cardiovascular risk in a British population: results of a national screening project. Int J Clin Pract 2008;62:1322–31. 10.1111/j.1742-1241.2008.01828.x
    1. Blomstedt Y, Norberg M, Stenlund H et al. . Impact of a combined community and primary care prevention strategy on all-cause and cardiovascular mortality: a cohort analysis based on 1 million person-years of follow-up in Västerbotten County, Sweden, during 1990–2006. BMJ Open 2015;5:e009651 10.1136/bmjopen-2015-009651
    1. Ogunmoroti O, Allen NB, Cushman M et al. . Association between life's simple 7 and noncardiovascular disease: the multi-ethnic study of atherosclerosis. J Am Heart Assoc 2016;5:e003954 10.1161/JAHA.116.003954
    1. World Health Organization. mHealth: new horizons for health through mobile technologies. Global observatory for eHealth series. Vol. 3 Geneva: WHO, 2011:1–99.
    1. Turakhia MP, Desai SA, Harrington RA. The outlook of digital health for cardiovascular medicine: challenges but also extraordinary opportunities. JAMA Cardiol 2016;1:743–4.

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