Public Health




 Interview
Screen, Plan, Act
Abu Dhabi’s initiative to reduce CVD

 

The first epidemiological results related to cardiovascular disease risk factors are available from Health Authority-Abu Dhabi’s robust Weqaya programme. Some of the figures are quite staggering. Initiated in 2008, the programme has collated health screening data from more than 95% of adult Emirati nationals in the Emirate of Abu Dhabi and, on this basis, has developed a clear plan of action to lower the high incidence of CVD risk factors in the national population. Callan Emery speaks to Dr Cother Hajat, section head, Public Health Programmes, Health Authority-Abu Dhabi, about the Weqaya programme, its findings and their implications.
 

Callan Emery: What is the Weqaya programme?
Dr Cother Hajat:
Cardiovascular disease has been known to be a high priority for several years in the UAE. This was reinforced by the World Health Organisation and International Diabetes Federation reporting that the UAE had the world’s second highest rate of diabetes, with one in five adults suffering from the disease. As a result, the Weqaya programme was established by the Health Authority - Abu Dhabi (HAAD) with the aim of preventing and reducing the risk of cardiovascular disease.

CE: Can you explain the structure of the programme?
CH:
There are several components to the programme. These are best described as screen, plan, act.

Screen
Screening allows early detection of risk factors for cardiovascular disease, thereby providing the opportunity to better control them. Over 70% of all heart attacks and strokes have been shown to be prevented just by controlling a handful of risk factors for cardiovascular disease, such as diabetes, high blood pressure, high cholesterol and smoking.

Plan
Planning of interventions is facilitated by the Weqaya programme for healthcare providers through an appointment booking system coordinated by HAAD and the publication of guidelines and standards for clinical care (available at www.haad.ae). It facilitates the public by providing them with their screening results available as a courier-delivered personalised report and also through a web portal with secure access to confidential screening results and recommendations tailored for the individual according to their results.

Act
We recognise that a range of actions are required to suit individuals’ needs and preferences. Figure 1 (below) symbolises these through interventions aimed at individuals (such as the Weqaya personal reports), groups (eg. schools, workplaces, antenatal clinics) and population (such as through working groups with other government entities, in particular those who influence the environment, food choice and physical activity).

   

CE: When was it initiated and how long will it run for?
CH:
Cardiovascular disease will remain the top priority for health in the UAE, as it is for almost all areas of the world, for the foreseeable future. Cardiovascular screening as part of the Weqaya Programme commenced in April 2008, with the subsequent launch of other Weqaya initiatives for follow up of individuals, group interventions and population level initiatives.

CE: How, where and who gathered the data?
CH:
The screening was conducted by a series of 26 dedicated clinics established by SEHA Ambulatory Health Services to deliver Weqaya screening. (SEHA is the Abu Dhabi Health Services Company – an independent, public joint stock company created to develop the curative activities of the public healthcare system in Abu Dhabi.) Nurses were recruited and trained to deliver the screening programme. The data was collated at HAAD.

CE: Why are only Abu Dhabi adult nationals included in the programme? - Why not expatriate residents?
CH:
The screening element of the programme targeted national adults in its first phase. Other elements of the programme, such as the group and population initiatives are aimed at the whole population. Expatriate residents may be subject to screening for future programmes, but the issue is complex due to the large number of different nationalities in Abu Dhabi with different levels of risk according to their ethnic background.

- Why not children?
CH:
Children are a key focus for HAAD’s healthy lifestyle programmes. Several initiatives have been implemented and are underway with HAAD’s dedicated family and school health team, the Abu Dhabi Education Council (ADEC) and the Abu Dhabi Food Control Authority. These initiatives include setting standards for nutrition and physical activity. In addition HAAD have initiated with SEHA and ADEC a school screening programme, part of which is aimed at tackling obesity. All school age children will receive annual Body Mass Index (BMI) screening and those with higher than recommended BMI will receive referral for further follow up. The initiative has been piloted at several schools and results confirm that rates of obesity and overweight are high throughout childhood. Evidence is clear that children who are of abnormal weight have very high risk of being overweight or obese as adults.

CE: The Weqaya study provides individuals secure access to their screening data on the Weqaya website. Can you explain some of the benefits of this? Are many of the participants in the screening using this web-based facility?
CH:
We aim to provide a range of actions for the whole population. Some will prefer to see a doctor directly, some will choose to book an appointment through our call centre and others will choose to use the website. The website offers the advantage of accessing securely the Weqaya screening results as well as the tailored recommendation for action. Appointments may be booked and managed online and there is advice for healthy living and links to providers of physical activity and weight management. We are beginning to see that a younger age group (age 20-39) are accessing the website. This age group is very amenable to change in terms of controlling any risk factors present and preventing the development of cardiovascular events, such as heart attacks and strokes.

CE: What are the key findings of the study? And what are the implications?
CH:
The initial findings and conclusions are best presented in figure 3 (below).

     

CE: Is cardiovascular disease a leading cause of mortality in Abu Dhabi?
CH:
The Weqaya programme screened individuals and can provide a projection of how likely individuals are of having cardiovascular disease. Mortality is monitored by HAAD through routinely collected death notification data. The top cause of mortality for both nationals and non-nationals is cardiovascular disease, followed by accidental injuries and cancer.

CE: What is significant about these findings? Is there anything that stands out as requiring immediate attention?
CH:
Abu Dhabi has a very young population with very prevalent cardiovascular risk factors. The age structure of the population means that if we do not bring about control of these risk factors within the next two decades, as the population ages, rates of diabetes, heart attacks, strokes and other consequences, such as kidney disease, will rapidly rise. This will result in considerable morbidity in the population with potential consequences of reduced productivity and increased mortality with a possible reduction in life expectancy. Furthermore, this will place an enormous burden on the healthcare system. Early detection and control of these risk factors can lead to substantial reductions in the onset of complications and healthcare costs. For example, a screening programme that identifies diabetic patients several years before they would normally be detected can lead to a halving of their risk of a heart attack or stroke and of the lifetime cost to the healthcare system to one third of the cost without early detection (Source: Waugh N et al Health Technology Assessment 2007; Vol. 11: No. 17). A recent study in Al Ain confirmed that the average cost of a diabetic patient identified through screening is less than half that of a diabetic patient detected clinically (Source: Maskari F et al, BMC Public Health, Nov 2010). CE: Do these findings, in general , differ from the findings of earlier studies? To what extent? CH: Some of the findings confirm previous findings for example that 1 in 5 adults currently suffer from diabetes. Other findings are novel. For example, the very high rates of those at higher-than-average risk of developing diabetes over the coming years, termed pre-diabetes. Whilst there is no licensed medication for prediabetes, we know that the vast majority of pre-diabetes patients can prevent the progression to diabetes through switching to a healthier diet and increasing their levels of physical activity. This is one of the aims of the Weqaya screening and the Weqaya reports.  

CE: How will these findings be used by HAAD?
CH:
The findings are already being used for clinical intervention of individuals as well as planning and designing cardiovascular programmes for prevention and treatment. The results are also very relevant for other countries in the GCC, MENA and other regions as the Weqaya programme is unique in its scale and comprehensive nature.

CE: Dr Hajat – your area of focus is the Cardiovascular Diseases programme. Can you explain the implications of these findings for your programme?
CH:
The findings are of utmost importance to Abu Dhabi and the region. The findings are being used directly to develop clinical programmes, such as clinical guidelines, health education programmes, such as awareness initiatives, strategic planning of healthcare delivery, such as the number and type of doctors and healthcare facilities treating patients for cardiovascular disease. The findings are of huge benefit to the evidence base both locally and globally. Indeed, the Weqaya programme has recently been highlighted internationally as a best-practice case study by several organisations, such as the BBC World Business Report, the Economist magazine, and the Diabetes Mena Leadership Forum, amongst many others. The risk factors for cardiovascular disease are becoming endemic globally and also in the UAE. Programmes such as Weqaya hope to curb this rapid rise by engaging individuals and groups, but also embedding health into population policies. Individuals are heavily influenced by the environment around them such as the availability of pedestrianised walkways, stairwells and cycle lanes which allow physical activity to be easily incorporated into the daily lives of most individuals. The increasingly abundant availability of foods that are calorie-dense and high in sugar, fat and salt content makes healthy food choices more difficult. Smoking rates are decreasing in Western populations partly due to smoking bans in public places and a reduction in the acceptability of smoking as a personal preference. Such population level changes are not easy to implement, but only through such coordinated action of the civil sector will the much needed change in cardiovascular risk be attainable. HAAD are working with the civil sector in Abu Dhabi to achieve this as a joint goal.

CE: Based on these findings what public health programmes do you plan to implement?
CH:
The individual approach has been fully implemented and we will continue to integrate these with the Abu Dhabi community. Interventions being implemented at group level include the Weqaya workplace wellness initiative, which aims to empower employers to be involved and influence the health of their employees. This will be launched in the very near future and employers will receive training and a toolkit for the delivery of this intervention. HAAD is also considering, like many other countries, a shift to a broader delivery of care for cardiovascular disease, some of which may be delivered outside of a traditional clinic setting. Such programmes, termed disease management programmes, have been shown to achieve better control of cardiovascular risk factors as well as achieving better patient satisfaction. Evidence clearly shows that patient satisfaction and engagement is key to the long term control of chronic conditions.

CE: Has any new policy / legislation been developed based on these findings?
CH:
The Weqaya workplace wellness initiative will be introduced as a voluntary programme. However, as part of the Environmental Health Safety and Management System (EHSMS) initiative, the Occupation Section at HAAD will be launching mandatory Standards for workplace wellness to be implemented at healthcare facilities in Abu Dhabi. These two initiatives are complementary and highlight the shift from treating the sick to preventing disease, termed wellness, also a shift of focus away from healthcare facilities into broader society, such as workplaces, schools and other community settings.

CE: What does the future hold with regards HAAD and the Weqaya programme?
CH:
Weqaya screening is repeated at 3 yearly intervals and the next round of repeat screening will commence in mid 2011. Many changes have been implemented to the programme to ensure convenience for the public whilst ensuring that we continue to record and collate population level data that is the cornerstone to the Weqaya programme.

We aim to constantly review the programme in light of the accumulating data and we strive to better understand the drivers for healthy and unhealthy lifestyles in our population and deliver interventions in areas of need.

The direction of the Weqaya programme is to focus more on the societal response to tackling the increase in cardiovascular disease. The way that healthcare is delivered will shift focus from treating to preventing disease and from pure delivery in healthcare settings to a broader range of delivery methods, incorporating our constantly increasing use and dependence on technology such as mobile phones and the internet. Interventions may also move from delivery to individuals to delivery to groups, such as families, employees, school children and pregnant mothers. 


 D
ate of upload: 17th Feb 2011

 

                                  
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