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Health Promotion and Cardiovascular Disease Prevention in Sub-Saharan Africa Uchechukwu K.A. Sampsona, b, c,⁎, Mary Amuyunzu-Nyamongod, e , George A. Mensahf a

Department of Medicine, Vanderbilt University Medical Center, Nashville, TN Department of Pathology, Microbiology and Immunology, VUMC, Nashville, TN c Department of Radiology and Radiological Sciences, VUMC, Nashville, TN d African Institute for Health and Development, Nairobi, Kenya e Consortium for NCD Prevention and Control in Sub-Saharan Africa f Office of the Director, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD b

A R T I C LE I N FO

AB S T R A C T

Keywords:

Recent population studies demonstrate an increasing burden of cardiovascular disease

Cardiovascular disease

(CVD) and related risk factors in sub-Saharan Africa (SSA). The mitigation or reversal of this

Sub-Saharan Africa

trend calls for effective health promotion and preventive interventions. In this article, we

Non-communicable diseases

review the core principles, challenges, and progress in promoting cardiovascular health

Health promotion

with special emphasis on interventions to address physical inactivity, poor diet, tobacco

Prevention

use, and adverse cardiometabolic risk factor trends in SSA. We focus on the five essential strategies of the Ottawa Charter for Health Promotion. Successes highlighted include community-based interventions in Ghana, Nigeria, South Africa, and Mauritius and schoolbased programs in Kenya, Namibia, and Swaziland. We address the major challenge of developing integrated interventions, and showcase partnerships opportunities. We conclude by calling for intersectoral partnerships for effective and sustainable intervention strategies to advance cardiovascular health promotion and close the implementation gap in accordance with the 2009 Nairobi Call to Action on Health Promotion. Published by Elsevier Inc.

Renewed attention to health promotion and cardiovascular disease (CVD) prevention in sub-Saharan Africa (SSA) has been triggered by the evolving health transitions that have engulfed the region. Historically, the SSA region has been plagued predominantly by communicable disease, maternal and perinatal disease, nutritional deficiencies, and poverty. However, the region now grapples with the added burden of non-communicable diseases (NCDs) such as stroke and heart disease, which constitute the principal components of CVD. In 1990, CVD and other major chronic diseases caused 28% of

morbidity and 35% of mortality in SSA, and by 2020 their shares are projected to rise to 60% and 65%, respectively.1 Although CVD is not yet the leading cause of death in Africa2–4 age-specific CVD mortality and morbidity are already higher in parts of SSA than in many developed countries. Consequently, there is justification for promotion of cardiovascular health and CVD prevention in an effort to mitigate observed adverse trends in CVD. In this article, we review the core principles of health promotion, as well as the challenges and progress that have

Statement of conflict of Interest: see page 353. ⁎ Address reprint requests to Uchechukwu K.A. Sampson, MBBS, MSc(Oxon), Section of Cardiovascular Disease Prevention, Vanderbilt University Medical Center, 315 Preston Research Building, 2220 Pierce Avenue, Nashville, TN 37232. E-mail address: [email protected] (U.K.A. Sampson). 0033-0620/$ – see front matter. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.pcad.2013.10.007

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Abbreviations and Acronyms CVD = Cardiovascular disease CORIS = Coronary Risk Factor Study NCD = non-communicable disease WHO = World Health Organization WHO-AFRO = World Health Organization Regional Office for Africa SSA = sub-Saharan Africa LMIC = low-to-middle income countries UNESCO = United Nations Educational, Scientific and Cultural Organization UIS = UNESCO Institute for Statistics DALY = disability adjusted life years CDTI = community directed treatment with ivermectin GDP = gross domestic product NHLBI = National Heart Lung and Blood Institute

been made in SSA in promoting cardiovascular health with special emphasis on the adverse trends in risk factors such as physical in activity, poor diet, and tobacco use. We highlight successes in community-based interventions and schoolbased programs such as the Health Promoting Schools Initiative (HPSI). Additionally, we address the major challenges and barriers to health promotion in the SSA. We conclude by presenting a paradigm for reducing health promotion implementation gap in SSA, which calls for the coalition of disciplines, sectors, and partners for effective, efficient, and sustainable intervention strategies in order to advance CVH promotion.

MRC = Medical Research Council DFID = Department for International Development ARL = African Research Leader AMREF = African Medical and Research Foundation

Emerging CVD burden and the rationale for health promotion

The increasing burden of CVD in SSA is inextricably linked with the fundamental phiUNICEF = United Nations losophy that epidemiChildren's Fund ologic transition attends UNFPA = United Nations Populaeconomic transition. This tion Fund notion is encapsulated in the well-known PHC = primary health care concept described by HiAP = health in all policies Omran who proposed that a transition occurs in the relative frequencies of major causes of mortality as human societies undergo industrialization and economic development. 5 The SSA region is in the early stages of its epidemiologic transition, thus CVD is not yet the leading cause of death, but it may rapidly become so if current trends persist. 2–4 For instance, in the recent landmark Global Burden of Disease 2010 Study hypertension now tops the list of risk factors for death and disability worldwide.6 In this context, HPSI = Health Promoting Schools Initiative

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another recent report interestingly notes that mean systolic blood pressure levels in East and West Africa have risen over the last 3 decades and now are among the highest in the world.7 Furthermore, it is estimated that from 2008 to 2025 the number of hypertensive subjects in Africa will increase from 75 to 126 million, thus representing a 68% increase in prevalence. 8 Diseases such as ischemic heart disease previously known to be rare are now increasing in incidence and prevalence, 3 stroke mortality rates in SSA are now among the highest in the world,4 and similarly female body mass index (BMI) and the prevalence of obesity have increased the fastest in South Africa.9 All of these trends call for renewed investments in health promotion and the prevention and control of hypertension, and other cardiovascular risk factors in an effort to stem the rising burden of CVDs and other NCDs. 2,10,11

Health promotion: declarations, principles, strategies, and relevance to CVD in SSA In the past four decades three key declarations have articulated the core principles and practice of health promotion and disease prevention. The 1978 declaration of Alma-Ata was the outcome of the International Conference on Primary Health Care.12 The conference affirmed that “health…is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector”.12 In this context, gross inequality in health status between and within developed and developing nations was recognized as politically, socially, and economically unacceptable. Economic and social development, governmental responsibilities, and primary health care (PHC) were highlighted as strategic imperatives. Almost a decade later, the First International Conference on Health Promotion in Ottawa presented a charter for action to achieve health for all by the year 2000 and beyond.13 The Ottawa charter defined health promotion as “the process of enabling people to increase control over, and to improve, their health”.13 The charter recognized that “the fundamental conditions and resources for health are peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity”, and that health improvement “requires a secure foundation in these basic prerequisites”.13 The charter identified five action areas to achieve health for all: build healthy public policy; create supportive environments; strengthen community action; develop personal skills; and reorient health services.13 The evidence that health promotion makes a difference was articulated in the Jakarta Declaration on Health Promotion (1997) adopted at the Fourth International Conference on Health Promotion.14 It recognized that research and case studies from around the world now provide convincing evidence that health promotion works, and that its strategies can positively change the lifestyle and socio-environmental and economic determinants of health.14 The five new

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priorities for the 21st century put forth in the Jakarta Declaration were to: promote social responsibility for health; increase investments for health development; consolidate and expand partnerships for health; increase community capacity and empower the individual; and secure an infrastructure for health promotion.14 The emerging burden of CVD and other NCDs in Africa highlights the importance of implementing the principles and practice of health promotion set forth in the Ottawa charter. Although there is evidence that the strategies of health promotion are effective and yield a return on investment, there is also consensus that many of the original challenges that precipitated the development of health promotion either still exist, are escalating, or that new threats have emerged. Sub-Saharan Africa epitomizes these realities, unmasking the existence of a gap in implementation, evidence, policy, practice, governance, and political will. In this regard, the purpose of the Nairobi Call to Action (2009) for Closing the Implementation Gap in Health Promotion was to “identify key strategies and commitments urgently required for closing the implementation gap in health and development through health promotion”.15 Given the surge in preventable diseases that threatens the economic well-being of countries, five urgent responsibilities for governments and stakeholders were delineated: strengthen leadership and workforces; mainstream health promotion; empower communities and individuals; enhance participatory processes; and build and apply knowledge. The recent 2013 8th Global Conference on Health Promotion in Helsinki continued to address the implementation gap via the central theme of health in all policies (HiAP), which drew special attention to need for intersectoral actions at the various levels of governance within the global, national, regional, and local arenas.16 Future trends in CVD and risk factor burden in SSA will serve as testament to the impact of these benchmark conferences.

Evidence of efforts in Africa over the past decades There is evidence of increasing health promotion efforts in different countries and settings within SSA. Individually, these efforts represent specific success stories for health promotion and disease prevention and control, especially within PHC. However, collectively they capture an evolving spectrum of interventions and approaches, which can inform more comprehensive efforts in the future. The evidence indicates that efforts such as reduction in dietary salt intake, increased fruit intake, use of mass media, policy and legislative interventions, and school-based initiatives can be effective approaches for implementing the principles and practice of health promotion in SSA. We discuss some of these efforts and provide examples of institutional efforts to advance health promotion and disease prevention and control in Africa. A Ghanaian community-based intervention to reduce dietary salt intake in 1,013 participants from rural and semi-urban villages in the Ashanti region demonstrated a

significant decrease in systolic and diastolic blood pressure levels following culturally-tailored health education intervention to reduce dietary salt intake.17 Adebawo et al. documented that the consumption of fruits and vegetables led to improvement in serum lipid risk factors in hypertensive study subjects in Nigeria.18 In South Africa, the Coronary Risk Factor Study (CORIS) demonstrated the feasibility and effectiveness of a community-based intervention program to reduce coronary heart disease risk factor levels over a 4-year period, using either a low-intensity intervention (small mass media) or a high-intensity intervention (small mass media plus interpersonal intervention to high-risk individuals).19,20 The intervention program implemented in the CORIS study has been shown to be effective in a poor working-class community, as demonstrated in the Mamre Study.21 In 1987, a governmentinstituted program was launched in Mauritius to promote health by modifying lifestyle risk factors using: extensive mass media; widespread school, community, and workplace health education activities; and policy and legislative interventions.22 A change in the composition of the commonly used cooking oil from mostly palm oil (high in saturated fatty acids) to soya bean oil (high in unsaturated fatty acids) exemplifies one of the policy interventions.22 This program led to a reduction in serum cholesterol concentration over a five-year period,22,23 as well as the reduction in blood pressure levels, physical inactivity, alcohol use, and prevalence of smoking.22

Examples of health promoting schools initiative (HPSI) in Africa The HPSI is based on actions contained in both the Ottawa Charter for Health Promotion and the Jakarta Declaration for Promoting Health. The HPSI is aimed at increasing international, national and local capacity to improve the health of students, school personnel, families and community members around the school. So far, the program has been implemented in forty-six countries of the World Health Organization Regional Office for Africa (WHOAFRO).24 Health promoting actions in schools take the form of changes to the physical environment, development and implementation of health-related policies, provision of health and related services, enhancement of health knowledge and skills, changes in the organizational structures, administration and/or management. Interest in the school as a setting for promoting health is based on the understanding that: school health programs help link the resources of health, education, nutrition and sanitation in one infrastructure. The accessibility of the school health programs to a large proportion of each nation's population, including staff as well as students, contributes to a low cost of programs.25 Although not many of the HPSIs were planned on an evidence-based platform, there is evidence that they have led to tangible health and related changes, as illustrated in the examples below. In Kenya, the HPSI approach was used to implement interventions in 247 primary schools spread over three provinces. The African Medical and Research Foundation

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(AMREF), a non-governmental organization was responsible for coordinating the implementation of activities in conjunction with the ministries of health and education and related institutions. The primary beneficiaries were 6–13 year old pupils, with teachers and parents being considered secondary beneficiaries. Participating schools were paired with control schools and a baseline study was carried out in 2000. An external evaluation conducted in 2004 established that compared to baseline and to the control schools, the pupils in the intervention schools had: (i) better understanding of the causes, symptoms and prevention of diarrhea; (ii) better sanitation facilities; and (iii) better hand washing habits after toilet use. In addition, there were a number of non-health outcomes including reduced absenteeism, improved academic performance and the establishment of clubs – environment, HIV/AIDS, education and hygiene. Furthermore, good working multi-sectoral partnerships had been developed to support project activities.26 By 2004, Namibia had implemented HPSI in most parts of the country. Partners involved included the ministries of health and education, UNICEF, WHO and UNFPA. A report of an evaluation visit to Okaranga District in 2004 indicated positive results from HPSI interventions. Using a checklist, the team documented that the pupils had a good understanding of the causation and prevention of common health problems, school health policies and regulations were being followed, classrooms were cleaner and better organized, toilets were clean and used in an orderly manner, school grounds were well kept, with well manicured trees and flowers. In addition, the pupils were actively involved in the program “the future is my choice” that addressed HIV prevention. Through in-depth discussions, teachers reported that the rate of pregnancy among schoolgirls had fallen, and parents were actively involved in school affairs, especially those related to health. All participating schools were reported to have developed health charters, which are policy documents that spelt out what pupils, teachers, and others needed to do to improve the health of the school community.27 In Swaziland an evaluation (descriptive research) was carried out in 21 schools that were implementing HPSI. Key informant interviews, focus group discussions and observations were used to gather data. Systematic random sampling was used to identify pupils and teachers who took part in the study while parents were selected purposefully. The study revealed a high level of understanding of the health problems and behaviors required for preventing various diseases. Students on the whole felt that school health rules and regulations protected them from unhealthy practices.28 Furthermore, physical activity was considered an important aspect of wellbeing and health. Schools were reported to be providing some social support to pupils and teachers with serious health problems. The study also established that there was readiness in the schools to take up health action as an important aspect of school life.28 There are prime examples of other well-organized institutional efforts to advance health promotion and disease prevention and control in Africa. Notable amongst

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these are the United Health and National Heart Lung and Blood Institute (NHLBI) Collaborating Centers of Excellence Initiative29 and the Medical Research Council (MRC) and United Kingdom's Department for International Development (MRC/DFID) African Research Leader (ARL) scheme.30 Briefly, the NHLBI Centers of Excellence Program is designed to combat chronic diseases in developing countries via network of Collaborating Centers, each of which includes a research institution in a developing country in partnership with at least one academic institution in a developed country with the aim to monitor, prevent, or control NCDs with a focus on CVD and pulmonary diseases. The strategy is to build capacity via training and research infrastructures that will drive and sustain such efforts. Two of the nine Centers are located in SSA, notably Kenya (Moi University) and South Africa (University of Cape Town). Akin to the NHLBI Centers of Excellence, the MRC/DFID ARL scheme is designed to strengthen “research leadership across the SSA by attracting and retaining exceptionally talented individuals who will undertake high-quality programs of research on key global health issues pertinent to sub-Saharan Africa”.30

Persistent challenges and barriers Despite the consensus that health promotion is effective and constitutes a critical component for the development and sustenance of communities burdened with disease and risk factors, formidable challenges and barriers mitigate its implementation. For insight, let’s consider the prerequisites for health stated in the Ottawa charter; these include: peace, shelter, education, food, income, a stable ecosystem, sustainable resource, social justice and equity.13 None of these prerequisites are readily demonstrable in many parts of Africa, thus creating major challenges for implementing the principles and practice of health promotion.

Economics Arguably, economics is the major underpinning factor for most of the challenges and barriers to health promotion in Africa. Fundamentally, health and economics are inextricably linked. The well-known aphorism, “health is wealth” is in many respects equally true when stated in reverse that “wealth is health”. Table 131 details the gross domestic product (GDP) per capita and growth rates from 2000 to 2009 in SSA, and reveals the variation in the overall economic picture within SSA. This variation has persisted as evidenced by growth rate of 5.8% in 2011 in East African GDP, a growth from 3.5% in 2010 to 3.8% in 2011 in Southern Africa, but a decline from 6.9% in 2010 to 5.6% in 2011 in West Africa, and from 5.2% in 2010 to 4.2% in Central Africa.32 More importantly, according to 2011 WHO Global Health Expenditure Atlas, the health expenditure in the African region was 6.5% of GDP, which translates to US $83 per capita. This represents the sum of public and private health expenditures as a ratio of total population, and covers the provision of health services (preventive and curative), family planning activities,

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Table 1 – GDP Per Capita and Growth Rates 2000–2009 in SSA.

Source: World Development Indicators Database (2011).

nutrition activities, and emergency aid designated for health but does not include provision of water and sanitation. For perspective, corresponding figures for Organization for

Economic Cooperation and Development countries are 12.4% of GDP (US $4341). Thus, the African region spends a paltry sum on health care despite recording the largest increase in

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the number of disability adjusted life years (DALYs) from 1990 to 2010, as reported in the recent global burden of disease study.33 Limited health expenditures in Africa are also related to the skewed allocation of resources to defense and infrastructure at the expense of health. In addition, inefficient use of available resources continues to be a major hindrance. Despite these economic realities, there are some African countries that have been able to advance health or institute health promotion practices and increase per capita health expenditure.

Health literacy and numeracy Literacy has remarkable relevance to knowledge, behavior and health outcomes. Literacy has been defined as an individual’s ability to read, write, speak, compute and solve problems at levels of proficiency necessary to function on the job and in society, to achieve one’s goals, and develop one’s knowledge and potential.34 A less complex definition is that health literacy is the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.35–37 According to the United Nations Educational, Scientific and Cultural Organization (UNESCO) Institute for Statistics (UIS), of the 180 countries evaluated 13 have less than 50% adult literacy rate, all of which are countries from SSA, with Mali coming in last with a 26.2% adult literacy rate.38 Patients with low literacy can have trouble reading prescriptions, following medical instructions, and interacting with the health care system. In addition, such patients have lower disease specific knowledge, report lower quality of life, and have poorer health related outcomes – even after adjusting for potential confounders such as education, insurance, race, and other factors.34,39,40 There is evidence that low literacy is common among patients with diabetes and is associated with less knowledge of diabetes self-management and worse clinical outcomes.41 Another study, of over 400 patients with diabetes, found that poor literacy was independently associated with worse glycemic control and higher rates of retinopathy.42 While there is a strong correlation between verbal literacy and quantitative skills, there are many patients who have adequate verbal literacy but are still unable to use math skills appropriately or are anxious/ intimidated about math. Numeracy is particularly important to patients with heart disease, or at risk for heart disease because prevention or management of heart disease requires self-management skills that rely on mathematics such as: determining sodium and fluid intake, interpreting weight status, taking medications appropriately, and possibly titrating diuretics based on volume status. These skills require the patient to deduce what arithmetic skills are needed for certain situations and to then perform complex multi-step math skills. Measures such as the use of colorcoded drugs and measurement kits have been employed to address literacy and numeracy issues in primary care settings.43 Such approaches may warrant further development, adaptation, or dissemination in effort to facilitate the implementation of health promotion.

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Culture Attitudes, customs and beliefs are crucial concepts that should be recognized when implementing the principles of health promotion. Together, these human dimensions constitute culture. A better understanding and appreciation of cultural dimensions must be incorporated into health promotion efforts. The attitude of Africans towards health and wellness are deeply rooted in their historical experience. However, attitudes can be addressed in the context of a supportive community. Community role models for wellness can become agents of change for long-held notions towards health symptoms that inevitably lead to high rates of morbidity and pre-mature mortality. In general, the approach to improving the health status of communities should involve providing the services within their comfort zone. The community directed treatment with ivermectin (CDTI) is a prime example of the successful implementation of this approach.44 The CDTI focuses on empowering communities to take responsibility, and represents a good model that the NCD community at large can learn from in an effort to foster health promotion.

Other factors Rural to urban migration poses challenges that are worthy of separate recognition albeit intertwined with economic constraints. The shift from rural to urban settlement precipitates systemic strain on the low-income urban settlement, and thus a deleterious living and working milieu that fosters the vicious cycle of infectious and chronic diseases associated with psychosocial stress. Urbanization, in and of itself, is a key factor in NCDs given the changes in lifestyle that it precipitates: sedentary lives, access to unhealthy foods, dependency on purchases that limit choice, etc. There are physical and structural barriers that worsen the consequences of migration and/or urbanization. Recognized structural barriers include legislative, policy, or regulatory measures that do not foster the principles and practice of health promotion. Examples of physical barriers include the lack of water, use of contaminated water, poor sanitation and waste management; while these barriers have the more immediate consequence of facilitating communicable diseases, they negate the practice of health promotion in general, thus setting the inhabitants and their offspring on the trajectory of risk for NCDs. Of note, all of the physical and structural barriers are also in attendance in rural settlements, and lead to similar problems. Additional challenges are created by wars and ethnic conflicts, and poor access to technology and educational materials.

Opportunities abound Regardless of the obvious challenges, opportunities exist to forge ahead in the quest for improvement; some of these opportunities center on adopting strategies and new paradigms or the novel assembly of existing ones. In this regard, some countries within SSA have successfully implemented

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preventive programs for NCDs with evidence of positive results. The falling mortality from myocardial infarction and stroke in Seychelles and South Africa constitutes prime examples of successful implementation of health promotion programs despite the obvious challenges within SSA.45,46

Effective and/or emerging strategies Given the challenges and barriers discussed above, it is unrealistic to believe that the optimum model for CVD prevention in SSA should center only on individual persons. The individual strategy is important but not enough. Policy and environmental changes are necessary and so are other population- or community-geared strategies. In this context, the WHO Africa Region's strategy for health promotion is likely to be more effective given its involvement of governments. The WHO strategy calls for governments to go beyond “the conventional health behavior focus which puts the burden of health improvement mainly on the individual” and address legislative, policy, and environmental changes.47 This strategy regards health as the responsibility of a wide spectrum of actors, including “the individual, the community and professionals.” The importance of communities in this regard cannot be overstated as discussed herein later in the context of social capital and community engagement and participation. The WHO recent emphasis on reducing the economic impact of NCD in low- and middle-income countries (LMIC) should provide impetus for government participation. In the recent WHO World Economic Forum,48 the linkage between health and economics was emphasized and presented as the rationale for governments to act given the staggering economic consequences of NCDs. The WHO report states that if “efforts remain static and rates of NCDs continue to increase as populations grow and age, cumulative economic losses to LMICs from the four diseases are estimated to surpass US $7 trillion over the period 2011–2025 (an average of nearly US $500 billion per year)”.48 However, the cost for scaling up the implementation of health promotion “best buy” intervention strategies is comparatively low, thus the investment returns “in health terms will be many millions of avoided premature deaths” and “in economic terms…many billions of dollars of additional output”.48 Overall, the philosophy of coimplementation should now constitute the modus operandi, thus mandating private-public partnerships and intersectoral collaboration.49 The “best buys” to combat heart disease, diabetes and stroke in Africa include: the provision multidrug regimens; food control legislation and public education; promotion of physical activity; strengthening and maintaining tobacco control activities; the prevention of rheumatic heart disease via treatment of sore throat with penicillin; needsdriven modular training of health professionals; strengthening district-based primary health system and integration of care; creation of regional centers of excellence; and the development of surveillance and quality assurance systems.50

An apparent role for primary health care as a central platform There exists a common thread across various calls and recommendations for mitigating the adverse CVD trends in

regions like SSA. The general consensus is that primary care models or approaches are needed to stem the rising burden of CVD and other NCDs. Interestingly, this philosophy is not new, going back to the 1978 declaration of Alma-Ata,12 which highlighted primary health care as one of the strategic imperatives for addressing gross inequalities in health status between and within high income and low-to-middle income nations. Consequently, it stands to reason that the goals of health promotion will be best achieved by employing the platform of an effective primary health care model. However, a fundamental set of criteria should underpin any healthcare delivery effort. These criteria can be referred to as the 4A criteria, which capture the need for care to be accessible, acceptable, appropriate, and affordable.51 Beyond these fundamentals, there are primary care models/practices that have been successful or impactful in sub-Saharan Africa. These models warrant mention to highlight unique characteristics attributable to their success. An example of a successful primary care model is the health post concept of community-oriented primary care in Tshwane South Africa.52 In Tshwane, health posts represent physical locations within communities staffed by health care teams that are mainly comprised of nurses and community health workers. Team members collectively and individually interact proactively with the households within their oversight jurisdiction. In their role as health workers they engage in health promotion, disease prevention, early detection, support treatment, palliative care and rehabilitation.52 In addition, the teams engender the development of capacity and shared responsibility for healthcare between the workers and the community residents.52 Lessons could also be learned from the approach that has reduced premature mortality in Rwanda.53 In the past decade in Rwanda an army of community health workers, after election by their communities, are trained to diagnose and provide empirical treatment for common ailments, as well as play key roles in health promotion efforts. It is important to note that national community based health insurance schemes have contributed immensely to the success observed in Rwanda.53 The Rwanda and Tshwane models have been highlighted because they capture the importance of accessible, acceptable, appropriate, and affordable primary care as a platform for the deployment of the principles and practice of health promotion. Furthermore, the two models provide forwardlooking scenarios on how to address effective, affordable information technology in primary healthcare and research in low resource settings. For instance, in the Tshwane model the health post teams capture health status assessment data electronically using cellular phones for onward transmission to web-based database. Aggregated data are then employed by the University of Pretoria and other partners for setting the priorities and goals for intervention. Similarly, Rwanda’s online health management information system, national AIDS informatics system, open source customizable electronic medical record system, mobile phone-based alert and audit service for maternal and child health, all exemplify innovations that can have far reaching impact if adopted to combat the rising burden of CVD and NCDs in SSA.53,54

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Understanding social capital and community participation in health promotion and disease prevention Social capital The quest to understand health determinants, and to improve health outcomes and overall well-being evokes the desire to revisit and reinvigorate a long tradition of scholarship that supports the relevance of informal support networks for wellbeing and the prevention of diseases. This tradition has a long and distinguished history in the social sciences, however, its reemergence is justified by a constellation of factors: the fiasco of varying public service delivery reforms, increasing apathy for ineffective neo-liberal policy discourse, and the recognition that sophisticated medical interventions are not the solutions to some of the most persistent social ills. Consequently, there is increasing attention on assessing the impact of peer group effects, network structures, associational memberships, civic participation, and other social arrangements. These come under the umbrella of what is now referred to as social capital, which can be defined as the nature and extent of one’s social relationships and associated norms of reciprocity.55 The causal pathway that gives rise to superior health practices is membership in a dense network of close friends, and may involve utilizing unique individuals in the community, referred to as positive deviants56 who have found way to develop healthy habits and better health within the environment. The importance of social capital has been documented in various fields but “in none is the importance of social connectedness so well established as in the case of health and well-being”.55 Social capital has been empirically linked to improved child development and adolescent well-being,57 increased mental health,58 reduced mortality,59 and sustained participation in anti-smoking programs.60 In the setting of demonstrably low social capital, inhabitants of affected urban and rural communities or subpopulations report higher levels of stress,61 decreased welfare and reduced capacity to respond to environmental health risks,62 and to receive effective health service interventions.63 The volume, diversity, and consistency of the empirical evidence identifying social capital as a significant determinant of health outcomes are impressive. However, despite this weight of evidence in support of social capital, it has not been extensively employed in addressing the health promotion in vulnerable populations. Similarly, policy decisions do not always reflect an understanding of the importance and potential impact of social capital in health care delivery. The increasing burden of CVD and other NCDs in SSA provides enough impetus for a revision in the methods and approach to public health intervention even if it entails revisiting an age-old concept—social capital—that remains significantly unexplored. On this point, it should be noted that the application of social capital to healthcare can occur at a macropolicy level – e.g. governmental funding for programs that enhance social capital in communities – or micropolicy level – e.g. local community organization to combat or reduce

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health care barriers. The mechanisms by which social capital impacts health may be explicit or tacit thus making it difficult to achieve precision in our empirical understanding of the phenomena at the individual and community level. However, we can hypothesize that social support for stress and modulation of deviant health behaviors could translate into improved personal responsibility (self-care) and adherence to health promotion practices.

Community participation The CVD epidemic in SSA strikes emotional resonance akin to any disaster. Thus the appropriate response should be disaster management that has community participation and health promotion as essential components. Community participation is the active involvement of an affected community in reaction to an identified problem,64 in this case, escalating CVD burden. True and effective participation requires a set of guiding principles. Fundamentally, the community should be involved in decision-making and in the planning, design, governance, and delivery of services to achieve improvement in health and well being, and sustainability of initiatives. To trigger and sustain community participation requires community engagement; an approach commonly used to support the involvement of communities in activities that can improve health and/or decrease inequalities. Different levels and types of community engagement have different impacts on a range of outcomes, including health status. Approaches that involve informing or consulting communities are likely to have a marginal impact on people’s health either at the individual or population level. In contrast, the more a community is supported to take control, by being involved in the design, development and implementation of activities to improve their lives (i.e. coproduction, delegated power or community control), the more likely their health (and a range of other outcomes) will improve.64 This approach, particularly in the socially and economically disadvantaged populations like in SSA, should be central to strategies for promoting health and reducing health inequalities. Arguably, apathy and disempowerment, conflicts and divisions, poverty, cynicism, attitudes, custom, beliefs, etc. are potential barriers to community engagement and participation. The ideal solution should be capable of addressing such potential barriers and provide an entry point into the community. The antidote may be rooted in determining the social capital of the community as well as the introduction of a social catalyst. The latter provides the drive while the former provides the medium or platform based on established roots and trust. Embracing the concepts of social catalyst, social capital, community engagement with resultant community participation, collectively may galvanize a fertile platform for the much needed health promotion activities in response to the disaster of escalating CVD burden in SSA. The concept of health as a resource for everyday living should be emphasized by the health promotion activities executed on a platform of care that focuses on prevention. Essentially, a model that employs social capital and community participation techniques will involve listening to members of the target population in order to understand

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perceived needs and the traditions that may be impediments to care. Using a community catalyst can help generate traction with care models in community meetings, shape care delivery, defuse societal legacies and give voice to stewardship. The community catalyst helps create a “caring community” within the target population. Brand development insures “belonging” to this new community, increases community participation, and provides positive feedback from identification. Integrating care at the pre-disease level casts the broadest possible net for stewardship. Optimizing communication by personalizing the message of risk addresses medical literacy. An increase in stewardship in a caring community serves to increase its social capital and medical literacy.

A hypothetical paradigm for sustainable health promotion The intimate and intricate interplay between health and economics implies that efforts to address health promotion may be futile if they are devoid of avenues to foster grassroots economic growth. Against this backdrop, health promotion policies should be linked with support for entrepreneurship in efforts to uplift communities, thereby creating a positive feedback loop for growth and sustainable implementation of health promotion. This paradigm is detailed in Fig 1. The model begins by creating private/public partnerships that will

foster community development via the double-pronged strategy of supporting local businesses and creating local health services using local entrepreneurs. First, provide business loans via macro lending programs to encourage and support the creation of local health services whose mandate will be to deploy the principles and practice of health promotion for primary care and disease prevention. This has the immediate effect of creating a workforce of empowered locals. Pari passu the creation of local health services, micro lending should be used to facilitate the growth of the major occupation(s) within the community; in the Figure farmers serve as the example. A condition for micro lending will be to mandate the purchase of health services from the local facility created via the macro-lending program. Thus, we have a positive loop of empowered farmers, whose businesses are likely to grow due to the micro development funds, and who will in turn ensure the growth and sustenance of the local health facility. The private/public partnerships that triggered this loop will have a vested interest to provide oversight in an effort to recoup investments costs. With the sustained loop in place, dissemination of health promotion principles and practices throughout the community can be undertaken by the local health facility in fulfillment of their primary mandate. The methods of dissemination will draw on the understanding

Fig 1 – A hypothetical paradigm for sustainable community health promotion and disease prevention. 1: Formation of private/ public partnerships. 2: Creation of loan programs: macro lending to support the creation of primary health care service facilities by local entrepreneurs; micro lending to support the predominant local business owners e.g. farmers. 3: The local business owners, by mandate, purchase health services from the local health facility, which in turn facilitates the maintenance of a healthy productive workforce thereby creating a positive feedback support loop. 4: Then the local health facility, by mandate, disseminates the principles and practice of health promotion and disease prevention. Critical to their effort will be the use of social capital e.g. the churches, local elders, respected farmers etc., and community engagement and participatory approaches. To accomplish the sustainable health promotion within vulnerable populations, it is important to repackage our approach to health promotion. An approach that addresses health promotion practices in conjunction with local economic support as well as the understanding and application of concepts such as social capital, culture, community participation and engagement. This model also provides a platform to address some of the challenges and barriers to health promotion implementation. HP, health promotion; DP, disease prevention.

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and use of the social capital of the community, as well as the engagement and participation of the community residents, many of whom (the farmers) already patronize the facility thus creating a sustainable circle of health promotion and economic emancipation. This model provides a platform to address many of the challenges and barriers to the implementation of health promotion. Furthermore, it is a model that can be scaled and replicated as deemed fit. Although the above-delineated model is an intriguing and sensible approach, it remains hypothetical and requires rigorous evaluation. At the very minimum it should foster the dialogue about integrating health promotion policies with entrepreneurship and community development in effort to stem the tide of rising CVD burden. In the spirit of such dialogue about the above-proposed paradigm, three fundamental questions should be asked: Why should entrepreneur promotion be tied to health promotion? Do employers need and/or have to pay for healthy workforce in SSA? Why is the sustenance of local health facilities tied to the economic vitality of local residents? We believe that answers to these questions rest on the central economic argument. Although beyond the scope of this paper, it suffices to recognize that social vitality is dictated by economic vitality, the absence of which negates the development and sustenance of factors— education, health, social services, housing, transportation and information flow,—which make living worthwhile.65

Conclusion The increasing burden of CVD and related risk factors in SSA is concerning and calls for an appropriately measured response. Clearly, the unfinished agenda of controlling infectious disease epidemics, nutritional deficiencies, maternal and perinatal disorders, and persistent poverty represents only part of the daunting public health challenges that face SSA as the region grapples with the increasing prevalence of CVD. However, we have existing tools to fight the emerging trend of increasing CVD burden. The principles and practices of health promotion represent a viable means for mitigating the burden of CVD in SSA. Although there are challenges to sustained implementation of health promotion, it is likely that novel approaches that couple implementation efforts with economic development of communities are likely to be effective and long-lived. In this regard, the WHO “best buy” strategies can yield positive returns on investment both in health and economic terms. This justifies the philosophy of co-implementation, which requires private-public partnerships and intersectoral collaborations in an effort to scale up the implementation of the “best buy’ interventions that are evidence-based, highly cost-effective, and also affordable, and feasible in sub-Saharan Africa.

Statement of Conflict of Interest The authors do not have any conflicts of interest to disclose. Dr. Sampson's effort was supported in part by Harold Amos Medical Faculty Award of the Robert Wood Johnson Foundation.

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