Cardiovascular disease prevention in Cochabamba, Bolivia : the importance of preventable risk factor distribution and inequalities for policy implementation

Sammanfattning: Background: The increase in the prevalence of cardiovascular diseases (CVDs) and cardiovascular risk factors (CVRFs) is considered one of the most important public health problems in Latin American (LA) countries. Accordingly, an accurate and comprehensive picture of the CVRFs situation is needed to prevent CVDs and consequently support the development of health policies to improve population health and reduce health inequalities. Objective: To estimate the distribution of CVRFs and to examine social inequalities in these factors in Cochabamba – Bolivia to provide useful information for public health practice and decision-making. Methods: This thesis is based on four studies that used quantitative and qualitative methods. For sub-studies 1, 2, and 3, the data collection procedure was based on the Pan-American version (V2.0) of the WHO STEPS approach adapted to the Bolivian context. Between 2015 and 2016; 10,754 individuals aged over 18 years old were surveyed. To sub-study 1, the prevalence of relevant behavioural risk factors and anthropometric measures were calculated, and then odds ratios were estimated for each CVRFs. Regarding sub-study  2, an intersectionality approach based on the method suggested by Jackson et al. was used to analyze the ethnic and gender inequalities in obesity followed by the Oaxaca-Blinder decomposition to estimate the contributions of explanatory factors underlying the observed intersectional disparities. For sub-study 3, bivariate and multivariable regression analyses were carried out to analyze the association between access to CVDs healthcare and to preventive activities for CVRFs, with demographic and socioeconomic factors, and healthcare needs. Finally, to sub-study 4, in-depth interviews were conducted among 14 key informants focusing on aspects related to the implementation process of the CVDs policy. The interviews were recorded, transcribed verbatim, and analyzed using reflexive thematic analysis.Main findings: Our findings revealed that Cochabamba had a high prevalence of CVRFs, with significant variations among the different socio-demographic groups. Indigenous populations and those living in the Andean region showed, in general, a lower prevalence for most of the risk factors studied. The prevalence of the metabolic risk factors were:  overweight (35.84%); obesity (20.49%); abdominal obesity (54.13%); and raised blood pressure (17.5%). It is important to highlight that 40.7% of participants had four or more CVRFs simultaneously.Dually and singly disadvantaged groups (Indigenous women, Indigenous men, and mestizo women) were less obese than the dually advantaged group (mestizo men). The joint disparity showed that the obesity prevalence was 7.26 percentage points higher in the doubly advantaged mestizo men than in the doubly disadvantaged Indigenous women. The lower prevalence of obesity in the doubly disadvantaged group of Indigenous women was mainly due to ethnic differences alone. Health behaviours were important factors in explaining the intersectional inequalities, while differences in socioeconomic and demographic factors played a less important role.The analysis also suggested a horizontal inequity in education, job status, region, and health insurance ownership regarding access to healthcare for CVDs and preventive activities for CVRFs. In the case of healthcare access, a lower probability of accessing healthcare for those with no formal education (OR=0.63; 95% CI=0.49-0.82) compared to those with higher education was found. Participation in preventive activities was significantly less among those with low educational levels, with the lowest participation observed in people with no formal education (OR=0.51; 95% CI=0.40-0.63). Individuals who were retired (OR=0.72; 95% CI=0.53-0.99), and those living in the Andean (OR=0.51; 95% CI=0.44-0.60) and Southern cone (OR=0.53; 95% CI=0.45-0.64) also displayed lower odds of participation. The challenges highlighted for the implementation of the CVDs policy in the Bolivian primary healthcare system were: the importance of i) local research, ii) a functional surveillance system, iii) effective leadership and coordination, iv) investments in municipal and community-level initiatives, and v) the need for health personnel capacity building. Conclusion: The prevalence of all CVRFs in Cochabamba was high, and nearly two-thirds of the population reported four or more risk factors simultaneously. The intersectional disparities illustrate that abdominal obesity was not distributed according to expected patterns of structural disadvantages in the intersectional spaces of ethnicity and gender in Bolivia. While vertical equity was observed in access to healthcare and in the participation of preventive activities, a horizontal inequity regarding education, region, and health insurance ownership was found. In addition, our findings highlighted five main challenges in the implementation of the CVDs policy in the Bolivian primary healthcare system; including local research; a functional surveillance system; leadership and governance; investment in municipal and community-level; and Health personnel for the implementation of CVD policy and its prevention strategies. The information generated by this study provides evidence for health policymakers at the regional level to carry out specific interventions to prevent CVDRFs both at the population and at the individual level. It is important to understand the contribution of socioeconomic factors and health needs in the process of formulating strategies that seek to reduce inequalities in access to healthcare in Cochabamba and nationally.