Health inequalities in secondary prevention

Abstract

Health inequalities are differences in health status or the distribution of health determinants between distinct populations or groups. These have important impacts on the accessibility and effectiveness of cardiovascular disease preventive measures. This article discusses the most relevant issues on this topic.

Keywords

Ethnicity gender health inequalities health disparities prevention

Introduction

Health inequalities are differences in health status or the distribution of health determinants between distinct populations or groups. Inequalities originate through an intertwined effect of access to resources (i.e. education, money, knowledge and power) and characteristics of the individual (i.e. age, sex and ethnicity). This combination generates an individualised pattern that influences interactions with the health care system through differences in health literacy, health-seeking behaviour and access to services, health promotion and therapeutic outcomes.^1–5 Several studies have identified a pattern in which the sickest patients get the least amount of care (also known as the ‘inverse care law’),⁶ emphasising how vulnerability may display predefined gradients.

Inequalities are intrinsically possible whenever resources are finite and their allocation is not formally given, but follows unspecified rules. If health care coverage is not universal, access to services will depend, among other aspects, on education and income.⁴ If therapies are not standardised and priorities not regulated, allocation of newer and possibly more efficacious medications might not match the criteria of efficacy or need.⁷ Whether health care should strive for equality (i.e. making the same offer accessible to all people regardless of potentially different needs) or equity (i.e. allocating means unequally based on the notion that different subpopulations have different needs) remains an open discussion with ample consequences.⁸

The mechanisms that generate inequality exemplify how preventive action can happen at two levels: the individual ‘agentic’ level or the societal ‘structural’ one.⁹ In recent decades, we have witnessed both increased attention towards population-wide prevention measures and a substantially market-driven trend towards individualised efforts. Growing evidence demonstrates how structural prevention strategies can reduce social inequalities,¹⁰ while agentic strategies more frequently increase them.¹¹

In the following review, we will explore the impacts of several determinants of inequality on access to secondary cardiovascular prevention with a focus on lifestyle aspects, which are amenable to structural prevention, and pharmacological ones, which have to be agentic in nature.

Determinants of health inequality

Gender

Lifestyle modifications represent one of the first interventions in both primary and secondary prevention, yet they cannot be applied to all patients in the same manner. Men and women experience different barriers to lifestyle change, display distinct dietary patterns and levels of physical exercise and are subject to heterogeneous psychosocial factors.¹² They also have different socio-cultural preferences that impact sustained adherence to healthy behaviour. Thus far, limited attention has been given to implementing gender aspects in lifestyle advice after a previous cardiovascular event. An appealing positive example is the recruitment of hard-to-engage men into a lifestyle programme delivered in and by Scottish Premier League football clubs.¹³ A persistent gender bias exists among health care providers towards engaging women in cardiac rehabilitation (CR) due to underestimation of their actual cardiovascular disease (CVD) risk. Women are twice as likely not to be referred to CR programmes compared to men, regardless of their higher age and comorbidity, although the effectiveness of such programmes has been shown to be comparable among both genders.^14–16 Women also experience more psychosocial barriers, home-based duties and less social support, all of which foster low engagement.¹⁷ The 2016 European Society of Cardiology (ESC) guideline on CVD prevention acknowledges that women are under-represented in most CR trials. It advocates for a more patient-centred approach that focuses on individual priorities and goals in order to better incorporate lifestyle changes within the context of women’s daily routines.¹⁸ Modern home-based CR programmes with e-health applications and the use of smartphones should include more women. Female personality traits and gender roles increase the risk for a recurrent acute coronary syndrome in young patients.¹⁹ Anxiety and depression are more often present in women than men and are known to affect outcomes in ischaemic heart disease (IHD) negatively.²⁰ These are also major barriers to exercise training, whereas the effectiveness of patient-tailored stress reduction programmes has yet to be determined.²¹

Despite the increasing awareness and knowledge among health care providers of the differences in the manifestations of IHD and heart failure between the sexes, there are still important disparities in evidence-based medical therapies. The under-representation of women in clinical trials has been studied in the EuroHeart project, which found that, since 2006, the percentage of women enrolled in each trial ranged between 15% and 60%, but only 31 of the 62 trials (50%) reported an analysis of the results by sex.²² Moreover, studies reporting sex-specific analyses are often conducted post-hoc without regard to whether the initial trial was adequately powered for such analyses. Underpowered subgroup analyses can produce false-negative results and incorrect conclusions, which can lead to ineffective or even harmful treatment strategies in women.^23,24 The under-representation of females in cardiovascular research may be partly explained by a lower willingness of women to be enrolled, due to multiple commitments, transportation issues or a lack of support to attend the follow-up visits. The EUROASPIRE III survey identified how prescription rates of drugs in the secondary prevention of IHD did not differ between the sexes, whereas control targets of the traditional risk factors (blood pressure, low-density lipoprotein cholesterol and diabetes) were less often achieved and maintained in women.²⁵ The factors affecting better target levels of risk factor control are significantly related to higher education level and younger age.²⁶ It is undetermined yet as to whether it is correct to strive for comparable control of traditional risk factors among men and women. As the impact of hypertension and diabetes on cardiovascular outcomes is higher in women compared to men, it remains to be established whether stricter control of these risk factors in females is more appropriate.^27–29

Women more frequently report side effects of medication than men, which importantly affect their adherence to long-term preventive drug therapy.^30,31 This is especially true for the use of statins.^32,33 Other factors that influence non-adherence are related to costs, inadequate communication and lack of motivation, which affect more women than men and vary among ethnic minorities and low-income countries.^34,35 The attitude towards chronic medication use and preferences for complementary and alternative medicines are also different between both genders.³⁶

Income

Poverty is one of the most significant modulators of the effectiveness of prevention, since its consequences produce a combination of lower awareness, lower access to health care services and dispensation thereof and limited adherence.⁵ These aspects are becoming increasingly relevant as the burden of CVD morbidity and mortality is increasing significantly in low-income countries³⁷ where economic resources are limited. Given that medication costs for secondary prevention significantly affect household budgets, income is one of the most relevant drivers of health inequality.

Income not only influences access to therapy, but also affects food choices. Consumption of five portions of fruit and vegetables a day is recommended by most nutritional and prevention guidelines,³⁸ yet the affordability and availability of produce might limit meeting this recommendation. Furthermore, structural aspects of the food system might challenge adhering to this recommendation, especially in low-income countries.³⁸ The Global Burden of Disease Study estimated that more than 1.5 million deaths annually worldwide are associated with a low intake of fresh fruit and vegetables.³⁹ However, the cost and consumption of fruit and vegetables in low-, middle- and high-income countries strikingly differ according to predictable patterns. In a recent study by Miller and colleagues, mean daily fruit and vegetable consumption in low-income countries was 2.14 servings a day, 3.17 servings a day in lower middle-income countries and 5.42 servings a day in high-income countries. More relevantly, the consumption of five portions of produce a day per household member accounted for 52% of household income in low-income countries compared to 2% in high-income countries.⁴⁰ Another staple of primary and secondary prevention is smoking cessation, which might pose particular challenges in low-income countries⁴¹ due to the presence of more aggressive marketing strategies by tobacco companies in these countries, laxer legislation and lower availability of pharmacological options for quitting.⁴² A recent consensus statement by the International Council of Cardiovascular Prevention and Rehabilitation summarises the challenges and options for secondary prevention in low-income settings⁴³ with a specific focus on lifestyle interventions.

The Prospective Urban Rural Epidemiology (PURE) study highlighted dramatic limitations in the access to secondary prevention medicines, especially in low- and middle-income countries. In low-income countries, 80% of eligible patients could not access any of their needed medicines, compared to only 10% in high-income countries.⁴⁴ The reasons implicated in these differences in access ranged from unaffordability to unavailability, as well as from the presence of side effects to general inconvenience in obtaining the medication due to a lack of infrastructure, transportation and medical facilities. Depending on the income level of a country, medicine costs differently affect patients’ family budgets. In a sub-analysis of the PURE study,⁴⁴ researchers investigated the availability and affordability of four essential medications for secondary prevention: β-blockers, statins, angiotensin-converting enzyme (ACE) inhibitors and antiplatelet drugs. While medication costs differed by a magnitude of three between low- and middle-income countries ($17 vs. $61), the ability to pay for medication varied by a magnitude of about 50 between these countries’ income ranges ($89 vs. $4238). As a direct consequence, 45% of households in low-income countries were unable to afford such medications compared to 5% in high-income countries.⁴⁵ A country’s income level not only affected patients’ ability to pay for essential medications, but also the availability thereof. All four essential medicines for secondary prevention were available in up to 90% of the rural communities of high-income countries, but only in up to 37% of the rural communities in low-income countries.⁴⁵ Inequality based on income therefore affects both the supply and affordability of medications, highlighting a combination of structural and agentic issues.

Ethnicity

Since multiple cardiovascular risk factors display a significantly higher incidence in non-white patients before an event,⁴⁶ their management becomes even more relevant for secondary prevention. Next to pharmacological interventions, prevention should focus intensely on lifestyle measures, such as smoking abstention, physical activity and stress reduction, which are cost effective, efficacious and universally accessible. The user perspective is especially relevant when addressing urban ethnic minorities. Participatory designs to increase awareness and achieve better risk factor control appear promising, although the duration of the intervention and the long-term benefits have not been ascertained.^47,48 Cardiometabolic risk profiles may differ based on ethnicity, and current recommendations for physical activity levels – mostly extrapolated from white populations – might not be applicable to non-white patients without adjustment.⁴⁹ This might also partially explain the contradictory results regarding the protective effect of physical activity against CVD in non-whites,^50,51 highlighting an urgent need for more robust data on the matter. Depression, stress and discrimination might affect medication adherence in non-whites.⁵² Alternative therapies for stress reduction are being increasingly investigated for non-white patients and might show promising results.^53,54

The investigation of the effect of ethnicity on pharmacological secondary prevention should consider two aspects: the potential need for differential therapy and limitations of access. As described for women, a potential need for therapeutic adaptation based on ethnicity has been raised,^55,56 and recent publications have confirmed the existence of potential differences in drug efficacy based on ethnicity, especially in the use of ACE inhibitors and diuretics.^55,57 A recent meta-analysis identified significant differences in adherence to statin therapy between women and men and, most significantly, between white and non-white patients. In fact, in this latter group, the odds of nonadherence were 53% higher than among comparable white populations.³² The authors cite, among others, the following reasons for these disparities: lack of a continuous relationship with a medical provider and lower level of quality of care; health illiteracy; and, potentially, a higher incidence of unwanted side effects of the medication. However, even if non-white patients are obtaining secondary prevention therapy, they might reach therapeutic goals less often, as described for anticoagulation in patients with atrial fibrillation⁵⁸ or polymedication in case of known atherothrombotic disease.⁵⁹

Discussion

The investigation of secondary cardiovascular prevention exemplifies the complex and intertwined factors that mediate health inequalities and the challenges that arise in trying to diminish them. Sources of inequality range from the individualised to the systemic level and each encompasses distinct aspects. When looking at individual factors, such as gender or ethnicity, we should not limit our focus to inequalities in access and distribution of resources, but start with physiological differences. In order to achieve equity, we might first have to consider that a non-male, non-white body might have a different cardiometabolic response to exercise or pharmacotherapy, and properly explore these differences so as to guide future prevention efforts. After a clearer definition of physiological need, a detailed exploration of the structural barriers to access should follow. These barriers are primarily economic, yet the role of education, health literacy, accessibility and policy cannot be discounted. This emphasises the need for economic subsidies, health education, inclusiveness and social policy.

Financial subsidies are among the most effective strategies to reduce inequalities, since a lack of affordability is associated with limited adherence in women and non-white patients and in residents of low-income countries.⁶⁰ Access to services strongly correlates with health equality and equity, and only universal health coverage can guarantee unrestricted access to preventive and pharmacological services for all subjects within a population. Several models are being explored that combine broad access with targeted services to specific subgroups, with the most widely described being proportionate universalism.⁶¹ This concept was introduced first in the Marmot review on Health Inequalities in England and specifically advocates for a combination of universal health action and proportionate interventions for disadvantaged group.³ Reasons for non-adherence, however, include many aspects that transcend financial restrictions. Next to targeted interventions, the advent of digital technologies and an increased awareness of the role of patient–provider communication could help limit several causes of the phenomenon and so reduce it.^62,63

Health education and inclusion are linked, since one cannot be achieved without the other. In order to achieve population-wide coverage, we need to tailor offers adequately to the intended recipients, which might prove more challenging when they diverge from the social norm or medical standard. Examples could be gender-sensitive prevention programmes^13,64,65 or community-centred efforts. An example of the latter is the EUROACTION programme: a nurse-coordinated prevention programme developed by the ESC and rolled out in several European countries during a large trial.⁶⁶ Patients were intensely supervised and family structures were involved in the activities in order to achieve the best results, demonstrating how inclusion of diverse patient groups could be achieved through intense follow-up.

Geoffrey Rose postulated that small risk changes in large populations are more effective at reducing CVD events than large changes in small, high-risk populations⁶⁷ with primary prevention in mind, yet this also holds true for secondary prevention. The notion that population-wide strategies and social policies have a mitigating effect on health inequalities supports the implementation of community-wide interventions, which can function as both primary and secondary prevention. Research shows that implementation of effective population strategies could reduce health-related inequalities between different social groups by up to 86%.⁶⁸ Evidence is accumulating on how to remove hurdles in the system⁶⁹; most recently, the Marmot Report³ presented strategies to mitigate social inequalities in health at different structural levels, from an individual basis to the macro level. The World Health Organization also emphasises how a structural approach is needed in order to represent real-world challenges and design change strategies in a more comprehensive way.⁷⁰

Overall, the mitigation of health inequalities in secondary prevention recapitulates many of the issues that have been described for primary prevention. Especially in the field of lifestyle intervention, increasing evidence is pointing to the substantial benefit of social interventions over solely personalised measures. Since pharmacotherapy is a cardinal aspect of secondary prevention, we need to guarantee the universal availability of medications to reduce preventable mortality in the most vulnerable patient groups.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

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