Prevalence of Coronary Heart Disease in India

Prevalence of Coronary Heart Disease in India Introduction According to WHO (2007) coronary heart disease (CHD) (including Myocardial ischemia) is the most common cause of death in the world and the biggest cause of premature death in modern and industrialised countries (Lopez et al., 2006; Lindsay and Gaw, 2004). In 2001, ischemic heart disease accounted for 7.1 million deaths worldwide among which 5.7 million (80%) deaths were in developing and underdeveloped countries (Lopez et al., 2006). Although geographical variations such as ethnic origin and social class influence the CHD mortality rates (Lindsay and Gaw, 2004), coronary heart disease remains common globally despite the development of a range of treatments (Brister et al., 2007). There is evidence that ethnicity is an important factor for coronary heart disease (Gupta et al., 2002; Brister et al., 2007) and a number of studies have suggested that there is increased incidence in coronary artery disease in South Asians (people originating from India, Pakistan, Bangladesh and Sri Lanka) when compared to the white population (Brister et al., 2007). South Asian people also have a greater risk of coronary heart disease than others from developed countries (Mohan et al., 2001; Joshi et al., 2007). In 2002 India had the highest number of deaths over 1.5 million due to coronary heart disease (Reddy et al., 2004). By 2010, it is expected that 66% of the worlds heart disease is likely to occur in India (Ghaffar, 2004). Therefore, this dissertation will focus on the prevalence of CHD in India and the impact of life style in the aetiology of CHD. There is wide range of evidence regarding the incidence and prevalence of coronary artery disease (CAD) in India (Reddy, 2004; Kasliwal et al., 2006; Patel et al., 2006; Brister et al., 2007), including Indian, British and Singaporean journal articles. This dissertation is broken down into three parts: the first discusses the topic in relation to the existing literature on the prevalence of CHD in India; the second part is a critical appraisal of the risk factors and the impact of life style of CHD in Indians; While the third presents the management of CHD, and includes a discussion of the nursing implications and future research into this area. Background THE DISEASE ASPECT- CORONARY HEART DISEAS/CORONARY ARTERY DISEASE Definitions Coronary heart disease â€Å"CHD covers a spectrum of disease such as angina, acute coronary syndrome, myocardial ischemia, ischemic cardiomyopathy, chronic heart failure and a proportion case of sudden cardiac death† (Lindsay and Gaw, 2004 pg no. 1). Acute coronary syndrome This is the clinical entity of myocardial ischemia and myocardial infarction. Myocardial Infarction â€Å"it is a condition that results from diminished oxygen supply coupled with inadequate removal of metabolites because of reduced perfusion to the heart muscle† (Woods et al., 2005 pg no. 541) Angina â€Å"A condition characterised by chest pain or discomfort from myocardial ischemia† (Woods et al., 2005 pg no. 541) Overview of Coronary Artery Disease CHD is the major cause of death in most countries and is considered almost to be an epidemic in western countries (Lippincott, 2003). In Britain it accounts for one in three deaths in men and one in four deaths in women, while 5,000,000 deaths annually are seen in US (Forfar and Gribbon, 2000). It is estimated that more than 80% of patients who develop clinically significant coronary artery disease (CAD), and more than 95% of those who experience a fatal CAD event have at least one major cardiac risk factor (Greenland and Klein, 2007). CHD is more prevalent in males, whites and the middle-aged, as well as elderly people. More than 50% of males age 60 or older show signs of coronary artery disease on autopsy. The peak incidence of clinical symptoms in females is between ages 60 and 70 (Lippincott, 2003). There is a marked difference in death rates due to coronary disease between countries: for example, a 10-fold greater age-standardized death rate for men aged 35 to 74 years in Scotland compared with Japan. Within Europe, a threefold difference in death rates and disease incidence can be seen with Finland and the United Kingdom higher than Italy, France, and Spain (Forfar and Gribbon, 2000). There are also marked contrasts in coronary disease mortality trends between developed and developing countries. In the United States, Western Europe, and Australia, mortality has been falling between 15 and 50 per cent for at least 20 years (Lippincott, 2003). In contrast, rates continue to rise in Eastern Europe, including Poland, Hungary, Bulgaria, and the Czech Republic. The fall could be due to a fall in disease incidence or case fatality rates, or both. Although the management of acute myocardial infarction in particular has improved over this time, with case fatality rates halved, there ha s also been an increased awareness of risk factor avoidance (Forfar and Gribbon, 2000). The Disease aspect Coronary arteries bring blood and oxygen to nourish the heart. The heart pumps deoxygenated blood to the lungs, where it receives oxygen before it is pumped to the whole body. Because the heart is a muscle, it needs a continuous source of oxygenated blood to function. Causes and symptoms CHD is usually caused by atherosclerosis. Cholesterol and other fatty substances accumulate on the inner wall of the arteries, which in turn attracts fibrous tissue, blood components, and calcium to the inner walls of the arteries which then hardens into artery-clogging plaques (Woods et al., 2003). Atherosclerotic plaques often form blood clots that also can block the coronary arteries (coronary thrombosis). Congenital defects and muscle spasms can also block blood flow. Recent research indicates that infection from organisms such as the chlamydia bacteria may also be responsible for some cases of coronary artery disease (Warrel, 2003). A number of major contributing factors increase the risk of developing coronary artery disease. Some of these can be changed and some cannot. People with more risk factors are more likely to develop coronary artery disease. Major risk factors Major risk factors are those factors that lead to CHD. They are mainly classified into two groups: non-modifiable and modifiable (Lippincott, 2003). Those that cannot be changed are the non-modifiable risk factors such as: Heredity if a persons parents have coronary artery disease he/she is more likely to develop it. Sex Men are more likely to have heart attacks than women and to have them at a younger age. Age Men 45 years of age and older and women 55 years of age and older are more likely to have coronary artery disease. However now-a-days, coronary disease may occasionally strike a person in their 30s (Lippincott, 2003). Major risk factors that can be changed (modifiable risk factors) are: Smoking Smoking increases the chance of developing CHD and the chance of dying from it. High cholesterol Dietary sources of cholesterol are meat, eggs, and other animal products. There are other factors also that increase the cholesterol level such as age, sex, heredity, and diet affect ones blood cholesterol. Total blood cholesterol is considered high when it is above 240 mg/dL and borderline at 200-239 mg/dL. High blood pressure High blood pressure makes the heart work harder, also increases the risk of heart attack, stroke, kidney failure, and congestive heart failure. A blood pressure of 140 over 90 or above is considered high. Lack of physical activity Lack of exercise increases the risk of coronary artery disease. Even modest physical activity, like walking, is beneficial if done regularly (Lippincott, 2003). Diabetes mellitus the risk of developing coronary artery disease is seriously increased in diabetics. More than 80% of diabetics die of some type of heart or blood vessel disease. Chest pain (angina) is the main symptom of coronary heart disease but it is not always present. Other symptoms include shortness of breath, and chest heaviness, tightness, pain, a burning sensation, squeezing, or pressure either behind the breastbone or in the arms, neck, or jaws (Lindsay and Gaw, 2004). Many people have no symptoms of coronary artery disease before having a heart attack: according to the American Heart Association 63% of women and 48% of men who died suddenly of coronary artery disease had no previous symptoms of the disease (Woods et al., 2001). THE COUNTRY PROFILE INDIA The country India India, situated in the South Asian region, is the seventh largest, and the second most populous, country in the world with a population of 1.103 billion (United Nations Population Division, 2005) in 32 states and union territories covering about four thousand towns and cities and about six lakhs villages (Nag and Sengupta, 1992). The population distribution is 71% rural and 29% urban (United Nation Population Division, 2005). Initially, India was a rural economy that subsequently participated in the industrial revolution with the help of colonial rule. After independence in 1947, the country followed socialist policies and hence large-scale infrastructure and industry development was carried out through the public sector. By the early 1990s, the Indian economy was opened up through liberalization and is now on the road to privatization through disinvestment policies. However, the economic growth in India during the 1990s as a result of the 1991 economic reforms has also seen an increase in poverty and a radical transformation in the well-being of the bottom half of the population (Rajeshwari et al., 2005). The consequences of these economic and social changes have led to an epidemiological transition (Joshi et al., 2006). An epidemiological transition is a focus on the complex changes in the patterns between the health and disease and the interaction between them and various other factors such as demograp hic, economic and determinants with their consequences (Omran, 2005). The urban population has increased by 4.5 times during 1951-2001 (WHO, 2000). The life expectancy from birth for males is 62 and females 64 (WHO, 2008). While the crude mortality rate is decreasing the percentage of children under 15 is declining (WHO, 2007). Total expenditure on health per capita (Intl $, 2006): 109. Total expenditure on health as % of GDP (2006): 4.9 (WHO, 2008). The leading cause of mortality after death during childbirth is cardiovascular disease, accounting for 188 deaths per 100,000 population (WHO, 2005). The health care system of India is overseen by two different bodies: The Department of Health Family Welfare. The Department of AYUSH (Ayurvedic, Unani, Siddha and Homeopathic Medicines). Each state has a Ministry of Health Family Welfare although their organization differs from state to state. Generally, there is a Directorate of Health Services providing technical assistance. Some states have a separate Directorate of Medical Education Research, and some have a separate Director of Ayurveda or Director of Homeopathy (WHO, 2007). In rural areas, Community Health Centres serve estimated populations of 100,000 and provide speciality services in general medicine, paediatrics, surgery and obstetrics gynaecology. However, there is still a shortfall in the number of community health centres in the rural areas of India. A Primary Health Centre (PHC) covers around 30,000 people (20,000 in hilly, desert or difficult terrain) and is staffed by a medical officer, and one male and one female health assistant along with supporting staff. A sub-centre serves around 5,000 people (3000 in difficult terrain) and is supported by one male and one female multipurpose health worker. T hese workers and health assistants have different designations in different states. Playing an equally important role in curative and preventive care in urban areas is the private sector. A large number of private practitioners exist and there are many large and small hospitals and nursing homes along with a large number of voluntary organizations providing health care (Bhat, 1993). Chapter One: Literature Review Aims The aim of this review is To analyze the prevalence of CHD in India To analyze the mortality rates related to CHD To understand the aetiology of CHD in India This review will also include a comparison study of the prevalence of coronary heart disease among migrant Indians and the natives of the particular migrant destination countries. Reason for the selection of the topic CHD remains the largest cause of death worldwide. Mortality rates from cardiovascular disease have been known to increase from five-fold to ten-fold around the world (National Institute of Health, National Heart, Lung and Blood Institute, 2000). A World Health Organisation (WHO) Multinational monitoring of trends and determinants in cardiovascular disease (MONICA) study analysed the event rates of CHD among 38 populations between the age group 35-64years, and found variations in CHD prevalence and mortality rates among different ethnic groups (Tunstall-Pedoe et al., 1994). India is a developing country which is seeing an increased rise and prevalence of CHD (Reddy, 2004). While the incidence of coronary artery disease (CAD) has decreased by 50% over the past 30 years in developed countries, in India it has doubled (Kasliwal et al., 2006). Prevalence is an epidemiological measure to determine a how commonly disease or condition occurs in a population, whereas incidence is another epidemiological measure that measures the rate of occurrences of new case of a disease or condition (Le and Boen, 1995). The prevalence of CHD is seen mostly from the age of 35 years and over (Kasliwal et al., 2006). CHD is the second leading cause of mortality in Indians (Patel et al., 2006). Joshi et al., (2006) conducted a survey in the rural areas of Andhra Pradesh, India, the results of which suggested that vascular diseases (including ischemic heart disease and stroke which accounts for 32%) are the main cause of mortality in India when compared to other chronic conditions such as infectious and parasitic diseases, tuberculosis, intestinal conditions, HIV, neoplasm and diseases of the respiratory system. However, CHD mortality rates have decreased in by 50% in most industrialised countries since 1970s (Unal et al., 2004). In United States the decline was seen during the 1980s (US Department of Health and Human Services, 2000), while in the United Kingdom the decline saw a slower pace (British Heart Foundation, 2003). In the United Kingdom the death rates fell by half in the 55-64 age group and slightly less than 40% in men aged 35-44. In women death rates fell by half and a third in those aged 55-64 years and 35-44 respectively (British Heart Foundation- BHF, 2004). However, even though the mortality rates from CHD have fallen it does not suggest that the prevalence has also fallen. The reasons for the decline are not clearly understood but some hypothesise that a reduction in smoking; management for lipid and blood pressure control; modern care for acute coronary syndrome; and secondary prevention has contributed (Luepker, 2008). The increased incidence of CHD has led to the increase in number of Coronary Artery Bypass Grafts (CABG) and other cardiac surgeries. It is estimated that 25,000 CABG surgeries are carried every year in India (World Health Organisation Statistical Information System, 2003). Hence, it could be noted that in a highly populous country like India with its increased prevalence of CHD that the estimated CABG surgeries reaching to the public is actually very few. Therefore, there could be considerable gap between the public need and treatment. Therefore, the reason for this thesis is to help us understand that there is high prevalence in CHD in the Indian population; the specific reasons for this increased epidemic; and how can it be managed so the population can remain healthy. Search strategy The literature was searched with the specific intention of examining the most up-to-date data concerning the prevalence of CAD in India. The search was performed by accessing specialised scientific medical and nursing databases carrying articles regarding the specified subject area (Craig and Smyth, 2002). The databases accessed included the Cumulative Index of Nursing and Allied Healthcare Literature (CINAHL), Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and MEDLINE and EMBASE using the Ovid SP interface. The keywords used for the search were: coronary artery disease, ischemic heart disease, and coronary heart disease, South Asians, prevalence, mortality rate, British white, Caucasians and India. The Boolean term AND was used simultaneously. The date range of the studies targeted was set between 1991 and 2009; and was chosen so the most recent evidence could be drawn on, although articles outside this date limit were also incorporated into the search so as to be able to compare whether there have been any changes in the literature over time. To focus the search more strategically the following inclusion and exclusion criteria below were applied. Inclusion and exclusion criteria used to narrow the search The inclusion criteria include prevalence of CHD in both rural and urban areas in order to compare the prevalence of CHD, the date range was set from 1991-2009 so that the recent evidence could be drawn on. The other inclusion criterions were British Indians, American Indians, migrant Indians and South Asians. The patient age group considered was from 35 years over as this matches the known incidences of coronary artery diseases (Kasliwal et al., 2006). The exclusion criteria were other cardiovascular studies such as peripheral artery disease since the literature review focussed on CAD only. Search Results Initially the search revealed 78 potentially relevant papers; however 48 did not contain data pertinent to the inclusion criteria or were not credible sources. The 30 papers that were used for the review included both qualitative and quantitative studies. They included a wide range of international literature to allow a comparison of the prevalence of CHD between British Indians and British whites. The literature that provided evidence from the Indian health care system were all medical journal articles by authors such as Bhardwaj, 2009; Mandal et al., 2008; Kamili et al., 2007; Chow et al., 2006; Patel et al., 2006; Kuppaswamy and Gupta, 2005; Patel et al., 2005; Sharma and Ganguly, 2005; Ward et al., 2005; Indrayan, 2004; Pinto et al., 2004; Gupta et al., 2003; Gupta and Rastogi, 2003; Gupta et al., 2002; Singh et al., 1997; Gupta et al.s 1997; Dhawan, et al 1996; Gupta et al., 1995; Gupta et al., 1993; Kutty et al. 1992. Journals from UK include Zaman et al., 2008; Whincup et al., 2002; Bhopal et al., 1999; Cappuccio et al., 1997; and Journal from Singapore are Mak et al., 2004; Tai and Tan, 2004; Kam et al 2002; Lee et al., 2001. From the analysis of the above literature the following themes were formulated The prevalence of CHD in the mother country, India, both in rural and urban areas. The reasons for the increase in CHD in India. A comparison of CHD prevalence and mortality rate between British Indians and British whites. Credibility of the Literature In order establish the evidence of increased prevalence of CHD in India it is necessary to analyse a wide range of literature. To assess the credibility and reliability of the evidence, the strengths and limitations of the texts were identified. Systematic reviews were used to determine the strength of the evidence. In the hierarchy of evidence, systemic reviews are considered the golden standard. This is because systemic reviews draw on â€Å"Statistical procedure[s] for combining data from a number of studies and investigations in order to analyse the therapeutic effectiveness of specific treatment or interventions.† (Helewa Walker, 2000, p.111). There was only one systematic review available for this literature review (Bhopal et al., 2000). This research paper has a clear search strategy stated, limits, and selection criteria. The search was limited to English research papers, however one exception was that only published studies reporting original comparative data were included. Unpublished studies and studies only reported as abstracts were not included, which ensures rigour in the analysis of the data by having a complete recount of the different studies; this also ensures that the studies had gone through an evaluation committee before being published. The conclusions reached in the systematic reviews support the conclusions reached across the other literature sourced (Mandal et al., 2008; Gupta et al.,1997). Observational studies are considered a good source of evidence, and are similar to Randomized Controlled Trials (RCTs) in terms of effectiveness, appropriateness, and feasibility of the evidence (Craig Smith, 2002). The studies examined as part of this essay also described the setting, location, and relevant dates, including periods of recruitment, exposure, follow-up, and data collection, thereby increasing their robustness (STROBE checklist, 2008). There was one observational study that mentioned its location, time period and setting, and therefore provided credible evidence for the literature review (Wilkinson, 1996). Most of the studies analysed for the literature review were population based surveys, while some studies were clearly addressed and statistically analysed (Mandal et al., 2008; Zaman et al., 2008; Chow et al., 2006; Patel et al., 2005; Mak et al., 2003; Whincup et al., 2002; Lee et al., 2001; Bhopal et al., 1999; Cappuccio et al., 1997, Gupta et al., 1997; Singh et al., 1997; Kutty et al., 1992) ethical issues were mentioned (Cappuccio et al., 1997; Kutty et al., 1992). Some studies however did not explain their statistical analysis (Bhardwaj, 2009; Pinto et al., 2004), and without knowing the specific characteristics of the statistical analysis, the studies cannot be replicated as evidence in this literature review. In regard to qualitative research, a great deal of debate is still going on regarding how to assess the quality of such work (Sandelowski, 1986). In particular, researchers suggest that it is difficult to develop a single benchmark against which the true value of claims can be judged (Craig Smith, 2002). Even though qualitative studies are not considered excellent or even good sources of evidence, based on evidence-based hierarchy, they can address questions that cannot be answered using other experimental methods (Green Britten, 1998). One qualitative study in the literature was used to examine and compare the illness beliefs of South Asian and European patients with coronary heart disease (CHD) about causal attributions and lifestyle change. The method of sampling and data analysis was appropriate. Although the reviews of the literature accessed for this literature review did not prove as rigorous as other sources of evidence, because they did not draw on empirical data, they were used to support the findings of other more robust forms of evidence, which were generated from systematic reviews, observational studies and survey. Reviews of the literature carried out by Goyal and Yusuf, 2006; Kuppaswamy and Gupta, 2005; Sharma and Ganguly, 2005; Tai and Tan, 2004; Barakat et al., 2003; Yusuf et al., 2001; Reddy et al., 1998 provided evidence, however the paper fails to present a search analysis. Evaluation of key studies The prevalence of CHD in India Coronary heart disease has emerged as an epidemic in India (Gupta and Rastogi, 2003). According to the National Commission and Macroeconomics and Health, Government of India the total number of CHD patients in India by the end of the century was around 30 million (5.3% ) of the adult population; this is forecast to increase to up to 60 million cases (7.6%) by the year 2015 (Indrayan, 2004). Although there are various comparative studies showing the burden of cardiovascular disease among Indian immigrants in Western countries, there has been less attention paid to CHD in India itself (Goyal and Yusuf, 2006, Reddy et al., 2004, Yusuf et al., 2001, Anand et al., 2000). Hence, this section of the literature review will focus on the prevalence of CHD in India. In developed countries, there are no rural-urban differences in the prevalence of CHD (Feinleib, 1995). However in India there is marked difference between the prevalence of CHD in the rural and urban areas with surveys showing that the prevalence rate of CHD in urban areas is about double that rural areas (Gupta et al., 2006; Reddy, 1998; Singh et al., 1996; Singh et al., 1997). Studies have been done in various states of India of the prevalence of CHD in the country. For example, Mandal et al., (2008) conducted a cross-sectional survey among the urban population of Siliguri in West Bengal, from a random sample population aged greater than or equal 40 years, to determine the prevalence of ischemic heart disease and the associated risk factors. The results showed that 11.6% had ischemic heart disease (IHD) and 47.2% had hypertension. Males had a higher (13.5%) prevalence of IHD than females (9.4%). About 5% of the patients had asymptomatic IHD. However, this study had a small sample size, which could limit the generalisability of the findings and is limited by the fact that other risk factors like diabetes and lipids were not included. On the other hand, Kutty et al. (1992) conducted a survey among the rural population of Thiruvananthapuram district in Kerala state, to analyse the prevalence of some indicators of coronary heart disease. The indicators included in the study were ECG changes and well-known risk factors such as obesity, hypertension, smoking and diabetes. From the above criteria it was found that rural Thiruvananthapuram has a lower prevalence of coronary heart disease when compared to urban centres like Delhi. However there were drawbacks to this study too, such as the fact that people were sampled on the basis of household list from the panchayat office (panchayat is south Asian rural political system) so anyone who did not belong to the house list in the panchayat was not included in the study. This could have caused a limitation in the generalisability of the results as there was bias in sampling technique. Similarly, Singh et al., (1997) conducted a cross- sectional survey in two villages in Northern India, which showed a significantly higher and increased prevalence of CHD in urban areas compared to rural areas. Reddy also (1998) conducted a cross-sectional survey which found the prevalence rate of CHD as being 6% in the rural areas of Haryana, India. Another study conducted was in the rural areas of Northern India in Himachal Pradesh which showed a CHD rate of 4.06% among the whole rural population in the age group between 50-59 years with a slightly higher incidence in men than women (Bhardwaj, 2009). However these research papers failed to set out their statistical analysis or research analysis, meaning that the reliability of the papers cannot be measured. Nonetheless, it can be noted that the prevalence of CHD was lower in the rural areas and also that the prevalence rates varied in different states of India. Chow et al., (2006) conducted a survey in the rural areas of Andhra Pradesh to investigate the prevalence of cardiovascular disease and levels of managing the major risk factors. Their results showed that cardiovascular disease is highly prevalent and the community knowledge about cardiovascular disease is quite good. However, the results also pointed out that even though people have the knowledge, their management for risk factors remains suboptimal. Hence it could be suggested that even though the people had good awareness regarding CHD the care provided for them was insufficient. Additionally there were a number of studies done to determine the increase in CHD prevalence in urban areas compared to rural areas of India (Pinto et al., 2004; Gupta et al., 2002; Gupta et al., 1995). However there are limitations to these studies, including such factors as: small and variable samples, low response rates, inappropriate diagnostic criteria, non-specific electrocardiographic changes, a lack of standardization, or incomplete results. Gupta et al.s (1997) survey in a rural area (Rajasthan) found that even though the prevalence of CHD was lower in the rural areas, it had nevertheless increased (to 3.4% in males and 3.7% in females) when compared to previous studies. The study was carried out with a detailed questionnaire prepared according to guidelines from the World Health Organization (WHO) the United States Public Health Service and a based on a review of previous Indian studies. The Performa elicited: family history of hypertension and CHD; social factors such as education, housing, type of job, stressful life events, depression, participation in religious prayer and yoga; along with conventional risk factors such as smoking, alcohol intake, amount of physical activity, diabetes, and hypertension. Blood pressure measurements and a 12 lead ECG using proper standardization were performed on all participants. Earlier studies from India used different criteria and showed higher CHD prevalence. When the diagnostic criteria in the present study are extended to include past documentation, response to WHO-Rose Questionnaire and ST-T wave changes in ECG as done in previous studies, the prevalence rises to a rate higher than those found in previous Indian rural studies. However, the results cannot be validated. For example, some of the previous studies from India included ECG criteria as the presence of left bundle branch block, complete heart block and presence of ST segment and T wave changes while some studies suggest that these findings are not reliable enough to diagnose CHD, especially so in females where ST-T changes may be non-specific (Reddy et al., 1996; Gupta et al., 1993). That said, it is clear evidence that there is still an increasing prevalence of CHD in India. Heart diseases are also occurring in Indians 5 to 10 years earlier than in other populations around the world (Dhawan, et al 1996). According to the INTERHEART study, the median age for first presentation of acute Myocardial Infarction (MI) in the South Asian (Bangladesh, India, Nepal, Pakistan, Sri Lanka) population is 53 years, whereas that in Western Europe, China and Hong Kong is 63 years, with more men than women affected (Yusuf et al 2004) (the INTERHEART study was a standardized case-control study that screened all patients admitted to the coronary care unit or equivalent cardiology ward for a first MI at 262 participating centres in 52 countries throughout the world). Epidemiological studies have shown that immigrant Indians share a significantly higher incidence of CHD than the native populations (Enas et al., 2005; Gupta et al., 2002). The first evidence of this was found in a 1959 study among expatriate Indians in Singapore (Kuppaswamy and Gupta, 2005). Similarly many studies have been done in various other countries to corroborate these findings (McKeigue, 1991; Enas et al., 2005). However, in the UK it is only recently that the importance of ethnicity and disparities in regard to CHD has been realised (British Heart Foundation, 2004). Several studies have reported that there is increased prevalence of CHD in British Indians when compared to British Whites (McKeigue, 1991; Bhopal et al., 1999; Enas et al., 2005). Hence, the review of the literature clearly shows the prevalence of CHD among the urban and rural populations in In

Health industry’s research Essay

Chou et al publication on health coverage and the health industry’s research and data analysis from current population survey has it that; about fifty four percent of United state citizen population had employer’s sponsors health insurance in 2006 with five percent (5%) having non-group insurance and almost sixteen percent (16%) of the total population are currently uninsured, several report shows that these set of people i. . the uninsured people receive less protective care, most of which are diagnosed at more complicated disease stages and tends to be given less beneficial care thus having higher mortality rates (Chou, 2009). The lack of insurance has unpleasant effect on the uninsured populace, regardless, the uninsured faces high out of pocket spending than their insured counterparts. eferencing the report of Bureau of Labor Statics that generally employment will increase about 10% between 2006 and 2016 therefore employment opportunity for homecare aids personnel will raise about 51%, automatically opportunities for physical therapist subordinates are expected to increase, more so, job opportunities for registered nurses will increase by approximately 24% though this statement look promising but what is not clear is, to what degree are these employment in health care associated to insurance coverage (p. 282). Result of research analysis carried out these experts indicates that differences in uninsurance rate exist in the health care labor force the disparities diverges extensively with relevance to the health care industry along with other industries and employees category, for instance employee working in ambulatory unit and residential care are liable to be uncovered hence health care personnel in nursing home and residential situate earn less, this factor can be associated to higher rate in uninsurance. However, most low salary earner cannot meet the expenses of first-class health insurance even when coverage is presented their employer (p. 2285). Chou et al in their final analysis statement affirm differences in uninsurance exist in the United States health care labor force and about 1 out 8 in the healthcare workforce require insurance coverage. Implementing policies distinctively meant to ensure adequate insurance for health care worker will not only aid the workforce but will promote of the health entire citizen (p. 287). Conversely, Das and Das made it clear in their publication â€Å"Health Care in the United States: Why is Price So Sensitive? † that the soaring health care rate has an unpleasant effect on productivity causing a negative impact in production in all industries at large. They added that the inability of consumer to be able to afford better health care was due to declining wages. As a result of this the United States comparative advantage becomes a nonissue (p. 462). Relatively wages increases situation forces the consumer and health care workforce with low income to exhausting a greater portion of their income on health care, obtainable literature could not explain why the rate of health care in the United Sates is increasing and why majority of the populace are not in the insurance network. It is not possible to explain the survey of price insensitivity to health care supply by examining the health care sector only consequently it must look into the interrelationship between health care and non- health care sector on the United States economy. The authors’ uses partial equilibrium model in their studies to explain the lethargic development of health care amid price inelasticity but the model cannot explain why health care supply is in elastic initially. Further disturbing issue relating to increasing health care cost is the high cost of comparative advantage of United States industries through labour productivity of the U. S. research conducts by other professional mentioned in Das and Das publication indicated that health related issue result in lost of economic productivity (p. 463). Further econometric study by the authors show that states with higher per capital health care cost have lower labour productivity in all U. S production industries either health or non health (p. 466). In order to put an end to this effect the authors indicated that partial equilibrium models will not enough rather the use of general equilibrium model should be employed. Conclusively, they derive evidence that health care rate is raising sharply in the U. S making the United States a major spender on health care, it was derived that increasing health care cost provides a negative externality by reducing labour productivity. The investigation provides clarification of the general equilibrium model of the health care and non-health care sector where higher health care rate reduce labour productivity. On the other hand, (Thompson and Cutler 2010), in the Benefits Quarterly, published a report on the health care consumerism movement. The publication was centered on the birth of health care consumerism movement which started as a result of the need to take care of the factors that contributed to the increase in health care costs and the backlash to managed care. According to the authors, the factors include â€Å"lack of consumer awareness of the cost of health care service, the effect of health care on profits and wages, and the need to engage consumers more actively in health care decisions† (p. 24). Additionally, the gaps which they identified included the fact that consumers do not have the required knowledge and education and therefore are disparate participants in the â€Å"provider-patient partnership† (p. 26). They also stated that the regular need of customers to seek expert guidance from professionals when in need of health care information make the customers feel under qualified when trying to determine the value of the required health services. Furthermore, they opined that most consumers would prefer feeling more in charge of the choices that are offered to them after which they identified the need for incentives in order to get the attention of both consumers and providers as one of the gaps in health care consumerism today. The researchers then moved forward to highlight some keys that are vital in sustaining the health care consumerism strategy after which they highlighted the role of the community in ensuring that good health is collectively achieved. In doing this, they emphasized on the importance of the employers incentives, wellness programs and other activities that could boost their employees’ health. The article was concluded by the researchers stating that there should be a communal approach by all the stakeholders in the health care system to better shape and simplifies the consumerism movement. In the same publication as the previously mentioned researchers (Benefits Quarterly), Domaszewicz, Havlin, and Connolly presented an article on health care consumerism as well, but this time, considered incentives, behavior change, and uncertainties. This article was directed at providing some lessons that will serve as a guide for employers who are presently thinking of implementing â€Å"a consumerist approach to improve employee health and control the cost trend† (p. 29), on the necessary courses of action. The researchers asserted to the fact that most organizations would strive to contain costs in all ramifications especially in health care benefits so as to curb the after effects of last year’s global economic meltdown. In order to curtail the effects of this on the employee, Domaszewicz et al. suggested that the employees should employ lower-cost options such as consumer-directed health plans (CDHPs) which are high-deductible plans that contain employee-controlled spending account. The employee-controlled account consists of a health savings account (HSA) or health reimbursement arrangement (HRA). The researchers however claimed that CDHPs are just the beginning and should therefore be followed with a â€Å"robust incentive- and value-based designs for health management† (p. 30). The researchers further highlighted the issues involved in the debate between â€Å"changing behaviors† versus â€Å"changing outcomes† after which they stated the several ways through which the employee can achieve the target of both taking action and achieving positive results. In addition, the researchers averred that incentives could take many forms and therefore recommended the right incentive mix after which they cited a case example. The researchers did not fail to mention the uncertainty that is evident in health care reforms and the measures that employers are taking against it. In summary, the researchers posited that the new strategies carry their own element of risk and as a result, they pointed out a few general lessons that can guide the cause of action. Comparison and Contrast of the Findings Chou et al in their publication investigated the rates of uninsurance amidst employees in the United States health care workforce via the health care industry, its sub category, and workforce. They used the 2004 to 2006 National Health data survey in assessing the rate of health insurance coverage by employing the use of multivariate logistic regression analysis to estimate the probability of uninsured workers in the health industry subtype (p. 2282). On the other hand, Monica Das and Sandwip K.  Das examined the insensitivity of price with regards to health care in the United States as a means of increase health care rate, it’s unpleasant effect and negative impact productivity in all production industries, they formulated a two sector model of the United States economy i. e. the non-health sector and the health sector employed the use of general equilibrium model and econometric model based on interstate production function for the estimation in providing explanation with a two sector general equilibrium model where higher health cost reduces labor productivities in both health as well as non-health sector (p. 72). Both publications were centered on the cost effects of Health Care in the United States. The difference in their manner of approach however, lays in the fact that while Das and Das concentrated on the insensitivity of the price of the supply of Health Care services, Chou et al. focused on the rates of uninsurance. However, Michael Thompson and Charles M. Cutler in their analysis examined the health care consumerism movement taking step forward, considering the rise in health care cost and lack of consumer awareness of the cost of health care services. The publication reviews the movement in health care consumerism and further identifies the gaps within recent health care consumerism; more so, the authors scrutinized the lack of consumer awareness of health care service cost, the effect of health care on wages, the need to engage consumers more actively in health care decisions, what sustainable health care consumerism framework should entail and what role on the community play in the movement of consumerism. From a similar perspective, Domaszewicz, Havlin and Connolly, examined Health Care Consumerism in a different context in their publication, the article focused on incentives, behavior change, and uncertainties. Presented in the article, are the methods of approach for employers thinking of implementing â€Å"a consumerist approach to improve employee health and control the cost trend† (p. 9), the authors however recommended that employees should utilize lower-cost options for instance the â€Å"CDHPs† that control employee-controlled spending account, the account which consists of Health Savings Account or the Health Reimbursement Arrangement and not failing to point out the uncertainty that is evident in health care reforms and the measures that employers are taking against it. The main difference between their manners of approaching the topic is that Thompson and Cutler discussed the birth of the consumerism movement, the gaps present and some effective keys that will enable the development of a sustainable health care consumerism network, Domaszewicz et al. based their publication on the provision of guidelines for helping employers on implementing a consumerist approach that will be of benefit to their employees’ work health. Synthesis  Juxtaposing the findings from the contributions of these articles, it will be observed that the ideas behind what the authors of the four publications centered on the need for the improvement of the health care system as a whole. From the insurance aspect of the health care system, to the general pricing system of health care services, and the health care consumerism movements. The four publications all raised various concerns on the need for better health care for the teeming populace which includes the health care professionals who make the services available and the consumers to whom the health care services are rendered. It should be agreed that increase in health care costs and the effect of health care costs on profits and wages, have an adverse effect in the supply of health care in the United States and unfavorable impact on labor force productivity creating a negative production externality in all industries. The results of the findings presented by the authors have shown that there are evident lapses in some aspects of the present Health Care system and there is a pressing need therefore, to right the wrongs found and presented by these authors.

Adverbs of Time - Definition and Examples

An adverb of time is an  adverb (such as soon or tomorrow) that describes when the action of a verb is carried out. It can also be called a  temporal adverb.  An adverb phrase that answers the question when? is called a temporal adverbial. Examples and Observations Indus father . . . had a textile business and settled in Birmingham, with the intention of returning soon to India. (Ziauddin Sardar, Balti Britain: A Provocative Journey Through Asian Britain. Granta, 2008)This morning, following the decision of the clinic leadership in the meeting last night, we move all seriously injured soldiers and handicapped patients to the Partys school. (Dang Thuy Tram, Last Night I Dreamed of Peace: The Diary of Dang Thuy Tram, 2005. Trans. by Andrew X. Pham. Harmony Books, 2007)Five months ago, after a crab dinner celebrating Chinese New Year, my mother gave me my lifes importance, a jade pendant on a gold chain. (Amy Tan, The Joy Luck Club. Putnam, 1989)Honorà ©: We met at nine.Mamita: We met at eight.Honorà ©: I was on time.Mamita: No, you were late.Honorà ©: Ah, yes, I remember it well.(Alan Jay Lerner, I Remember It Well, 1958)On Thursday We Leave for Home(Twilight Zone episode, 1963)I always thought that Isolde was deep, but now I see that deep dow n shes shallow.(Peter De Vries, The Tunnel of Love. Little, Brown, 1957) Now: Temporal Adverb or Discourse Marker? We are used to thinking about now as a temporal adverb. There is however a use of the word where it is non-temporal and differs in many respects from other adverbs. . . . Now has a number of properties associated with discourse particles. It is short and placed initially in the utterance; it does not belong to the propositional content of the utterance and it has a discourse-organising function. . . .There is . . . a great deal of fuzziness between the particle and the temporal adverb. (Karin Aijmer, English Discourse Particles: Evidence From a Corpus. John Benjamins, 2002) Now as Temporal AdverbNow its time to say goodbye to all our company.Now as Discourse Marker  Now  at that time, the bards were in great favor with the king. Temporal Adverbs and Future Reference The present continuous tense is used to talk about plans and arrangements in the future with a time adverb. Sarah and Harriet are meeting at ten oclock on Tuesday. I am flying to Glasgow on Friday. The present simple tense is used with a time adverb to talk about future plans which are part of a timetable or previous arrangement. The main film starts at 2:45 p.m.We leave at 4:p.m. tomorrow. The future perfect tense (will have the past participle) is used with a time adverb to talk about an action that will be finished at the time in the future you are referring to. I was hoping to meet James, but by the time I arrive he will have gone home. (Collins Easy Learning Grammar and Punctuation. Harper Collins, 2009) Bare Time Adverbs Consider (28): (28) Abdul left this Sunday/last year/yesterday/June 19, 2001. The time adverbs in (28) are locating adverbs--even though they are not introduced by an overt preposition. Take the bare time adverb June 10, 2001. As a locating adverb, it contributes to the temporal interpretation of the sentence in which it occurs, the time interval that it designates, as well as the relation that holds between the designated time (June 10, 2001) and the past time of the event described by the VP ABDEL LEAVE. This relation is one of central coincidence. The bare time adverbs in (28) thus specify that the past time of Abdels departure is contained within the time designated by last year/June 10, 2001. (Hamida Demirdache and Myriam Uribe-Etxebarria, Syntax of Time Adverbs. The Syntax of Time, ed. by Jacqueline Guà ©ron and Jacqueline Lecarme. MIT Press, 2004) The Lighter Side of Temporal Adverbs Sam Marlowe: Perhaps Ill come back tomorrow.Arnie: Whens that?Sam Marlowe: The day after today.Arnie: Thats yesterday. Todays tomorrow.Sam Marlowe: It was.Arnie: When was tomorrow yesterday?Sam Marlowe: Today.Arnie: Oh, sure. Yesterday.(John Forsythe and Jerry Mathers, The Trouble With Harry, 1955)

Essay on Money and Democracy’s Dilemma - 1588 Words

Money and Democracy’s Dilemma Americans hold sacred their freedom over all else and many have fought fervently to protect it even to their own death. Yet our freedom and our protected rights are at odds with the power and influence of money at all levels of government; none more obvious than those in Washington. It is precisely this freedom that makes the concept of interest groups and lobbyists a part of our democracy’s dilemma. In â€Å"The Interest Group Society,† Jeffrey M. Berry and Clyde Wilcox state: The dilemma is this: If government does not allow people to pursue their self-interest, it takes away their political freedom†¦although the alternative- permitting people to advocate whatever they want- is far more preferable, it also†¦show more content†¦In â€Å"The Sound of Money, How Political Interests Get What They Want,† Darrell M. West and Burdett A. Loomis state â€Å"Strong organization and control of financial resources have allowed many interest groups to exercise substantial –even disproportionate- influence in American politics† (205). Those with the most money and deepest pockets have the greatest resources in order to provide favors to legislators. It is with this money and its power that bonds and relationships are created allowing a lobbyist to ask for favors. In turn, these favors result in legislation that benefits the interest group. â€Å"This creates serious problems in terms of representation. To the extent that elected of ficials listen more to or are influenced by those who are wealthy†¦it skews out representational system in favor of the haves over the have-nots† (West and Loomis 229). This means the sector that primarily benefits from interest groups are big businesses. The wealthy corporations attain the most benefits and their self-interests become the forefront in Washington. West and Loomis expand on their point in saying: The dilemma for democracy is that not everyone has equal access to financial resources necessary for often elaborate efforts. If there were rough equity among various interests, money would not be so problematic. However, when a few interests have large amounts of money and many have little, democracyShow MoreRelatedAdvantages And Disadvantages Of Social Contract Theory1351 Words   |  6 PagesThe term social contract represents implied agreements by which people form democracy’s and maintain a social order. This means that the individuals give up some of their rights to a government in order to receive security and social order. The social contract theory rationalizes why it is in one’s best interest to willingly give up their natural rights in order to acquire the many benefits provided by a social structure. I will argue that the social contract theory justifies the concept that stateRead MoreReaction Paper : The End Of Poverty3923 Words   |  16 PagesOctober 2014 Reaction Paper: The End of Poverty The most pressing problem in today’s world that bleeds into other social problems and helps perpetuate them is poverty. When Americans and other Westerners think of poverty it is easy for many to send money to a charity of their choice with knowledge and comfort that they contributed to help better the lives of the poor. Then again it is not difficult either to dismiss the plight of the poor while people lead individualistic lives and adapt an out-of-mind-out-of-sightRead MoreManagement History Essay10156 Words   |  41 Pagesuse of some yardstick of utility (usually money). * Has the ability to choose the alternative that maximizes utility. The concept simply means that a typical person was assumed to make decisions so as to maximize that persons own utility or self interest. Unfortunately, since no one has been able to come up with a better method of measuring utility, self-interest has traditionally been interpreted to mean economic self-interest as measured by money. The economic man assumption of rationalRead MoreOne Significant Change That Has Occurred in the World Between 1900 and 2005. Explain the Impact This Change Has Made on Our Lives and Why It Is an Important Change.163893 Words   |  656 Pagesfrontier populations produced both higher wages and increased opportunities for employment and trade. At the same time, increased commercialization impacted rural relations around the world, creating both the need and the opportunities to spend money earned through the wages of migrants. The growth of commercial agriculture and rural industry also provided an impetus for seasonal rural-to-rural moves.7 In Europe alone, this type 12 †¢ CHAPTER 1 of migration increased nearly ten times