Table 2.

Recommendations to improve CVD health in vulnerable populations

General Principles

Think regionally and globally (Share information, data and success stories; insist on integrating NCDs, including CVD, and their risk factors into larger development and economic agendas/programs; promote cross-sectoral (all-of-society) approaches combining the experience and efforts of multiple government sectors/bodies, civil society, academia, the private sector and international organizations Develop programs that combine population- and individual-level approaches to address the proximate causes of CVD (i.e. smoking, unhealthy alcohol use, diet high in salt, sugar and trans-fats, inadequate physical activity) plus the distal causes or social determinants of health (e.g., issues related to equity, education, gender, migrant status, ethnicity, economic, cultural and environmental factors) Use a life course approach that targets children, youth and future generations (pregnant women) while focusing on vulnerable groups (e.g., the poor, ethnic minorities, migrants, women, etc.) Improve health systems by: a) integrating NCD/CVD prevention and control into primary health care (through training as well as capacity-building), b) strengthening the health sector workforce through training, education and task shifting (more use of non-physician providers), c) integrating the use of m-health to prevent, detect and manage NCDs/CVD risk factors Link research and action by: a) applying evidence-based solutions based on data from surveillance and local/regional research that, b) disaggregating data by such factors as geographic region, level of development (HICs, MICs, LICs), SES, gender and ethnicity

Addressing Proximal Causes of CVD: Smoking
Individual approaches	Provide culturally relevant affordable or free tobacco cessation programs (including diagnosis, pharmacological treatment & counseling) targeted to specific groups (e.g., pregnant women)
Population-wide approaches	Legislation: a) taxes (with proceeds spent on NCD/CVD programs); b) ban smoking in indoor spaces & on public transport; c) ban on advertising & sponsorship, deceptive ads & incentives for products; d) combat illicit trade in tobacco products; e) prohibit distribution/sale of tobacco products in public, especially to minors Information/education/communication (IEC) campaign: a) visible health warnings in print & pictures; b) access to public awareness programs on health risks
Combined approaches	Develop & disseminate locally relevant evidence-based clinical guidelines for healthcare practitioners & program providers → develop, offer & evaluate smoking cessation programs Create viable alternatives for tobacco growers/sellers → provide education & other supports for former growers/sellers
Gender-linked risk	Gender-linked risks (e.g., more males than females smoke; smoking rates risking much faster for females; some gender-specific tasks put females at increased risk of second-hand smoke) so develop gender-specific programs
Ethnicity-linked risk	Tobacco use very high among Aboriginal people in some countries (e.g., Canada, the US), particularly among minors so develop culturally-relevant and age-appropriate programs

Addressing Proximal Causes of CVD: Excessive Alcohol Use
Individual approaches	Provide culturally relevant, affordable or free programs for people with alcohol dependence/addiction (including diagnosis, pharmacological treatment & counseling)
Population-wide approaches	Legislation: a) taxes (with proceeds spent on NCD/CVD programs); b) ban on advertising & sponsorship, deceptive ads & incentives for products; c) combat illicit trade in alcoholic products; e) prohibit distribution/sale of tobacco products in public, especially to minors Information/education/communication (IEC) campaigns on health risks targeted to specific groups (e.g., men, women especially when pregnant, minors, the poor, ethnic minorities) Improve labeling (visible health warnings in print & pictures on packages)
Combined approaches	Develop & disseminate locally relevant evidence-based clinical guidelines for healthcare practitioners & program providers → develop, offer & evaluate alcohol cessation programs Create programs targeting specific groups (e.g., women, minors, ethnic minorities, the poor)
Gender-linked risk	Females at greater risk of undetected alcohol dependency/addiction due to smaller size & sex-specific hormones (so smaller amount of alcohol needed to produce negative effects in females), false perception that excessive alcohol use is a male problem so can be undetected in women, additional risk to unborn child if woman drinks during pregnancy so develop programs for females

Addressing Proximate Causes of CVD: Poor Diet, Suboptimal Levels of Physical Activity
Individual approaches	Programs providing education/counseling & financial support for improved diet for specific groups (e.g., minors, pregnant women)
Population-wide approaches	Legislation: a) require reduced levels of salt, trans-fats and sugar to safer levels in packaged or prepared foods; b) require improved labeling, in text & pictures, to promote healthy food & beverage choices (e.g., colour-code the amount of salt, sugar & fats in beverages & food products: green = acceptable level, yellow = moderately high, red = very high); c) ban on unhealthy foods & beverages sold in schools & workplaces; d) ban on advertising foods & beverages with high levels of salt, sugar & fats; e) taxes on beverages & foods with high levels of salt, sugar &/or fats; f) where possible, subsidize healthier food & beverage options where products or ingredients are sold Information/education/communication (IEC) campaigns on health risks targeted to specific groups (e.g., minors, the poor) Create safe green spaces for increased physical activity Promote sports programs for girls through schools, religious institutions, etc.
Combined approaches	Provide community-based programs to increase public awareness of healthier life choices + pro-exercise groups for harder-to-reach subgroups (e.g., escorted walks for women & girls)
Gender-linked risk	In many societies females have less control over finances and physical movement so should develop programs specifically for females that include healthy diets and increased activity in culturally acceptable ways
SES-linked risk	The poor have less disposable income available for transportation to or shopping in areas providing more expensive, higher quality foods so should develop food security and quality programs that meet their needs