7 / 68
CARDIOVASCULAR JOURNAL OF AFRICA • Volume 30, No 3, May/June 2019
AFRICA
135
to benefit. This is the highest unmet need of any WHO region,
which is concerning given the projected accelerated increases in
incidence of CVD (Figs 1, 2). In African countries without CR,
unmet need is greatest in Ethiopia (138 477 IHD patients/year
need spots), Sudan (111 063) and the Democratic Republic of
Congo (82 818 IHD patients), among others.
14
Table 2 displays key characteristics of African CR
programmes.
15
Most CR programmes were offered in an urban
context (83%). Most were hospital based (39%; Table 2),
and offered through a physical medicine and rehabilitation
department (17%). All CR programmes were funded privately.
Programmes had on average almost five staff [most commonly
dietitians, followed by exercise specialists (e.g. biokineticists),
physiotherapists, and administrative assistants] (Table 2).
Programmes in Africa served significantly fewer patients per
staff member than programmes in other WHO regions.
14,15
In terms of the type of indications accepted for CR,
15
in
Africa, acute coronary syndrome and stable coronary artery
disease patients were universally accepted, followed by heart
failure (88%), cardiomyopathy (88%), percutaneous coronary
intervention (81%), valve procedures (81%) and congenital
patients (81%), among others (rheumatic heart disease, 63%).
Other chronic conditions/indications (high-risk/primary
prevention, diabetes and cancer) were significantly more often
accepted than in other WHO regions.
Initial assessment, management of risk factors, structured
exercise (although inherent to the inclusion criteria), patient
education, end-of-programme re-assessment, and communication
with primary care were offered by all African programmes,
but nutrition counselling (75%), stress management (67%),
tobacco-cessation interventions (53%) and return-to-work
counselling (47%) were not as commonly offered (shown by
country elsewhere).
15
An average of eight ‘core’ components (of
11) were offered, over a median ‘dose’ of 32 sessions. During
initial assessment, all the major risk factors were universally
assessed, except diet (88%), blood glucose level (88%), depression
(81%) and lipid levels (75%). Over 80% of programmes used an
exercise stress test, with 93% using another functional capacity
test (six-minute walk test).
Eighty per cent of African programmes fulfilled the 20
structure and process indicators (e.g. assessment of risk factors),
which were assessed in the survey (shown elsewhere).
15
While
this is acceptable, it was the lowest of any WHO region.
One programme offered alternative models, including home-
based and smartphone-based delivery. The greatest barriers
reported by the respondents were: lack of patient referral (11/18
Table 2. Key characteristics of responding CR programmes identified in Africa
Country,
n
Context,
n
Hospital-
based, %
Funding
source,
n
Direct cost to
patient (mean
± SD; PPP) Who refers?
n
Core components delivered,
n
Most common disciplines
on team,
n
Dose (
n
sessions);
mean ±
SD
Algeria, 1
NA
NA NA
NA
NA
NA
NA
NA
Kenya, 1
Urban
100
Private
$1 598
Physician
Initial assessment
Risk assessment
Exercise prescription
Patient education
Management of CVD risk factors
Nutrition counselling
Stress management
Smoking cessation
Secondary prevention medications
Communication with primary care
Physiotherapist
12
Mauri-
tius, 1
Urban
100
Private
NA
Physician
Allied HCP
Initial assessment
Risk assessment
Exercise prescription
Management of CVD risk factors
Nutrition counselling
Stress management
Secondary prevention medications
Communication with primary care
Exercise physiologist
NA
Nigeria, 1
Urban
100
Private
NA
Self-refer
Physician
Initial assessment
Risk assessment
Exercise prescription
Patient education
Management of CVD risk factors
Nutrition counselling
Stress management
Smoking cessation
Secondary prevention medications
Communication with primary care
Physiotherapist
32
South
Africa, 14
Urban, 12
Suburban, 2
29
Private, 13
Hybrid
§
, 1
$1 251
± $1 063
Self-refer, 13
Physician, 14
Allied HCP, 10
CHCW, 6
Insurer, 3
Initial assessment, 13
Risk assessment, 12
Exercise prescription, 13
Patient education, 11
Management of CVD risk factors, 12
Nutrition counselling, 9
Stress management, 7
Smoking cessation, 6
Secondary prevention medications, 9
Communication with primary care, 13
Missing, 1
Sports physician, 6
Exercise physiologist, 3
Physiotherapist, 2
Rehabilitation physician, 1
Nurse, 1
NA, 1
36
±
25
CHCW, community healthcare worker; CVD, cardiovascular disease; HCP, healthcare professional; NA, not available; PF, patient funded; PPP, purchasing power parity
(2016 $USD
27
);
§
private and public.