https://doi.org/10.33698/NRF0221- Unnas,Kavita, J.S.Thakur, Sandhya Ghai, Sushma K.Saini
Abstract : Background Cardiovascular diseases (CVDs) are the primary cause of death in India and worldwide. Most of CVDs are preventable. CVD risk assessment is an approach which can be used to identify people at high risk of developing CVDs by using World Health Organization/ International Society of Hypertension (WHO/ISH) CVD risk prediction charts. Objective : To assess risk of the developing CVDs and prevalence of their risk factors among adult (age 40 years). Methods : A cross sectional study was conducted in rural area availing the health services from various health institution of the Chandigarh. Total 414 adult (age 40 years) were screened by using purposive sample techniques for the CVD risk assessment. The necessary information was obtained by using a pre tested questionnaire and participants were also subjected to anthropometric measurements which included height, weight and waist circumference. WHO/ISH CVD risk prediction charts for the SEAR-D was used to assess the CVD risk among the study subjects. Results : The mean age of the participants was 51.12 ±9.6 years. Most (88.8%) of the adults were female and only 11.83% were male. Nearly 3% of the subject were having high risk and majority of (80.4) subject having low risk of developing CVDs in future. In addition, CVD risk factors were alcoholism (3.9%), smoking (9.9%), Diabetes (15.9%) and hypertension (34.3%) were identified among participants. Conclusion It was concluded that most of the study population was at low risk and very few subjects were at high risk of developing CVDs in future.
Keywords
CVD- Cardiovascular diseases WHO/ISH- World Health Organization/ International Society of Hypertension
Correspondence at
Mrs. Kavita
Lecturer
National Institute of Nursing Education (NINE) PGIMER, Chandigarh.
Mail: gaurikavita@rediffmail.com
Introduction
Globally, there was about 17.9 millions death occurred due to the cardiovascular diseases in 2015. This is rose by 12.5% between the time periods of 2005 to 2015.1 It is estimated that the hypertensive heart diseases will increase to about 60% (1.56billion) by 2025.2 Most of the CVDs are preventable. Risk factor modification can reduce clinical events and premature death in people with established cardiovascular disease as well as in those who are at high cardiovascular risk due to one or more risk factors. WHO provides evidence-based pocket guidelines on how to reduce the WHO/ISH risk prediction charts. In addition CVD risk factors like smoking (32%), alcoholism (53%), Low High- Density incidence of first and recurrent clinical events Lipoproteins (HDL) (56.3%)cholesterol due to cardiovascular diseases. A cross- (61.5%) were observed among study cultural, cohort study shows that for a long participants.6
A cross sectional study was time that dietary and lifestyle interventions are only of importance for primary prevention.3 Cardiovascular disease risk assessment is the approach that has been proven to indicate a person’s chance of having cardiovascular diseases such as heart attack or stroke in future. Risk assessment tools estimate the people’s 10 years risk of developing cardiovascular diseases (CVDs). There are various tools for CVD risk assessment like as Joint British Society cardio vascular disease risk prediction chart, WHO/ISH CVD risk prediction chart and Framingham risk score table/ chart, The QRISK2 calculator, Joint British Societies’ Coronary risk prediction chart, ETHRISK calculator etc. 4 The World Health Organization/International Society of Hypertension (WHO/ISH) risk prediction charts used to estimation of absolute 10 years CVD risk assessment of the people for primary prevention of the cardiovascular diseases. These charts indicate 10-years risk of a fatal or non fatal major cardiovascular event (Myocardial infarction or stroke).5
There are many studies which had shown the absolute 10 years CVD risk assessment using by WHO/ISH CVD risk prediction charts done successfully. A cross sectional study to estimate the CVD risk by using WHO/ ISH chart done by Ghorpade et al in south India. This study covered 570 adults aged above 40 years. The mean age of the subject was 54.2 years and 53.3% subjects were women. Seventeen percent of the participant had moderate to high risk for the occurrence of cardiovascular events by using conducted by Priya et al to find out CVD risk in bus drivers by using waist to height ratio and WHO/ISH risk prediction charts. The study was conducted on 200 bus drivers. All the participants of the study were male with a mean age of 44.53 years. The result of study shows that 90% study subject had CVD risk <10%, 6% had 10-20%,3% had 20-30% and only one percent subjects had risk ≥40 %.7
As shown above paragraphs there is a high burden of CVDs and WHO/ISH CVD risk assessment charts are helpful to stratify the population as low, moderate and high risk of developing CVDs in future. The action was taken earlier for primary prevention of these diseases after screening the population. In this way both economic and disease burden will be reduced to some extent. So the need was felt to assess the CVD risk by using WHO/ISH CVD risk prediction charts in rural area of Chandigarh.
Objectives
To assess the risk of CVDs and prevalence of their risk factors among adults (40 years).
Material and Methods:-
A cross sectional study was conducted at various Anganwadi centres of Dhanas, UT, Chandigarh. Dhanas located at 5.4 km from ISBT-17 and 3.5 Km from PGIMER, Chandigarh. The approximate population of Dhanas complex is 72853 (2015-2016) as per AWWs record. Research setting (Dhanas) was selected purposively because this area is nearby the PGIMER, Chandigarh. Out of total population 414 adults (age 40 years) were screened for CVD risk by using purposive sampling technique. Ethical approval was institute ethics obtained from Institute Ethical Committee and written permission was taken Social Welfare Department.
The interview schedule and physical assessment methods were used to collect the data. The interview schedule comprised of three parts i.e. (A) Socio-demographic profile sheet of Adults (B) Personal history and medical history (C) WHO/ISH CVD risk prediction charts:-These charts are standardized tool which were developed by WHO/ISH to CVD risk assessment. These charts indicate 10-years risk of a fatal or non- fatal major cardiovascular event (myocardial infarction or stroke) according to age, sex, blood pressure, smoking status, total cholesterol and presence or absence of diabetes mellitus for 14 WHO epidemiological sub-regions. There are two sets of charts. One set can be used in setting where blood cholesterol level can be measured and another chart used where cholesterol level is not measured because of economic resources limitation. WHO divide Asia in to two region- SEAR-D and SEAR-B region. India comes in SEAR-D region. So we used SEAR-D without cholesterol WHO/ISH CVD risk prediction charts in this study. Before applying these charts the following information is necessary- status of diabetes, gender, smoking status, age, systolic BP and total blood cholesterol level. For calculation of CVD risk prediction nine steps should be followed, which are selection of charts depending on diabetes status, gender table, smoker or non smoker boxes, age group box, cell in the box where systolic blood pressure find and calculate risk according to color of this cell. Physical measurement sheet includes height, weight, central obesity, body mass index and blood pressure measurement.
Procedure of data collection:-
- Written informed consent was taken from each adult who visited Anganwadi centres and explain about the procedure of CVD risk
- After their consent first reading of the blood pressure was We used an automatic blood pressure machine (OMRON HEALTH CARE Co., Ltd. Kyoto, Japan) for blood pressure measurement. Blood pressure was measured in right upper arm in supine position or sitting on a chair with back straight and with arm resting on a table at the level of heart with appropriate size of cuff. Two reading of BP were taken and mean of two reading was taken for CVD risk assessment. After 5-6 minute second reading of blood pressure was taken and mean of both reading was used for the CVD risk assessment.
- History of the socio-demographic, personal history and clinical profile was collected by using interview
- Height, weight and waist circum-ference were taken. The height was measured in centimeters with the help of a measuring tape in standing position with subject’s shoes and socks removed prior to Waist circumference was measured at a level midway between the lowest rib and the iliac crest using measuring tape. Subjects with a waist circumference of>102 cm (male) >88cm (female) were have abdominal obesity. Body mass index also calculated to determine the level of the obesity of the adult. The study subjects were classified as underweight (<18.99kg/m2), normal (18.99- 24.99kg/m2), overweight (25- 29.99kg/m2) and obese (>30kg/m2).
- After collected the data, CVD risk assessment was done by using WHO/ISH CVD risk prediction
- At the end calculated risk was communicated to the subject and health education was provided for the prevention of the cvd
- Operational definition:-
Smoking was defined as the use of the any smoke form of tobacco products in last one year. The adult was considered diabetic if he/she was on orally anti hypoglycemic medication. Subjects were considered as hypertensive if systolic blood pressure was ≥140 mm Hg and diastolic blood pressure ≥90 mm Hg or taking antihypertensive medication.
Descriptive and inferential statistics was used to analysis data that was presented in the form of tables and graphs. Data collected was analyzed by using descriptive and inferential statistics with the help of SPSS (SPSS version 20.0).
Result
The socio-demographic variables of the adult (age ≥ 40 years) revealed that most (88.80%) of the adults were female and only 11.83% were male. More than half (52.2%) of study subjects were in the age group of 40- 49 years. Only 6.5% study subjects were more than 70 years of age. Majority (76.6%) of study participants were Hindu. Only 8% study subjects belongs to Muslim religion. Most of the (84.3%) subjects were married, 64.5% subjects were illiterate, only 0.7% study subject had post graduation education qualification. Almost all (99.8%) study subjects not had any type of professional education. Majority (82.1%) of study subjects were working as housewife. Out of all only 3.9% study subjects were working in professional organization. Almost all (91.1%) study subjects were undertaking moderate type of work. Socioeconomic status was categorized as per B.G. Prasad socioeconomic scale8. More than one third (38.1%) study subjects come under SES-IV. Nearly one fourth participants come under SES-III and SES-V class (Table 1).
Table 1: Socio-demographic profile of the subjects enrolled for CVD risk assessment, Dhanas, Chandigarh
N=414
| S.N. | Variables | Total |
| 1. | Gender | |
| Male | 049(11.83) | |
| Female | 365(88.66) | |
| 2. | Age (Years)* | |
| 40-49 | 216(52.2) | |
| 50-59 | 102(24.6) | |
| 60-69 | 069(16.7) | |
| ≥70 | 0270(6.5) | |
| 3. | Religion | |
| Hindu | 317(76.6) | |
| Muslim | 035(08.5) | |
| Sikh and others | 062(15.0) | |
| 4. | Marital status | |
| Current Married | 349(84.3) | |
| Never Married / Widowed / Divorced | 065(15.7) | |
| 5. | Educational qualification | |
| Illiterate | 267(64.5) | |
| Metric | 122(29.5) | |
| Higher Secondary | 012(02.9) | |
| Graduate | 010(02.4) | |
| Post Graduate | 003(00.7) | |
| 6. | Professional education | |
| Yes | 001(00.2) | |
| No | 413(99.8) | |
| 7. | Occupation | |
| Professional | 016(03.9) | |
| Skilled Worker | 020(04.8) | |
| Unskilled worker | 032(07.7) | |
| House wife | 340(82.1) | |
| Unemployment | 006(01.4) | |
| 8. | Type of work | |
| Sedentary | 020(04.8) | |
| Moderate | 377(91.1) | |
| Heavy work | 017(04.1) | |
| 9. | Per capita income as per | |
| Prasad’s SES classification57 | ||
| SES-I(>6277 Rs) | 019(05.2) | |
| SES-II (3139-6276) | 027(07.4) | |
| SES-III (1883-3138) | 099(27.1) | |
| SES-IV (942-1882) | 139(38.1) | |
| SES-V (<942) | 081(22.2) |
*Mean age± SD (Range) years, 51.12 ±9.60 (40-80)
* Mean Per capita Income± SD (Range) Rs. 2161.94±2775.77 (Rs233-35000)
*SES- Socioeconomic status
*Figure in parentheses are percentages
Table 2 shown the distribution of the CVD risk among adults. The results revealed that most of study subjects were having low risk (<10%) and very few subjects had high risk of developing cardiovascular diseases in next 10 years as calculated by using WHO/ISH CVD risk prediction charts.
Table 2: Distribution of 10 years absolute CVD risk among adults as per WHO/ISH CVD risk prediction chart.
N=414
| S.N | CVD risk category as per WHO/ISH risk prediction charts | Male
N-49 n(%) |
Female
N-365 n(%) |
Total | X2/ Fisher’s test, df
P-value |
| 1. | <10% | 39(79.6) | 294(80.5) | 333(80.4) | 2.031#, 4, |
| 2 | 10-20% | 09(18.4) | 48(13.2) | 57(13.8) | 0.769 |
| 3 | 20-30% | 01(02.0) | 17(04.7) | 18(4.3) | |
| 4 | 30-40% | —- | 03(00.8) | 3(0.7) | |
| 5 | ≥40 % | —- | 03(00.8) | 3(0.7) |
Table 3 depicts prevalence of risk factors of cardiovascular diseases among adults (Age ≥ 40 years). Nearly 10% of the study subjects were smoker while 3.9% were alcoholic. Diabetes mellitus was found in15.9% with the mean year duration ± SD (Range) 5.19±3.9 (1- 21 years). Nearly one sixth subjects were already on anti hypertensive medication with the mean duration ± SD (Range) 5.24±5.1 (1-30) years. Only 5.8% adult females were found with history of premature menopause. 2.2% subjects were family history of the heart diseases. Two third (60.4%) of the subjects had central obesity with mean waist circumference (Range) 94.93±12.64 (55-140) centimeter. Approximate one third subjects were overweight as calculated by body mass index.
Table 3: Prevalence of CVD risk factors among adults (age ≥40 years) enrolled
for CVD risk assessment. N=414
| SN | CVD Risk factors | Total | |
| 1 | Smoker | 041(09.9) | |
| 2 | Alcoholic status | 016(03.9) | |
| 3 | Vegetarian | 244(58.9) | |
| 4 | Diabetic | 066(15.9) | |
| 5 | On Antihypertensive medication | 066(15.9) | |
| 6 | Premature menopause (n= 365) | 024(06.5) | |
| 7 | History of Heart diseases | 09(02.2) | |
| 8 | Central obesity | 250(60.4) | |
| 9 | Body Mass index | ||
| Overweight (Pre-Obese) | 134(32.4) | ||
| Obese-I | 064(15.5) | ||
| Obese-II | 016(03.9) | ||
| Obese-III | 02(00.05) | ||
| 10 | Systolic BP (mm/Hg) | ||
| Pre-HTN (120-139) | Mean Systolic BP±SD (Range) 125.60±20.20 | 142(34.3) | |
| HTN-I (140-159) | (84.5-206.5) mm/Hg | 71(17.1) | |
| HTN-II (160) | 24(5.8) | ||
| 11 | Diastolic BP (mm/Hg) | ||
| HTN (80-89) | Mean Systolic BP±SD (Range) 78.83±10.47 | 129(31.2) | |
| HTN-I (90-99) | (55-117) mm/Hg | 44(10.6) | |
| HTN-II (100) | 18(4.3) | ||
Table 4 depicts association of different CVD risk factors with absolute CVD risk as calculated by WHO/ISH risk prediction charts. There were three risk factors which were statically associated (p<0.005) with risk of cardiovascular diseases in next 10 years as per calculated by using WHO/ISH CVD risk prediction chart (Dietary pattern, Diabetes mellitus and hypertension). Rest of CVD risk factors (type of work, smoking, alcohol, premature menopause, histor y cardiovascular diseases in family, central obesity and overweight) were not significantly associated (p>0.05) with absolute 10 years cardiovascular diseases risk.
Table 4: Association of Absolutely 10 years CVD risk prediction with CVD risk factors among adults age ≥40 years.
N=414
| S.N. Variable | Absolute 10 years CVD risk |
Total |
X2/ Fisher’s test, df P-value |
||
| Low
<10% |
Medium (10-20%) | High (>20%) | |||
| 1. Type of work | |||||
| Sedentary | 14(70.0) | 4(20.0) | 2(10) | 020 | 5.32#, 4, |
| Medium | 300(79.6) | 54(14.3) | 23(6.1) | 377 | 0.233 |
| Heavy | 17(100) | 0(0.0) | 0(0.0) | 017 | |
| 2 Smoking status | |||||
| Smoker | 31(75.6) | 7(17.1) | 3(7.3) | 041 | 0.886*, 2, |
| Non smoker | 300(80.4) | 51(13.7) | 22(5.9) | 373 | 0.627 |
| 3 Alcoholic status | |||||
| Yes | 13(81.2) | 2(12.5) | 1(6.2) | 016 | 0.219*, |
| No | 318(79.9) | 56(14.1) | 24(6.0) | 398 | 2, 0.984 |
| 4 Dietary pattern | |||||
| Veg. | 182(74.6) | 42(17.2) | 20(8.2) | 244 | 11.072*, |
| Non-Veg. | 149(87.6) | 16(9.4) | 5(2.9) | 170 | 2, 0.004 |
| 5 Diabetes status | |||||
| Yes | 46(69.7) | 12(18.2) | 8(12.1) | 066 | 6.533, |
| No | 285(81.9) | 46(13.2) | 17(4.9) | 348 | 2, 0.039 |
| 6 On Anti Hypertensive Medicine | |||||
| Yes | 40(61.5) | 13(20.0) | 12(18.5) | 065 | 20.271, |
| No | 291(83.4) | 45(12.9) | 13(3.7) | 349 | 2, 0.001 |
| 7 Premature Menopause (n= 365) | |||||
| Yes | 20(95.2) | 1(4.8) | 0(0.0) | 021 | 4.381#, |
| No | 272(79.1) | 48(14.0) | 24(7.0) | 344 | 4, 0.103 |
| 8 History of CVD | |||||
| Yes | 5(55.6) | 3(33.3) | 1(11.1) | 009 | 4.159*, |
| No | 326(80.5) | 55(13.6) | 24(5.9) | 405 | 2, 0.115 |
| 9 Central Obesity | |||||
| Yes | 200(80.0) | 33(13.2) | 17(6.8) | 250 | 0.90, |
| No | 131(79.9) | 25(15.2) | 8(4.9) | 164 | 2, 0.630 |
| 10 Body Mass Index | |||||
| Underweight (≤18) | 25(69.4) | 10(27.8) | 1(2.8) | 036 | 9.973*, |
| Normal (18.99-24.99) | 132(81.5) | 24(14.8) | 6(3.7) | 162 | 6, 0.113 |
| Over weight (25-29.99) | 108(81.2) | 14(10.5) | 11(8.3) | 133 | |
| Obese (≥30) | 66(79.5) | 10(12.0) | 7(8.4) | 083 | |
Statically significant if p<0.05, * Yete’s correction test
*Figure in parentheses are percentages
Table 5 has shown the association of CVD risk with socio-demographic profile of the study subjects. There was no significant association (p>0.05) between the selected socio- demographic variables (gender, religion, educational qualification, professional education, occupation and per capita income) and absolute 10 years CVD risk. Only age and marital status were significantly associated (p<0.05) with the CVD risk in next 10 years as per calculated by using WHO/ISH CVD risk prediction charts.
N=414Table 5: Association of 10 years absolute CVD risk with Socio-demographic profile of study subjects enrolled by AWWs.
N=414
| S.N. Variable | Category |
Total |
X2/ Fisher’s test, df P-value |
||
| Low
<10% |
Medium (10-20%) | High (>20%) | |||
| 1. Age (Years) | |||||
| 40-49 | 206(95.4) | 10(4.6) | 0(0.0) | 216 | 115.714#, |
| 50-59 | 83(81.4) | 12(11.8) | 7(6.9) | 102 | 6, 0.001 |
| 60-69 | 35(50.7) | 21(11.8) | 13(18.8) | 069 | |
| 70 | 7(25.9) | 15(55.6) | 5(18.5) | 027 | |
| 2. Gender | |||||
| Male | 39(79.6) | 9(18.4) | 1(2.0) | 049 | 2.020* , |
| Female | 292(80.0) | 49(13.4) | 24(6.6) | 365 | 2, 0.326 |
| 3. Religion | |||||
| Hindu | 260(82.0) | 40(12.6) | 17(5.4) | 317 | 6.729*, |
| Muslim | 29(82.9) | 4(11.4) | 2(5.7) | 035 | 4, 0.134 |
| Sikh and others | 42(67.7) | 14(22.6) | 6(9.7) | 062 | |
| 4. Marital Status | |||||
| Married | 291(83.1) | 43(12.3) | 16(4.6) | 350 | 14.310, |
| Widowed / Divorced / Never Married | 40(62.5) | 15(23.4) | 9(14.1) | 064 | 4, 0.001 |
| 5. Educational status | |||||
| Illiterate | 211(79.0) | 39(14.6) | 17(6.4) | 267 | 1.157#, |
| Up to 10th | 097(79.5) | 17(13.9) | 08(6.6) | 122 | 8, 1.000 |
| Above metric | 023(92.0) | 02(08.0) | 00(0.0) | 025 | |
| 6. Professional Education | |||||
| Yes | 1(100) | 0(0.0) | 0(0.0) | 001 | 1.773 #, |
| No | 330(79.9) | 58(14.0) | 25(6.1) | 413 | 2, 1.000 |
| 7. Occupation | |||||
| Professional | 14(87.5) | 2(12.5) | 0(0.0) | 016 | 8.167#, |
| Skilled | 20(100) | 0(0.0) | 0(0.0) | 020 | 8, 0.317 |
| Unskilled | 25(78.1) | 6(18.8) | 1(3.1) | 032 | |
| House wife | 268(78.8) | 48(14.1) | 24(7.1) | 340 | |
| Unemployed | 4(66.7) | 2(33.3) | 0(0.0) | 006 | |
| 8. Per capita income (Rs) | |||||
| SES*-1 | 15(68.2) | 5(22.7) | 2(9.1) | 022 | 6.558* , |
| SES-2 | 27(81.8) | 4(12.1) | 2(6.1) | 033 | 8, 0.560 |
| SES-3 | 85(78.7) | 16(14.8) | 7(6.5) | 108 | |
| SES-4 | 126(78.3) | 23(14.3) | 12(7.5) | 161 | |
| SES-5 | 78(86.7) | 10(11.1) | 2(2.2) | 090 | |
Statically significant if p<0.05, SES- Socioeconomic status, #- Fisher’s exact test, *- Yate’s correction tes
Discussion
Cardiovascular diseases are the primary cause of death worldwide. These diseases are those which are related to blood vessels and heart muscles. It is estimated that 17.9 million people died from cardiovascular diseases globally in 20151 In India, among top five causes, CVDs are the first cause of mortality.9 Most of the cardiovascular diseases caused by risk factors that can be controlled, treated or modified. So these diseases are preventable if identified in early stage. It is supported by a case control study done by Kromhout D et, that approximately 80% of the CVDs related mortality and morbidity is preventable by exercise, healthy dietary habits, maintaining a healthy body weight and avoiding smoking.3
CVD risk assessment is an approach which is used to screen the people for primary prevention of CVDs. WHO/ISH CVD risk prediction charts can be used for this purpose. These charts are easy and inexpensive tool for screening the people for CVDs. There are many studies which has shown that absolute 10 years CVD risk assessment can be done successfully by using WHO/ISH risk prediction charts. Screening for CVDs also emphasized under national programme for prevention and control of cancer, diabetes, cardiovascular diseases and stroke but for effective implementation of which require adequate health man power. Among 414 adults assessed for CVD risk prediction, mostly were females. It is because of the data was collected between the time 9 AM to 4 PM. In this time period most of the men had gone to their working places and women were available at home. So the number of females was higher in this study. More than half of the adults were in the early middle adult age group and very few subjects were older adult. Most of the population residing in this area was migratory population. They leave their elderly in their village. So the older people were enrolled in this study were less in number compare the middle age adult. Most of the adults were married because inclusion criteria was adults aged 40 years and at this age most of the adults are already married. Most of them had low level of education. It may be because majority of the subjects had migrated from rural areas for the job and in rural areas the literacy rate is lower than urban areas. Majority of the subjects were undertaking petty job which include household labor and labor works. Almost all adults were undertaking moderate type of working activity because household work also comes under this category. They were from lower socio- economic status.
The common belief is that the CVD risk is high in low socioeconomic/ socially deprived population. The present population was of low income status and risk of absolute 10 years was low <10%). It is because of most of the subjects were physically active and early middle age (40- 49 years) group. A very few subjects had a high risk (<30%) of the CVDs in 10 years. In present study higher percentage of females were in high risk group than males. Common risk factors of CVDs are central obesity, obesity, Diabetes mellitus, hypertension, smoking and alcohol consumption and similar risk factors were observed in present study. Similar study reported the prevalence of CVD risk factors among supportive staff of JSS hospital which indicated higher prevalence was of hypertension following diabetes mellitus, and tobacco consumption. The prevalence of CVD risk factors higher in current study compared to this study. It may be due to previous study was under taken among hospital staff and were aware of regarding primary prevention of CVDs diseases and their risk factors. The literature reveals that religion, marital status, educational status, professional education, occupation is not associated with the risk of developing of the cardiovascular diseases and in present study results had also shown that there was no association between 10 years absolute CVD risk with these variables. Educating the people about life style modification is important for prevention and management of the CVDs.
It was concluded that most of the study population was at low risk and a few subjects were on high risk of fatal or nonfatal CVDs in future. It was recommended that community health workers like as ANM can utilized these charts for mass screening in the community for primary prevention of the CVDs.
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