Background Information
Prevalence of non-communicable diseases such as the coronary atherosclerosis and artery diseases has raised concern in public health institutions worldwide. There is a need to establish appropriate interventions that are based on evidences to solve such problems. Evidence-based approaches such as screening instil elements of community engagement, systematic use of data and information, prudent decision-making, and application of programme frameworks in delivery of healthcare.
The process is evaluated at every stage to ensure that long-term decisions and objectives are achieved. Evidence-based approach response entails systematic collection, analysis, interpretation, and presentation of information that pertains to the diseases. This approach aims at reducing mortality rates, creating awareness of the importance of healthy living. The policy enables planning of immediate actions to prevent further infections.
Moreover, it provides information about the health risks that are associated with risky behaviours such as sedentary lifestyles and poor eating habits that augment the risk of developing atherosclerosis. The programme is also carried out to promote health programmes and educate people on the importance of implementing appropriate fitness procedures to preventing coronary infections. This research paper provides a critical analysis of the Stanford Coronary Risk Intervention Project (SCRIP) with a view of providing quality evidence of cardiovascular coronary and arteriosclerosis diseases.
The intervention programme also incorporates activities that reduce and/or change behaviours such as alcohol consumption, smoking culture, and sedentary lifestyle amongst men and women. It promotes activities that target populations that are at higher risks of developing cardiac diseases through exercising, joining working, and conducting campaigns to reduce stress and other problems that are associated with such diseases (China Tuberculosis Control Collaboration, 2004).
Successful implementation of this project requires the government to show its involvement through its various health sectors and other organisations that promote prevention and treatment of cardiac-related diseases. It should also support campaigns that advocate for cessation of tobacco smoking and improvement of health through physical training. According to the China Tuberculosis Control Collaboration (2004), the government has significantly dwindled support towards reducing prevalence of coronary diseases. It has also been supporting various unsuccessful projects in an attempt to control tuberculosis in the region (China Tuberculosis Control Collaboration, 2004).
The policy targeted various towns of the United Kingdom that included Stanford and Wales. According to Makkar et al. (2012), these towns have recorded the highest number of coronary infections in the past few years.
Rationale for the Policy
The purpose of conducting this policy is to monitor problems and risk factors such as smoking and sedentary life that are associated with cardiovascular infections and arteriosclerosis. The policy also provides guidelines for determining the intensity of the diseases and their complications. It also enables monitoring of both pandemic and epidemic infections. In addition, the policy facilitates identification of people who are most vulnerable to the diseases. Furthermore, it outlines procedures of evaluating new public policies and identification of changes in progresses that are meant for curbing the problem and resource allocations.
Theoretical Underpinning
Numerous medical researchers attest that most of the existing methods and activities that pertain to health promotion and early response to cardiovascular and arteriosclerosis diseases are based on evidence-based medical care. McQueen (2001) reveals that epidemiological fields of evidence rules are majorly drawn from proof and notions that are concerned with cause and effects. According to Petticrew and Roberts (2002), randomisation-controlled trials and quasi-experimental trials that are used in medical treatments are viewed as the highest standards of controlling coronary atherosclerosis. However, the designed rules have limited correlations with action-oriented guidelines that are used for health promotion in various disciplines (McQueen, 2001).
The policy outlines evaluation procedures that provide evidences that are beyond reasonable doubt since most cases are based on mere speculations and proposals. These evaluation procedures are aimed at showing the types of proof that are used as frameworks for formulating concrete research hypotheses (Petticrew & Roberts, 2002). The evidence-based evaluation and surveillance should only be incorporated in areas where strengths of evidence are high to draw conclusions and recommendations that pertain to the particular coronary disease under investigation.
As a result, it is recommended that medical researchers should utilise a variety of methods in conducting evaluation and surveillance of cardiovascular and arteriosclerosis cases rather than basing arguments on plain speculations (Tones, 1997). Knowledge of the locality of the problem and its correlation with the available evidence is paramount to arrive at a concrete decision rather than conclusions that are drawn from evidence-based approaches alone.
Researchers also debate about the availability of varying knowledge, composition of evidence, and strengths and weaknesses of the various research methods that are applied in examination of coronary diseases. This situation leads to inconclusive recommendations on the best ways to alleviate the prevalence of such diseases (Petticrew & Roberts, 2002).
Other concerns about evidence-based programmes include their incapability to take into account the experiences of practitioners. The evaluation procedures that are used in evidence-based programmes do not assess the needs of all the populations. In addition, this approach is expensive. Therefore, many people rely on theoretical aspects to deliberate on ways to alleviate prevalence of coronary diseases. For instance, a provider who is not in a position to implement the programme eventually thinks that adaptation methods can be used to complete the research. Most of the theoretical underpinnings of the evidence-based approaches are derived from the field of psychology that majorly deals with the treatment of mentally impaired patients (Petticrew & Roberts, 2002).
Epidemiology of Cardiovascular and Arteriosclerosis Disease
Cardiovascular and arteriosclerosis diseases account for substantial number of deaths globally. Although public agencies together with non-governmental health organisations have made tremendous efforts towards control and treatment, the diseases are still viewed as global health problems. According to the World Health Organisation (WHO), it many people die annually due to development of cardiovascular diseases as compared to other forms of diseases (World Health Organisation, 2011).
An estimated level of 17.3 million people died in 2008. This number was a representation of 30-percent of global deaths. The figure was inclusive of the deaths that were related to stroke, which killed about 6.2 million people in the same year (World Health Organisation, 2011). The World Health Organisation (2011) reveals that about 80-percent of the total number of deaths that are reported annually is almost equal for both men and women who die from cardiovascular illnesses.
Researches indicate that the number of people who die from cardiovascular and arteriosclerosis diseases annually will increase to 23.3 million worldwide by the year 2030. The disease is also projected to remain a leading cause of deaths internationally (Mathers & Loncar, 2006).
Despite the number of deaths that have been caused by cardiovascular and arteriosclerosis infections, various researchers have reveal that the diseases can be prevented by addressing risk factors such as tobacco use, unhealthy diets, obesity, sedentary lives, and high blood pressure among others (Mathers & Loncar, 2006). A report that was released by the World Health Organisation (2008) shows that about 9.4 million deaths are realised each year. Out of this figure, 16.5-percent deaths are due to blood pressure while 45-percent are caused by coronary heart disease.
About 670,000 people in United Kingdom (UK) have been reported to have heart problems heart attacks and other cardiac-related illnesses due to coronary diseases (Swanton, 2006). The prevalence of coronary heart infections has significantly increased amongst the residents of England due to lifestyle factors such as sedentary lifestyles, smoking, and alcoholism. Numerous researchers attest that the number of deaths is projected to rise from 2.4 million to 2.8 million by 2020 (Swanton, 2006).
Studies that have been undertaken to establish the Risk Factors
Individuals are at risk of contracting cardiovascular and/or arteriosclerosis diseases when they are prone to various risk factors such as poor dieting, smoking, and excessive alcohol consumption, and/or sedentary lifestyles among other factors (Haskell et al., 1994).
Several studies attest that other factors such as age, family history, elevated lipid levels, cigarette smoking, diabetes, and/or hypertension among others are substantial risk factors that escalate prevalence of cardiovascular infections. However, cigarette smoking and diabetes are more likely to cause either of the conditions than any of the other factors. The studies further reveal that dyslipidemia is also associated with cardiac diseases due to elevated levels of triglycerides and cholesterols in the body (Hiatt, Hoag, & Hamman, 1995).
Various studies that were conducted to investigate cardiac illnesses among men and women indicate that novel factors such as lipoproteins, apolipoproteins, and fibrinogens among other causal agents enhance the prevalence of cardiovascular diseases (Ridker, Stampfer, & Rifai, 2001). Other studies indicate that genetic risk factors that cause arteriosclerosis can be hereditarily determined. A study that was conducted by Framingham Heart Study suggested that 50-percent of various abdominal calcifications (an arteriosclerosis marker) are genetic (O’Donnell et al., 2002).
A separate study that was carried out by Ridker et al. (2001) showed that there is a link between chronic infections and cardiovascular diseases. Periodontal infections enhance the risk of a patient to contract cardiovascular diseases due to increased gram-negative species bacteria, detectable cytokines, inflammatory infiltrates, and association between fibrinogens and white blood cells (Kinane, 1998). Bacteria in the mouth trigger pathways that lead to development of cardiovascular diseases (Haskell et al., 1994).
Evidence shows that Streptococcus sanguis and Porphyromonas gingivalis induce aggregation of platelets that further leads to thrombus production (Herzberg & Meyer, 1996). The organisms have proteins on their surfaces that induce heart attack. Antibodies that react to the organisms localise in the heart. This situation triggers activation of T-cells that increase the likelihood of a heart attack (Herzberg & Meyer, 1996). Studies show that 42-percent of atheromas that are studied in patients with periodontal infections indicate Porphyromonas gingivalis adhere and attack the walls of endothelial cells. This situation triggers development of cardiovascular diseases (Deshpande, Khan, & Genco, 1998).
Level of Evidence on the Cost-Effective Interventions
To cut costs on interventions effectively, clear measurements of natural units must be noted. Deliveries of interventions that are cost-effective require cooperation between institutions and organisations that are concerned with healthcare systems. Factors such as equity, social justice, medical provision, and epidemiological examinations must be applied in allocation of resources (Cookson & Dolan, 1999).
Cost-effective ratios should be used to establish cut-offs that cannot be surpassed by the interventions. Such ratios vary amongst different places and regions with respect to health services that are delivered in such areas, disease burden, and spending preferences. The WHO describes less spending as a situation where individuals utilise a smaller amount of money that does not exceed 100 US dollars in healthcare. This trend is mostly noted in poor and/or developing nations (Cookson & Dolan, 1999). Another way of using cost-effective means for health interventions is enabling policy makers establish favourable trade-offs.
The evidence-based intervention aimed at activities such as reduction of tobacco smoking, encouraging physical activities, and advising on proper dieting. This intervention incorporated two levels. The first level included the community where activities were carried out in school, workplaces, and open forums to educate, train and create awareness of healthy dieting and anti-smoking habits among others.
At level two, the focus was on individuals. This level entailed delivery of clinical prevention services that included screening, counselling, chemoprophylaxis, examination of lipoproteins and cholesterols, measurements of heart rates, and systolic and diastolic analyses among others. Other interventions that target various age categories have been planned to curb behavioural factors such as smoking and alcohol consumption in an attempt to lessen the prevalence of cardiovascular, arteriosclerosis, and other coronary infections.
Preventions Aiming Youths
Promotion of school education programmes on tuberculosis that is caused by smoking cigarettes can delay prevalence of cardiac-related diseases. This strategy poses minimal costs of prevention and treatment of such diseases to governments and other stakeholders. Although the strategy is relatively easier to implement, its overall impact is minimal. Another intervention programme is restriction of smoking in schools. However, the efficacy of the method is unknown but the cost incurred is minimal. Its effective implementation can also be difficult but it is required for setting up examples (Doll & Crofton, 1996).
Interventions Aiming Adults
According to Doll and Crofton (1996), advising smokers in clinics decreases the prevalence of smoking and increases the number individuals who quit usage of cigarettes. The method is a low-cost approach as compared to other interventions. It can be implemented in recommended places such as hospitals and clinics among other health institutions. Another intervention method is the use of telephone in advising smokers to quit using cigarettes. The method has lowered the prevalence of cardiovascular diseases by 19-percent in a six-month period in Scotland during a mass campaign to sensitise people on the consequences of cigarette smoking (Doll & Crofton, 1996).
Another method is restriction of smoking in public and workplaces. This method is effective on reduction of tobacco consumption. However, there is minimal data to indicate its effect on the prevalence of cardiovascular and atherosclerosis. In addition, a minimal cost is incurred in health sectors when the method is implemented. The method should be used to protect non-smokers against long-term effects that can occur due to inhalation of tobacco smoke from burning cigarettes.
Lastly, advertisement through media is highly effective in controlling smoking. However, its efficacy is a bit controversial (Doll & Crofton, 1996). Education on matters that pertain to hygiene was also used to sensitise individuals on the importance of taking good care of the mouth and teeth to prevent oral infections. Doll and Crofton (1996) reveal that patients with oral diseases have increased risks of contracting cardiovascular infections because they develop gingivitis that causes bacteraemia.
Evidence of the Intervention within the Setting
Clinical events, lifestyle changes, and use of lipid-altering medications resulted in improvement of the risk reduction profiles when a comparison was done between data that was obtained from the physicians of various individuals. The reduction resulted in further positive angiographic processes of coronary atherosclerosis and hospitalisation for clinical cardiac events. The risk reduction event also promoted attendance of patients to the intervention that was held at least in every 2 and 3 months.
Rationale for Intervention in Health Sector
Prevalence of cardiovascular and atherosclerosis interventions enable caregivers to train on matters that pertain to coronary diseases, their causes, prevention, and related healthy behaviours. The caregivers further create awareness to family members, infected patients, and volunteers who further spread information about the training. Interventions also pave way for treatments and establishment of various referral mechanisms. Therefore, it leads to intensification of the findings on prevalence and modes of treatment.
Mechanism for Implementation of the Intervention
Successful implementation of evidence-based approach such as screen and angiographic reduction of coronary and cardiovascular prevalence is accomplished through incorporation of partnership work and community engagement. Various factors that were considered included screening and angiographic application among others. The inclusion of such factors led to effective implementation of the evidence-based approach. As a result, there was a need to involve partners to ensure efficient handling of such cases. Implementation of the evidence-based approach in the community included various phases that are discussed below.
Establishment of Infrastructure
Collaboration and communication are crucial for managing cases of coronary and cardiovascular infections amongst researchers, stakeholders, and the communities that are involved. This phase encompassed identification of reliable partners, clear definition or duties and responsibilities, securing of funds for dissemination, and implementation of the approach. Combination of all these phases brought together stakeholders. This situation enhanced consensus that enabled accomplishment of goals and needs of the affected population (Layde et al., 2012). Partnership enabled distribution of resources, power, and decision-making by researchers and community-based organisations. It also gave guidelines on procedures of solving problems and ownership policies.
Gathering of Information
Information based on evidences were gathered by identifying patients who had heart-related diseases, materials and procedures, community-based practices, and contextual factors with a view of carrying out research on the community stakeholders. Identification of relevant practices was considered to meet the needs of the population at higher risks. Information was also obtained from the identified and tested research via reviews, articles, community partners, and stakeholders among other sources (Hawe, Shiell, & Riley, 2004). Formative research to study various determinants of cardiovascular and atherosclerosis diseases entailed interviews with personal physicians, focus groups, and field observations (Nápoles-Springer et al., 2009).
Synthesis of Information
This phase involved a review of the evidence-based approach, community practices, and integration of results from formative research into the intervention. Identification of various features of evidence-based approaches and practices that are reviewable and synthesisable was also carried out (Nápoles-Springer et al., 2009). The process also involved building of consensus by enhancing frequent meetings and forums to address the underlying problems of the diseases. Other factors that were considered included status of the individuals, their cultures, and lifestyles.
At the personal level, mechanisms such as randomisation of the subjects to be included in the research, screening of the patients to increase their eligibility, and recruitment of the subjects were applied. Clinical measurement was done at an interval of three weeks after hospital discharge to evaluate the risk factors prior to randomisation. A coronary segmentation was also inculcated to ensure comparable measurements to arrive at qualified segments. This form of segmentation was enhanced through computer-assisted quantification to check on accuracy, design, and precision. A follow-up was frequently done on arteriography.
Building of Capacities and Delivery Processes
Community capacity will be ensured during implementation of various programmes that are geared towards interventions. Training of community providers will also be done for effective delivery of duties. Implementation of intervention programmes to curb prevalence of cardiovascular, atherosclerosis, and other coronary diseases was done through establishment of processes and plans for delivery and feedback mechanisms amongst the parties involved (Nápoles-Springer et al., 2009). Technical assistance was also provided to ensure that all the processes run effectively.
Evaluation
Various evaluation designs were used to assess the overall process of evidence-based approach and design (Nápoles-Springer et al., 2009). Combinations of qualitative and quantitative processes of evaluation were used in baseline evaluation and were linked to the implementation processes.
Resources those were required for the implementation of intervention included financial resources to acquire equipment for effective diagnosis and treatment. Human resources over and above infrastructure and supplies were needed to ensure smooth management, operation, and diagnosis of the underlying conditions and education. The various stakeholders that were involved in the implementation of the interventions against cardiovascular diseases included public health sectors, researchers, community stakeholders, physicians, the University management among others (Nápoles-Springer et al., 2009).
Barriers that are encountered during the Implementation of Intervention
The management of cardiovascular and coronary diseases prevention and intervention was hectic due to ignorance amongst the infected individuals who were reluctant towards healthy living and behaviour change. Another barrier was inconsistent adherence to medications amongst the patients. Efficient implementation of intervention was also derailed due to biasness and stigmatisation towards obese patients and those who had other complications such as HIV infections.
Internal barriers that were faced mostly by the patients included inadequate time, cultural characteristics, personal experience, lack of motivation, fatigue, boredom, and disbelief that change interventions can bear fruits in their lives. For instance, the act convincing obese patients to consume less fatty foods is hectic to be implemented by the individuals.
Another barrier was development of interpersonal relationships amongst friends. Unbecoming friendships encourage unhealthy behaviours such as smoking and alcohol consumption. Differences in food preferences make diets difficult to change. Interpersonal barriers also enhance unhealthy eating. Environmental factors include difficulty in accessing sufficient quantities of high-quality foods at low prices. This situation results in poor dieting. Barriers were personally addressed to encourage individuals to avoid wrong assumptions. For instance, a professional can conclude that cultural background is a cause of poor eating habit.
Good governance is paramount to effective implementation of successful approaches to curb the prevalence and increasing spread of cardiovascular and atherosclerosis diseases amongst world’s nations. Public advocacy and campaigns should also be enhanced to address effects of stigmatisation and the importance of drug adherence for effective treatment. Education and training should be provided to people who are at a higher risk of contracting cardiovascular diseases should be enhanced. Lastly, the government should advocate for healthy lifestyles such as promotion of non-smoking lifestyle, healthy eating, and heavy taxation on cigarettes that do not promote risk factors that enhance cardiac-related diseases.
Knowledge Gaps
Although researches have been conducted to examine ways of preventing cardiovascular and coronary diseases, there is a need to study the relationship between evidence and practice especially in poor nations. Another area that needs to be addressed is knowledge and experiences of the physicians and technicians who handle such cases. Moreover, this study did not include patients who have chronic complications such as kidney diseases.
Tremendous researches have been done to find medications to lower cholesterol level and high blood pressure. Drugs such as polypills reduce the risk of coronary related diseases to a reasonable level and are currently administered to patients. Gene and cytokines therapies are also done as alternatives to angioplasty and bypass surgeries. Nonetheless, these researches should be conducted further to establish surety of such interventions.
Implications of Interventions to Vulnerable Groups
The most vulnerable groups include obese and diabetic patients, HIV-infected persons, drug users and alcoholics, cigarette smokers, and people who are prone to sedentary lifestyles among others. These people carry the burden of such diseases and can have difficulty in accessing various healthcare services.
To manage effective equality and equity, the various activities for surveillance considered various population categories separately. For instance, control and care among children, good health services for sedentary patients, and guidance on life changing behaviours among alcoholics, drug users, and smokers.
Ethical issues were applied to minimise discrimination through provision of social justice by producing benefits, prevention of harms, and maximisation of utility (Childress et al., 2002). Addressing the socioeconomic issues of the patients and family at the diagnostic stage enabled a quick detection of barriers to treatment adherence. A holistic approach was also applied to the achievement of universal access to higher quality diagnosis and patient-centred treatment (Childress et al., 2002).
Impacts of the implementation of the Intervention
The impacts of the intervention implemented on the prevalence of cardiovascular and coronary diseases revealed a variety of infection differences among men and women of different age categories. The results also showed indicators of burden and an evidence of realising a substantial reduction of cardiovascular and atherosclerosis disease prevalence.
Evaluation of the intervention
The evaluation of the intervention was initiated immediately when the programme started and carried out throughout the whole process for effective implementation in an attempt to achieve objectives using both qualitative and quantitative approaches. A baseline evaluation enabled determination of the elements of the intervention. This plan focused on the effectiveness of materials and communication. It also enabled feasibility of the intervention. Evaluation during the process ensured proper programme implementation (Shadish, 2006).
The impact evaluation that was conducted also ensured that the objectives that can lead to a change in knowledge and attitude among others were achieved. The use of tested measures such as computer-assisted quantitation ensured validity and reliability of the implemented policy. An outcome evaluation was conducted to ensure long-term feedback on changes in health status of cardiovascular, atherosclerosis, morbidity, mortality, and provision of equitable services.
The various systems that were put in place to monitor the impacts of interventions on the stakeholders included standardised recording of individual data that entailed information about treatment outcome, diagnostic information, and the use of technology to enhance confidentiality (Shadish, 2006). This information enabled evaluation of the performance of the implemented intervention. The impacts that were easily noted include the epidemiological burden of the diseases and their trends. Additionally, the impact indicator showed that new cases and mortality were measured to reveal the progress of control. An evaluation of extent to which the intervention had lowered the impacts of the disease was also done (Shadish, 2006).
Conclusion
Various interventions have been used to curb problems that are associated with non-communicable diseases such as cardiovascular, atherosclerosis, and other coronary disorders through treatment and creation of awareness about the risk factors. To achieve the goals of prevention and reduction of prevalence of various such cases, evidences of when and how the implementation of intervention is required in a particular setting is crucial. These evidences promote better implementation of interventions to similar cases.
Evidence of coronary diseases in a context is more reliable than the use of suggestions that are based on theoretical and/or recorded information about a certain illness. Inclusion of various ways and evidences are paramount to solve public health problems in a wider area rather than exclusive reliance on evidence-based approaches. More research on information about combination of methodologies should be done to enhance effective implementation of interventions since adherence to single approaches such as the evidence-base technique is both expensive and tedious.
Reference List
Childress, J., Faden, R., Gaare, R., Gostin, L., Kahn, J., Bonnie, R.,…Kass, N. (2002). Public health ethics: Mapping the terrain. Journal of Law, Medical & Ethics, 30(2), 170-8.
China Tuberculosis Control Collaboration. (2004). The Effect of Tuberculosis Control in China. Lancet, 364(9432), 417-22.
Cookson R., & Dolan, P. (1999). Public Views on Health Care Rationing: A Group Discussion Study. Health Policy, 49(12), 63-74.
Deshpande, R., Khan, M., & Genco, C. (1998). Invasion of aortic and heart endothelial cells by Porphyromonas gingivalis. Infection and immunity, 66(11), 5337-43.
Doll, R., & Crofton, J. (1996). Tobacco and health. British Medical Bulletin, 52(1), 1-4.
Haskell, W.L., Alderman, E.L., Fair, J.M., Maron, D.J., Mackey, S.F, Superko, H.R.,…Williams, P.T. (1994). Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease. The Stanford Coronary Risk Intervention Project (SCRIP). Circulation, 89(3), 975-90.
Hawe, P., Shiell, A., & Riley, T. (2004). Complex interventions: how “out of control” can a randomised controlled trial is? BMJ Journals, 328(7455), 1561-3.
Herzberg, M.C., & Meyer, M.W. (1996). Effects of oral flora on platelets: possible consequences in cardiovascular disease. Journal of periodontology, 67(10), 1138-42.
Hiatt, W., Hoag, S., & Hamman, R. (1995). Effect of diagnostic criteria on the prevalence of peripheral arterial disease: The San Luis Valley diabetes study. Circulation, 91(5), 1472-9.
Kinane, D.F. (1998). Periodontal diseases’ contributions to cardiovascular disease: an overview of potential mechanisms. Annals of periodontology, 3(1), 142-50.
Layde, P., Christiansen, A., Peterson, D., Guse, C., Maurana, C., & Brandenburg, T. (2012). A model to translate evidence-based interventions into community practice. American Journal of Public Health, 102(4), 617-24..
Makkar, R., Smith, R., Cheng, K., Malliaras, K., Thomson, L., Berman, D.,…Marbán, E. (2012). Intracoronary cardiosphere-derived cells for heart regeneration after myocardial infarction (CADUCEUS): a prospective, randomised phase 1 trial. The Lancet, 379(9819), 895-904.
Mathers, C., & Loncar, D. (2006). Projections of global mortality and burden of disease from 2002 to 2030. PLoS medicine, 3(11), 442.
McQueen, D. (2001). Strengthening the evidence base for health promotion. Health Promotion International, 16(3), 261-8.
Nápoles-Springer, A., Ortis, C., O’Brien, H., & Diaz-Mendez, M. (2009). Developing a culturally competent peer support intervention for Spanish-speaking Latinas with breast cancer. Journal of Immigrants and Minority Health, 11(4), 268-80.
O’Donnell, C., Chazaro, I., Wilson, P., Fox, C., Hannan, M., Kiel, D.,…Cupples, L. (2002). Evidence for heritability of abdominal aortic calcific deposits in the Framingham Heart Study. Circulation, 106(3), 337-41.
Petticrew, M., & Roberts, H. (2003). Evidence, hierarchies, and typologies: horses for courses. Journal of Epidemiology and Community Health, 57(7), 527–9.
Ridker, P. M., Stampfer, M. J., & Rifai, N. (2001). Novel risk factors for systemic atherosclerosis: a comparison of C-reactive protein, fibrinogen, homocysteine, lipoprotein (a), and standard cholesterol screening as predictors of peripheral arterial disease. Jama, 285(19), 2481-85.
Shadish, W. (2006). The common threads in programme evaluation. Web.
Swanton, R.H. (2006). The National Service Framework: six years on. BMJ Health, 92(3), 291-2.
Tones, K. (1997). Beyond the randomised controlled trial: a case for a judicial review. Health Education Research, 12(2), 1-4.
World Health Organisation (2008). The global burden of disease: 2004 update. Geneva: World Health Organisation.
World Health Organisation, (2011). Global status report on non-communicable diseases 2010. Geneva: World Health Organisation.