ORIGINAL

Cardiovascular Health in a Single ABSTRACT

Community in Rural Haiti: A Cross- Introduction

There is a growing burden of cardiovascular disease in
sectional Study low- and middle-income countries and assessment of
Vincenzo B. Polsinelli1,2, Ketheline Rock Dantil2, Vincent cardiovascular health (CVH) may identify populations at
DeGennaro3, Darius L. Fénelon4, Dufens Pierre Louis4, risk for poor CVH.
Joseph L. Izzo Jr.5, Gene F. Kwan6,7 Methods
Between July 2014 and August 2014, we performed a
1
Department of Medicine, University of Pittsburgh Medical household survey from a convenience sample among
Center, Pittsburgh, Pennsylvania adult community members in rural northern Haiti. We
2
Friends of Fontaine, Fontaine, Haiti used a modified World Health Organization STEPwise
3
Innovating Health International, Port-au-Prince, Haiti approach to chronic disease questionnaire to capture self-
4
Zanmi Lasante, Haiti reported data on tobacco, diet, physical activity, and
5
Department of Medicine, Jacobs School of Medicine and diabetes, and measured blood pressure and body mass
Biomedical Sciences, Buffalo, New York index. We used an adapted American Heart Association
6
Section of Cardiovascular Medicine, Boston University definition and thresholds for determining ideal,
Medical Center, Boston, Massachusetts intermediate, and poor cardiovascular health. We used
7
Department of Global Health and Social Medicine, linear and logistic regression to examine associations
Harvard Medical School, Boston, Massachusetts between socio-demographic characteristics with CVH
score and ideal CVH.

Results
Corresponding Author:
Among 540 participants (mean [SD] age = 40.3 [17.1]
Vincenzo B. Polsinelli, MD
years, 67% women), there was a high prevalence of poor
Resident, Internal Medicine
CVH (n=476, 88.1%) compared with intermediate (n=56,
Department of Medicine
10.4%) and ideal (n=41, 7.6%) CVH. Ideal metrics for
University of Pittsburgh Medical Center
blood pressure (47%) and diet (26%) were least often
[email protected]
met, while body weight (84%), physical activity (83%),
and smoking (90%) were most often met. Men were
associated with better CVH score (0.31, [0.04–0.59];
DOI: doi.org/10.48107/CMJ.2021.07.01
P=0.03), and being a farmer was associated with ideal
Copyright: This is an open-access article under the terms CVH (P=0.006).
of the Creative Commons Attribution License which
Conclusion
permits use, distribution, and reproduction in any
In this community-based sample of a farming community
medium, provided the original work is properly cited.
in rural Haiti, very few adults had ideal CVH. Higher CVH
©2021 The Authors. Caribbean Medical Journal published score was associated with male sex, and farming as a
by Trinidad & Tobago Medical Association primary occupation. Women and non-farmers may
represent at-risk subgroups within this population. Blood
pressure and diet may represent possible areas for
improvement.

Keywords: Haiti; Cardiovascular Health; Cardiovascular

disease epidemiology; Hypertension.

CMJ | Published online on July 25th, 2021 1

INTRODUCTION members were living and working away from home, they
were not sampled.
Haiti is the most impoverished nation in the Americas and
has a high burden of cardiovascular disease (CVD)
We used a modified step 1 and 2 of WHO STEPwise
including hypertension, diabetes, and heart failure.1-5 In
approach to chronic disease questionnaire.10 Routine
Haiti, ischemic heart disease and cerebrovascular disease
STEPwise questions were used to obtain information
are estimated to be the top two causes of death.6 One
pertinent to CVH including daily fruit and vegetable
strategy to reduce CVD is primary prevention by
intake, physical activity by Global Physical Activity
improving cardiovascular health (CVH). CVD incidence
Questionnaire, tobacco use, and self-reported diagnosis
and mortality is lower when a set of health behaviors
of hypertension, diabetes, and cardiovascular diseases.
(smoking, healthy diet, body mass index [BMI], and
Anthropometric measurements were obtained in each
physical activity) and health factors (blood pressure,
participant’s home. Height was measured on a flat
cholesterol, and glucose) are at ideal levels.7, 8 Identifying
surface with the participant standing upright without
areas of improvement in CVH may inform policymakers
shoes using a tape measure and clipboard. Weight was
and guide interventions to promote CVH through
measured with electronic scales (Seca 803, Chino, CA) on
screening and public health initiatives. The Haiti Mortality,
a flat, hard surface; participants were permitted to wear
Morbidity and Service Use Survey (EMMUS-VI 2016-2017)
light clothing but no shoes. Brachial oscillatory blood
reported a high prevalence of CVD risk factors like
pressure and pulse were measured three times using an
hypertension and diabetes, with low health service
automated device (Omron BP785 10 Series, Lake Forest,
utilization. Studies comparing CVH in low- and middle-
Illinois) after the participant was sitting at rest for at least
income countries may have region specific needs to
5 minutes with arm, back, and feet supported. The mean
reduce CVD, for example although in much of the world
of the three measurements was used. Scales and blood
men are at greater risk of ischemic heart disease than
pressure devices were calibrated by the manufacturer but
women, there is no sex difference observed in sub-
not by the study team. Blood glucose samples were not
Saharan Africa, underscoring the need for regional data.9
taken.
Therefore, obtaining data at a regional level is extremely
important for public health officials to make appropriate We adapted the AHA definition for ideal, intermediate,
guidelines and recommendations. The objective of this and poor CVH to categorize the study population.11
manuscript is to report the CVH of a community sample Definitions of each category are outlined in Table S1.
of rural Haitians to identify the prevalence of ideal CVH Each of the six available metrics were allocated a score of
and subpopulations at greatest risk. 0 (poor), 1 (intermediate), or 2 (ideal) based on
convention.11 Three categories, smoking, diet, and
METHODS diabetes, were allocated a score of 0 or 2 because data
on recent tobacco cessation and impaired fasting glucose
From July 2014 to August 2014, we obtained a
were not collected, diabetes was self-reported. Ideal CVH
convenience sample of 572 community-based participants
was defined as full achievement of all factors (CVH score
at their homes in Fontaine, a town of approximately
= 12 out of 12). Intermediate CVH is defined as a
10,000 people in northern Haiti. A private hospital and
participant having at least one intermediate metric, and
non-profit clinic is available approximately 8km away, and
no poor metrics. Poor CVH is defined as having at least
the primary economic activity is farming. Research
one poor metric.
assistants trained by one of the investigators (V.
Polsinelli) conducted interviews in Haitian Creole, the To determine differences in CVH score between sexes,
locally spoken language. Every household within a 3-5 we used X 2 for categorical variables, Student’s t-tests for
square kilometer radius of the town center was offered continuous variables and Wilcox rank sum for non-
participation in the study. Subjects at least 18 years of parametric data. Univariate (model 1) and multivariate
age were selected through a non-random voluntary basis (model 2) linear regression were used to examine
in each household, members of the household who were associations between demographic characteristics and
not present were re-visited at a later time. If household CVH score, and ideal CVH. Model 1 is age adjusted linear

CMJ | Published online on July 25th, 2021 2

regression of the independent covariates, and model 2 is Prevalence of ideal (green), intermediate (yellow), and
age adjusted and adjusted for all other listed covariates. poor (red) cardiovascular health metrics overall, and by
A two-sided P value < 0.05 defined statistical category is separated by sex. Percentage of the total men
significance. All statistical analyses were performed using or women is on the x-axis. Significant sex differences
Stata version 12 (StataCorp, LLC, College Station, Texas, were observed in the categories of blood pressure, body
USA). The Comité National de Bioéthique, Haiti and the weight, and smoking (P<0.05) †.
Health Sciences Institutional Review Board of the State
The mean ± SD CVH score was 9.1 ± 1.6 overall in the
University of New York at Buffalo approved the study. We
sample. Within the total cohort we observed a difference
obtained informed consent from all participants.
in CVH score by sex, 9.3 ± 1.5 among men and 9.0 ± 1.7
among women (P = 0.004). We evaluated the association
between social and demographic determinants and total
RESULTS
CVH score using multivariable regression—shown in the
Among the 572 participants interviewed, complete Table 1. After adjustments for age, the female sex was
information for CVH determination was available in 540 associated with worse CVH score. After adjustments for
participants. The number of individuals screened was not educational achievement and occupation, there were no
recorded, but participation in study was high (estimated observed associations with social and demographic
>95% of those invited participated). Participants’ mean characteristics. After adjustments for age, sex, and
(SD) age was 40.2 (17.1) years, and 66% were women. educational achievement, being a farmer was associated
Only a minority completed secondary school (11%). Men with ideal CVH (ß =2.38 (0.69 – 4.08; P=0.006).
compared with women were more often farmers (116
[62%] vs. 34 [9%]; P<0.001) less likely homemakers (4 DISCUSSION
[2%] vs. 189 [51%]; P<0.001). Smoking was more In this convenience sample of a rural agrarian community
common in men (30 [16%] vs. 30[8%], P=0.005). Mean in northern Haiti, we described the distribution of CVH
± SD daily fruit or vegetable servings was 3.8 ± 1.6 for among Haitian adults, and several population
men and 4.0 ± 2.0 for women (P=0.17). Men reported characteristics associated with ideal CVH. Among all
more weekly metabolic minutes (MET-minutes [IQR]) of surveyed adults, we observed a very low prevalence of
physical activity than women (11340[4800 – 23030] vs ideal CVH of 7.2%. Several ideal CVH metrics were more
4320[960 – 12000]; P<0.0001). There was no difference common among men compared to women, and an
in systolic blood pressure (mmHg) between men and occupation of farmer was associated with ideal CVH.
women (123.1 ± 19.7 vs. 123.8 ± 27.1; P=0.76). These data may help inform public health officials in rural
However, we observed a lower diastolic BP in men Haiti to develop programs aimed at improvement of CVH.
compared to women (78.1 ± 12.4 vs. 82.2 ±15.4;
P=0.001), lower BMI (20.4 ± 2.9 vs 22.1 ± 4.4; Among our study participants, low smoking prevalence
P<0.0001). Fewer men were obese (1.6% vs. 6.3%; and smoking differences between men and women were
P=0.015). similar to other studies in Haiti.2, 6 Comparing our data to
a 2018 study from rural Haiti, the current study’s
The prevalence of ideal, intermediate, and poor CVH was prevalence of overweight or obese was close to the
7.2%, 9.8%, and 83.1% respectively and there were no reported estimate of 18%.2 Thus, these measurements of
differences by sex (P=0.6). Prevalence by each metric is body weight appear consistent with rural lifestyle. Very
shown in the Figure 1. Overall, ideal CVH metrics were few participants, (3% women; 2% men) had self-
more often observed among men compared to women. A reported diabetes. This prevalence is likely an
greater proportion of men had ideal CVH metrics for underestimate due to ascertainment bias as other studies
blood pressure, body weight, and physical activity more utilizing fingerstick random glucose or hemoglobin A1c
often (P<0.02). One exception is smoking, as fewer measurements have reported diabetes prevalence
women reported smoking tobacco compared to men ranging from 5% to 20%.2, 5, 6 EMMUS-VI observed a
(P=0.005). There were no differences for diabetes or relationship in diabetes prevalence and socioeconomic
diet. position. They observed diabetes prevalence to be lower

CMJ | Published online on July 25th, 2021 3

Figure 1. Distribution of cardiovascular health by sex

for people in the lowest vs highest socioeconomic quintile lower prevalence of diabetes.
for both women (11% vs. 18%) and men (5% vs. 10%),
Our reported prevalence of ideal CVH of 7.2% is several-
though the data from EMMUS-VI was based on an age
fold higher than other countries, including the United
range of 35 to 64, which is different than our studied
States (0.1%) and Ghana (0.3%), although we used a
sample. Other studies have observed high prevalence of
different scale in the current study.7, 14, 15 By each
food insecurity, and associations of food insecurity with
category, achievement of ideal CVH metrics was most
illiteracy, poverty, less diverse diet, and death from
often met within smoking, physical activity, diabetes, or
cholera.12, 13 Thus, it is possible that regional food
BMI, and least often met within the hypertension and diet
insecurity may explain our findings of lower BMI and
categories. These trends are similar to what has been

CMJ | Published online on July 25th, 2021 4

 Table 1. Linear and logistic regression of covariates as predictors of CVH score and Ideal CVH. All co-
variates adjusted for age.

N (%) Model 1 Model 2 Model 1 Model 2

Linear re- Linear regres- Logistic Logistic regres-

gression sion sion
regression
ß-Coeff. ß-Coeff. ß-Coeff.
ß-Coeff.
95% CI 95% CI 95% CI
95% CI
(n=519) (n = 472) (n = 467)
(n=519)
Covariate CVH score Ideal CVH
Sex 519
Female 350 0.31* -0.03 -0.15 -0.95
(67.4%)
(0.04 – 0.59) (-0.42 – 0.35) (-0.86 – 0.56) (-1.96 – 0.06)
Education 472
No formal 156 Ref. Ref. Ref. Ref.
education (33.1%)
Less than -0.56 -0.35
0.08 0.04
primary 120
(-1.52 – 0.41) (-1.36 – 0.65)
school (25.4%) (-0.29 – 0.46) (-0.35 – 0.43)
Primary -0.05 -0.10 -1.28* -0.78
144
school
(30.5%) (-0.44 – 0.35) (-0.52 – 0.31) (-2.34 – -0.22) (-1.89 – 0.34)
Secondary 0.61* 0.53 -0.50 0.18
52
school
(11.0%) (0.09 – 1.13) (-0.03 – 1.08) (-1.65 – 0.65) (-1.08 – 1.44)
Occupation 509
Employed 68 Ref. Ref. Ref. Ref.
(13.4%)
Farmer 124 0.35 0.43 1.88* 2.38*
(24.4%)
(-0.96 – 0.80) (-0.09 – 0.94) (0.35 – 3.42) (0.69 – 4.08)
Student 72 0.13 0.15 0.38 0.62
(14.2%)
(-0.38 – 0.63) (-0.38 – 0.68) (-1.31 – 2.08) (-1.13 – 2.37)
Homemak- 179 -0.16 -0.05 1.06 0.93
er (35.2%)
(-0.57 – 0.26) (-0.49 – 0.38) (-0.46 – 2.59) (-0.61 – 2.48)
Retired 66 -0.31 0.17 1.33 1.32
(13.0%)
(-0.82 – 0.19) (-0.70 – 0.37) (-3.48 – -0.22) (-0.39 – 3.02)
*P < 0.05, **P < 0.001, Model 1: Individual covariates are adjusted for age and not with other covariates
listed. Model 2: Covariates are adjusted for age and all other covariates listed (Sex, Education, Occupa-
tion).

observed in rural Ghana.14 Many lifestyle characteristics observed burden of heart failure and estimated burden of
are optimized for ideal BP (low BMI, high level of physical ischemic heart disease and stroke in Haiti.4, 16, 17
activity); however, BP control levels are low.1 Thus
This study observed relevant trends with social and
improving access to medications to lower BP treatment
demographic characteristics. After adjustment for all
may contribute to improved CVH in this population. Our
other covariates, farmers were more likely to have ideal
findings of low ideal CVH are consistent with the high
CMJ | Published online on July 25th, 2021 5
 Table 2. Definitions of cardiovascular health metrics, as adapted from the American Heart Association’s 2020 Strate-
gic Impact Goals Committee.11

Overall CVH ≥ 1 poor metric ≥ 1 intermediate 12 ideal metrics

metric and 0 poor
metrics
Smoking Active smoker - Non-smoker
Physical Activity No Physical Activity 1–149 min/wk of mod- 150 min/wk of moder-
erate intensity, 1–74 ate intensity, 75 min/wk
min/wk of vigorous in- of vigorous intensity, or
tensity, or 1–149 min/ 150 min/wk of moder-
wk moderate plus vigor- ate plus vigorous inten-
ous intensity activity sity activity (in which
(whereby time in vigor- time in vigorous activity
ous activity is doubled) is doubled)
Body Mass Index BMI ≥ 30 kg/m2 BMI 25–29.9 kg/m2 BMI <25 kg/m2
Diabetes Self-reported diabetes - No self-reported diabe-
tes
Blood Pressure Treated BP >140/ >90 SBP 120–139 or DBP 80 BP <120/<80 mmHg
and SBP ≥ 140 or DBP –89 or treated BP
≥ 90 mm Hg <140/ <90 mm Hg
Diet Diet score = 0 Diet score = 1 Diet score = 2-3

* Adaptations to previously published Cardiovascular Health score were made to Diet, smoking status, and diabetes due
to incomplete data. Diet score (scale: 0 – 3) was calculated on the basis of one point for each of the following compo-
nents, including; ≥ 4 servings of fruit or vegetables per day, ≥ 2 servings of fish per week, lowest tertile of reported dai-
ly sodium consumption. Intermediate smoking status was not obtained, diabetes status was limited to self-reporting.

CVH; we speculate this is likely due to a physically active participants who were wealthier and closer to the urban
lifestyle necessary for farm work. Several metrics of CVH center. Re-sampling participants who were working
were observed to be worse in women, including our during initial was inconsistently performed, and could
report of physical activity and weight. Culturally, women bias the population toward less healthy individuals not
typically sell goods, or work around the home which are able to work. Our diet metric was adapted as a simple
activities that may provide less physical activity and may and convenient measure, and the adaptation of the WHO
explain why CVH metrics were worse in women. STEPS instrument for development of the CVH score has
Furthermore, there exists in Haiti a high prevalence of not yet been validated. Diabetes was self-reported,
pre-eclampsia which may explain poor CVH metrics, however, we used a standardized instrument to minimize
particularly BP, among women. These data suggest a reporting bias and to facilitate comparisons to other
need for CVH promotion particularly among women. populations.
Further investigation may be integrated at surveillance
CONCLUSION
data including why women may be at higher risk, and
linking those data with health system data to trial In conclusion, this study among this rural, Haitian
resource-effective ways to improve CVH. population demonstrates a low prevalence of ideal CVH
overall. Farmers are most likely to have ideal CVH, and
This study has several limitations. Random sampling
women had worse CVH compared with men. We
methods were not used but convenience sample chosen
identified blood pressure and healthy diet as targets for
to optimize sample size, however, may biased towards
CMJ | Published online on July 25th, 2021 6
interventions to improve CVH at a regional level. These Prevalence of Diabetes and Hypertension in Haiti
data may have important implications for CVH health (PREDIAH). Diabetes & Metabolism, 2006. 32(5
promotion and cardiovascular disease prevention and Pt 1): p. 443-51.
control. 6. (MSPP), M.d.l.S.P.e.d.l.P., Haïti Enquête Mortalité,
Morbidité et Utilisation des Services (EMMUS-VI
2016-2017). 2018, Institut Haïtien de l’Enfance:
Conflict of interest statement: None declared
Pétion-Ville, Haïti.
Informed Consent statement: Not applicable 7. Folsom, A.R., et al., Community prevalence of
Funding statement: GFK was supported in part by the ideal cardiovascular health, by the American
American Heart Association [grant number Heart Association definition, and relationship with
17MCPRP33460298] and National Heart Lung Blood cardiovascular disease incidence. Journal of the
Institute [grant number 1K23HL140133]. American College Cardiology, 2011. 57(16): p.
1690-6.
Authors Contribution: Authors would like to thank; the 8. Lloyd-Jones, D.M., et al., Defining and setting
Arnold P. Gold foundation student summer research national goals for cardiovascular health
fellowship and the Glasauer summer travel fellowship for promotion and disease reduction: the American
providing funding to V. Polsinelli, Pierre-Louis Joizil for Heart Association’s strategic Impact Goal through
his tremendous help in staff support and supporting the 2020 and beyond. Circulation, 2010. 121(4): p.
V. Polsinelli, Kener, Abegi, Madianie, Wilred, and Iranel; 586-613.
research assistants for their unduly dedication to this 9. Sacco, R.L., et al., The Heart of 25 by 25:
study, Kathryn H Lee, MD, Joseph Morvillo, DO and Achieving the Goal of Reducing Global and
Robert Scagnelli, MD for their assistance with data Regional Premature Deaths From Cardiovascular
management in the field, Nikhil Satchidanand, PhD, Ranjit Diseases and Stroke: A Modeling Study From the
Singh, MBBS, David Holmes, MD, Mark Huffman, MD, American Heart Association and World Heart
MPH for their support in initial data analysis, support, and Federation. Circulation, 2016. 133(23): p. e674-
mentoring. 90.
10. Organization, W.H., WHO STEPS surveillance
manual: the WHO STEPwise approach to chronic
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