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 Table of Contents  
Year : 2018  |  Volume : 7  |  Issue : 2  |  Page : 72-77

Prevention of cardiovascular disease in India: Barriers and opportunities for nursing

1 Manipal College of Nursing Manipal, Manipal University, Manipal, Karnataka, India
2 Stanford Prevention Research Center, Cardiovascular Medicine and Coronary Interventions, Redwood City, California, USA
3 Department of Community medicine, Kasturba Medical College, Manipal University, Manipal, Karnataka, India

Date of Web Publication23-Mar-2018

Correspondence Address:
Ms. Sulochana Badagabettu
Manipal College of Nursing, Manipal University, Manipal - 576 104, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JCPC.JCPC_31_17

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Currently, the nursing profession lacks specialized training, to be a part of preventive cardiovascular healthcare team. The article aims to describe the obstacles Indian nurses face in becoming active and valued members of the cardiovascular healthcare team and to propose solutions. Cardiovascular disease (CVD) imposes substantial and increasing physical, psychological, societal, and financial burdens. More emphasis needs to be placed on preventive measures, which should be made available and affordable in rural as well as urban areas. Nurses are well positioned to be leaders in these initiatives. However, nurses in India face numerous obstacles in providing optimal care, including a significant shortage of trained personnel. Nursing education at advanced levels needs to be standardized and should reflect core competencies. Appropriate use of nursing resources in CVD prevention can allow physicians to treat the sickest patients, reduce cost of care, and help relieve the human burden of morbidity and mortality due to CVD.

Keywords: Barriers, cardiovascular prevention, India, leadership, nurses

How to cite this article:
George A, Badagabettu S, Berra K, George LS, Kamath V, Thimmappa L. Prevention of cardiovascular disease in India: Barriers and opportunities for nursing. J Clin Prev Cardiol 2018;7:72-7

How to cite this URL:
George A, Badagabettu S, Berra K, George LS, Kamath V, Thimmappa L. Prevention of cardiovascular disease in India: Barriers and opportunities for nursing. J Clin Prev Cardiol [serial online] 2018 [cited 2023 Mar 29];7:72-7. Available from: https://www.jcpconline.org/text.asp?2018/7/2/72/228340

  Introduction Top

According to estimates by the World Health Organization (WHO), in 2015, approximately 17.7 million deaths were attributable to cardiovascular disease (CVD). Of these, Southeast Asian countries accounted for 3.8 million (27.7%), with ischemic heart disease at 2.0 million (14.5%) and stroke at 1.3 million (9.8%) as the leading causes of cardiovascular death [Figure 1].[1] In these regions, 77% of premature deaths due to CVD occurred in persons <70 years of age.[1] The WHO has projected that by 2030, CVD will be the single greatest cause of death in the world, accounting for more than 32% of mortality in Southeast Asia.[2]
Figure 1: World Health Organization Global Health Estimates 2015: Estimated death rate by cause per 10,000 population in Southeast Asia

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  Burden of Cardiovascular Disease in India Top

India is undergoing a demographic transition: the population increased from 888 million in 1991 to 1.2 billion in 2011 and to 1.3 billion in 2015.[3] Life expectancy had increased to 70 years in females and 67 years in males by 2015.[4] In 2000, there were nearly 29 million cases of CVD, including coronary heart disease, stroke, rheumatic heart disease, and congenital heart disease in India; by 2015, this had doubled to 64 million. Although there was a significant increase in the rate of CHD, it is more evident in younger age (20–29 years) and old age (60–69) compared to middle-age group (30–59 years) [Figure 2].[5] CVD was responsible for 16 million deaths in 2000 and 34 million deaths in 2015.[5] CVD is the greatest contributor to disability and mortality in India, and mortality rates are expected to rapidly increase in the next few years as the population ages.[6] The number of years of life lost before the age of 60 as the result of coronary heart disease is expected to increase from 7.1 million in 2004 to 17.9 million in 2030, while the projected death rate caused by CVD will increase from 2.4 million in 2004 to 4.0 million in 2030.[7]
Figure 2: Prevalence rate (%) of coronary heart disease in India: 2000–2015

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The prevalence of the various behavioral risk factors for CVD in India is 44.1% for current daily tobacco smoking, 25.2% for physical inactivity, and 2.6% for excessive alcohol intake.[7] Regarding metabolic risk factors, WHO reported in 2011 that 32.5% of the Indian population had elevated blood pressure, 27.1% had elevated cholesterol, 11.0% were overweight, 10.0% had elevated blood glucose, and 1.9% were obese.[8] Chow et al. observed that in rural India, the prevalence of cardiovascular risk factors was tobacco smoking (20%), hypertension (20%), high total cholesterol or high low-density lipoprotein cholesterol (12%), obesity (4.4%), and diabetes mellitus (3.7%).[9] Banerjee and Dwivedi reported in 2016 that in rural India, hospital-based prevalence rates of CVD were 14.63%/1000 population in 2004 compared with 22.44%/1000 population in 2014.[10]

  Heathcare System in India Top

India is currently undergoing a period of extraordinary social and economic change, which is seen primarily in the urban middle class.[3],[11] The Indian healthcare sector has shown progress over recent decades, but it has significant challenges to meet before it achieves international standards. While the government guarantees healthcare to everyone in the country, 80% of outpatient and 60% of inpatient care are provided by the private sector, which encompasses 68% of all hospitals in the country.[12] The majority (60%) of preventive services are available in urban areas and serve only 10% of the total population.[13] Only 13% of the rural population has access to a primary healthcare facility, and <10% have access to a hospital. This leads to increased patient flow and patient overload in tertiary care hospitals.[12]

The Indian primary and secondary healthcare systems are focused predominantly on infectious diseases, child and maternal health, and injuries. These overburdened systems are underprepared to handle CVD prevention.[12] Currently, affordable preventive and cardiac care services are scarce in India, and there is also a shortage of qualified healthcare professionals. Most healthcare providers are situated in large metropolitan areas in facilities that cater mainly to affluent individuals. Further, these facilities focus disproportionately on treatment rather than prevention, and this is costly. Larger hospitals use hi-tech technology, which increases the cost of treatment. Only a small portion of the Indian population has health insurance coverage, but even insured patients have no coverage for preventive, diagnostic, or outpatient care.[12] This barrier dramatically reduces the utilization of the preventive programs and activities to lower the burden of CVD. Most of the population cannot afford the preventive health checkups available at tertiary care hospitals; thus, CVD risk cannot be mitigated. This leads to the development of serious costly and chronic diseases such as CVD and stroke. Around 28% of all diseases in rural areas go untreated due to financial constraints.[12]

Health promotion and disease prevention should be the essential components of CVD management in developing countries. Unfortunately, in India, the growing incidence of CVD is not yet seen as a public health challenge, and few programs have targeted its prevention. Recently, however, the government has begun to introduce programs focusing on screening and detection of CVD in some rural areas. Such efforts need to be expanded to serve the entire population. A strong and focused policy targeting CVD prevention and treatment can reduce the rising rates of mortality and morbidity.

  The Nursing Profession in India Top

Confronting the increasing prevalence of CVD and achieving preventive goals could be significantly advanced and sustained with the involvement of nurses.[14] However, the Indian healthcare system is currently suffering from a massive shortage of human resources. There is an estimated deficit of 2.4 million nurses, especially in rural areas, where low literacy rates and endemic poverty exist.[15] The WHO reports that the density of nurses in India in 2010 was 1.6/1000 population and in 2011, it was 1.7/1000 population.[16] This is dramatically lower than the global average of 2.3 nurses per 1000 people.[13] According to the 2009 WHO world health statistics report, a country is unlikely to provide quality care when the proportion of nurses is <23/10,000 population.[17] Survey data reported by Rao in 2016 showed that the mean density ratio for nurses and midwives in India was 3.2 (2.4–4.0)/10,000 population and there was a large variation in density across the country [Figure 3].[18] Of currently employed nurses and midwives, 58.4% do not possess the necessary professional qualifications, and 48.8% of nurses in rural areas and 59.8% of those in urban areas are privately engaged.[18] Nursing as a profession is not attracting sufficient numbers of young women and men possibly because working conditions are suboptimal and in-service education and salary are poor. Nurses must contend not only with staff shortages but also with inadequate equipment and lack of adequate infrastructure. Moreover, the nursing profession in India lacks clear career paths and promotion norms.[19] A lack of clear job descriptions prevents nurses from working to the full level of their skills. Finally, inadequate regulatory bodies and lack of support in a physician-dominated healthcare system are major obstacles for nurses, who have very little role in decision-making for either preventive or curative aspects of patient care.[11],[19]
Figure 3: Percentage of nurses and midwives in Indian states (per 10,000 population)

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Nursing education is regulated by the Indian Nursing Council, which requires a uniform curriculum throughout the country. Although the curriculum is well planned and organized for the prescribed duration of training, 61% of institutions of nursing education are currently considered substandard, for reasons that include poor infrastructure, a shortage of qualified teaching faculty, and uneven distribution of training institutes throughout the country.[11],[19] Moreover, most (95%) schools of nursing are managed by private institutions. The private institutions provide little opportunity for nursing students to acquire clinical experience and necessary competencies.[11],[19]

Barriers in Preventive Cardiovascular Nursing in India

Although evidence suggests that empowered healthcare practitioners can play a leading role in improving the delivery of preventive cardiovascular services in underserved areas, a shortage of skilled staff mentorship opportunities and inadequate access to advanced education are major challenges to nurses in India. There is currently little opportunity for specialized nurses to work in areas such as critical care, emergency departments, orthopedics, neuroscience, and cardiovascular care. Moreover, a recent review from India reported that there is a very little scope for nursing professionals to participate in policy decision-making to bring about reframing of leadership at all levels. Informed decision-making by nurses could greatly improve progress, quality, and accountability of healthcare including CVD prevention.[20],[21] If we hope to extend and improve preventive healthcare throughout India, it will be critical to overcome these barriers. Nursing organizations have an important role to play in this regard.

Barriers to effective preventive cardiovascular nursing in India are presented in [Table 1].[7],[11],[13],[18],[19],[20]
Table 1: Barriers in preventive cardiovascular nursing in India

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  Opportunities for Cardiovascular Nurses in India Top

The American Heart Association and the WHO have recognized that nurses play a vital role in supporting the goal of a 25% reduction in cardiovascular death and disability by 2025. Nurses can play a significant role in cardiovascular prevention, and these opportunities have been well described in the literature and stress the importance of effective leadership, advanced educational, interprofessional collaboration, and elimination of barriers.[22]


  • Nurses can play a vital role in both primary and secondary CVD prevention throughout the Indian healthcare system
  • Nursing leadership is essential for advancing education in preventive cardiovascular nursing
  • The five core competency criteria proposed by the World Health Organization should drive curricula for advanced training in preventive cardiovascular nursing
  • Development of interprofessional education for practice and research in preventive cardiovascular nursing is needed
  • Centers for excellence in preventive cardiovascular nursing would help to reduce barriers and improve nursing practice.

Effective leadership in cardiovascular disease prevention

Transformational leadership is a prerequisite for innovation: the primary responsibility of the leader is to foresee challenges and develop an action plan.[22],[23] A creative leadership willing to take risks is essential to improve the training and education of nurses in India. This training should be based on competencies and should focus on what nurses should be able to do rather than just what they should know. This includes leadership and organizational skills, an understanding of group dynamics, and effective team management. Leadership development has the potential to contribute to the progress of cardiovascular nurses at all levels of the healthcare system.[24]

With respect to CVD prevention, nursing education should be based on a system of shared assumptions regarding the nature, burden, and pattern of disease. The Preventive Cardiovascular Nurses Association supports CVD prevention throughout the healthcare system by emphasizing the importance of research, education, and advocacy. Evidence attests to the successful work of cardiovascular nurses in delivering risk reduction strategies in hospital and outpatient settings and in community-based facilities.[23],[25] Nurse team leaders have demonstrated their skill in encouraging adherence to treatment guidelines, which decreases hospitalizations, reduces morbidity and mortality, and improves outcomes. These strategies have been found to be cost-effective and can be implemented in both developing and developed countries.[24],[25] [Table 2] lists the contributions that nurses and specialized (cardiovascular) nurses make in primary and secondary and tertiary care.[5],[6],[7],[8],[24]
Table 2: Potential contributions of nurses and specialized nurses

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As cardiovascular care becomes more complex and moves into the community, nurses must be more active in providing high quality preventive cardiovascular and stroke care.[25] A report published by the Institute of Medicine USA has emphasized strengthening nursing organizations to allow nurses to become partners in improving the healthcare delivery system.[26] Indian nurses need to become decision-makers to influence health outcomes. Nurses can bring about innovation in nursing practice by reconceptualizing their roles in new settings. Healthcare in India would be advanced through nursing leadership in CVD prevention efforts in both urban and rural communities.

Advanced nursing education

Continuing education will help improve the knowledge and clinical skills of practicing nurses and develop leadership skills.[22] Evidence suggests that higher education results in better patient outcomes, including reduced mortality rates and improved patient-reported outcomes. The WHO has proposed that 5 core competencies drive the curricula of all health professions: (1) patient-centered care, (2) partnering, (3) quality improvement, (4) information and communication technology, and (5) a public health perspective.[22],[27],[28] These competencies are central to advanced training for cardiovascular nursing. In addition, to prepare cardiovascular nurses for leadership roles in preventive cardiovascular practice, the American College of Cardiology, American Nurses Credentialing Center, and American College of Cardiology Foundation have agreed on the following core competencies:[22]

  • Vascular biology-pathophysiology of atherothrombosis
  • Epidemiology and research concepts
  • Pharmacology
  • Gene–environment interaction
  • Advanced risk assessment and assessment of subclinical disease
  • Nutrition and exercise counseling.

These core competencies provide a structure for developing an advanced curriculum for CVD prevention for nurses and thereby improve preventive and patient care. Instructional materials should be based on these competencies and should be utilized throughout interprofessional education.

Interprofessional collaboration

Effective delivery of healthcare services depends largely on the level of education, basic and advanced training, and on an appropriate orientation toward community health. Interprofessional collaboration for primary and secondary cardiovascular and stroke prevention is essential and can be achieved through an emphasis on interprofessional education throughout the nursing curriculum. This will also result in the development of a culture of collaborative management.[29]

An integrated team-based cardiovascular prevention approach throughout the healthcare system will have a major impact in reducing cardiovascular risk factors in primary, secondary, and tertiary care. Studies have demonstrated that effective coordination and communication among health professionals can enhance the quality and safety of patient care.[22],[30],[31] The team should seek input from every collaborator, with each team member contributing his or her knowledge and skill. The collaborative approach has been shown to yield better patient outcomes and improve the quality of life and patient satisfaction.[22],[30],[31]

Eliminating barriers to practice and care

Centers of excellence in preventive cardiovascular nursing would improve the competencies of nurses and enhance the quality of their education. Advanced training for nurses focusing on CVD prevention would improve the workforce at all levels of the healthcare system, including research and evidence-based practice, at the primary, secondary, and tertiary levels. In many cases, advanced practice registered nurses could be used to address the primary care shortage, allowing physicians to care for more complex cases requiring their expertise.[26],[32] In this way, centers of cardiovascular nursing can improve access to care and aid in reducing healthcare costs.

A schematic representation [Figure 4][4],[5],[6],[7],[24] illustrates the roles that nurses can and should play throughout the healthcare system. At the community level, community-based participatory research will support health literacy and healthcare utilization.
Figure 4: Approaches to prevention of cardiovascular disease.[4],[5],[6],[7],[24] QOL: Quality of life

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  Discussion and Conclusions Top

CVD is a serious concern globally and is considered the leading cause of death and disability-adjusted life years, particularly in developing countries. CVD crosses geographic, socioeconomic, and gender boundaries. In a developing country such as India, interprofessional collaboration and mentoring are needed to support leadership roles for nurses. The nursing force needs to be well prepared and has a greater role in prevention, including research, practice, and policy change. Future nurse leaders should initiate change within their community healthcare system, which can be as important as country wide system overhauls. Those who embrace change, great or small, will experience benefits today while creating a foundation for success in the future. Well-reported literature on leadership roles played by nurses and nursing organizations in CVD prevention has indicated that greater nurse participation leads to improved clinical outcomes. India should aim to educate and guide cardiovascular nurses to become partners in decreasing the enormous burden of CVD in India. Improving the role of nurses in India will have a far-reaching effect on other countries by demonstrating the societal benefit of education, empowerment, and collaboration of the Indian nursing profession.


We express our sincere gratitude to Ruth Sussman, PhD, for her invaluable editorial assistance.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization. Global Health Estimates 2015: Deaths by Cause, Age, Sex, by Country and by Region, 2000-2015. Geneva, Switzerland; 2016. Available from: http://www.who.int/healthinfo/global_burden_disease/en/. [Last accessed on 2017 Feb 20].  Back to cited text no. 1
World Health Organization. Projections of Mortality and Causes of Death, Age, Sex, by Region, 2015 and 2030: Geneva, Switzerland; 2013. Available from: http://www.who.int/healthinfo/global_burden_disease/projections/en/. [Last accessed on 2017 Mar 03].  Back to cited text no. 2
World Health Organization. Global Health Observatory Data Repository: Population Data by Country (Recent Years). Available from: http://www.apps.who.int/gho/data/node.main.POP107?lang=en/. [Last accessed on 2017 Mar 03].  Back to cited text no. 3
World Health Organization. Countries Statistics Life Expectancy at Birth Male and Female (Years, 2015) 2015. Available from: http://www.who.int/countries/ind/en/. [Last accessed on 2017 Mar 03].  Back to cited text no. 4
National Commission on Macroeconomics and Health Ministry of Health and Family Welfare (NCMH) Government of India, Background Papers-Burden of Disease in India, New Delhi; 2005. Available from: http://www.who.int/macrohealth/action/NCMH_Burden%20of%20disease (29%20Sep%202005).pdf. [Last accessed on 2017 Feb 20].  Back to cited text no. 5
Srivastava RK, Bachani D. Burden of NCDs, Policies and Programme for Prevention and Control of NCDs in India. Indian J Community Med 2011;36 Suppl 1:S7-12.  Back to cited text no. 6
Patel V, Chatterji S, Chisholm D, Ebrahim S, Gopalakrishna G, Mathers C, et al. Chronic diseases and injuries in India. Lancet 2011;377:413-28.  Back to cited text no. 7
World Health Organization, Non-Communicable Diseases Country Profiles 2011. WHO Global Report. Available from: http://www.who.int/nmh/publications/ncd_profiles2011/en/. [Last accessed on 2017 Mar 26].  Back to cited text no. 8
Chow C, Cardona M, Raju PK, Iyengar S, Sukumar A, Raju R, et al. Cardiovascular disease and risk factors among 345 adults in rural India – The Andhra Pradesh Rural Health Initiative. Int J Cardiol 2007;116:180-5.  Back to cited text no. 9
Banerjee K, Dwivedi LK. The burden of infectious and cardiovascular diseases in India from 2004 to 2014. Epidemiol Health 2016;38:e2016057.  Back to cited text no. 10
Evans C, Razia R, Cook E. Building nurse education capacity in India: Insights from a faculty development programme in Andhra Pradesh. BMC Nurs 2013;12:8.  Back to cited text no. 11
Cardiovascular Diseases in India: Challenges and Way Ahead. International Heart Protection Summit. Deloitte (ASSOCHAM); 2011. Available from: http://www. 2.deloitte.com/content/dam/./in-lshc-cardio-noexp.pdf. [Last accessed on 2017 Mar 03].  Back to cited text no. 12
Rao KD, Bhatnagar A, Berman P. So many, yet few: Human resources for health in India. Hum Resour Health 2012;10:19.  Back to cited text no. 13
Abraham EJ. Pulse on health and nursing in India. Nurs Health Sci 2007;9:79-81.  Back to cited text no. 14
Senior K. Wanted: 2.4 million nurses, and that's just in India. Bull World Health Organ 2010;88:327-8.  Back to cited text no. 15
World Health Organization, Global Health Observatory Data Repository; Workforce Statistics; Aggregated Data; 2016. Available from: http://www.who.int/countries/ind/en/. [Last accessed on 2017 Feb 23].  Back to cited text no. 16
World Health Organization World Health Statistics, Health Workforce, Infrastructure, Essential Medicines 2009. p. 95-105. Available from: http://www.who.int/gho/publications/world_health_statistics/en/. [Last accessed on 2017 Mar 21].  Back to cited text no. 17
Rao KD, Shahrawat R, Bhatnagar A. Composition and distribution of the health workforce in India: Estimates based on data from the national sample survey. WHO South East Asia J Public Health 2016;5:133-40.  Back to cited text no. 18
Rao M, Rao KD, Shiva Kumar AK, Chatterjee M, Sundararaman T. Human resources for health in India. Lancet 2011;377:587-98.  Back to cited text no. 19
Bagga R, Jaiswal V, Tiwari R. Role of directorates in promoting nursing and midwifery across the various States of India: Call for leadership for reforms. Indian J Community Med 2015;40:90-6.  Back to cited text no. 20
[PUBMED]  [Full text]  
Reddy KS, Patel V, Jha P, Paul VK, Kumar AK, Dandona L; Lancet India Group for Universal Healthcare. Towards achievement of universal health care in India by 2020: A call to action. Lancet 2011;377:760-8.  Back to cited text no. 21
Lanuza DM, Davidson PM, Dunbar SB, Hughes S, De Geest S. Preparing nurses for leadership roles in cardiovascular disease prevention. Eur J Cardiovasc Nurs 2011;10 Suppl 2:S51-7.  Back to cited text no. 22
Fischer SA. Transformational leadership in nursing: A concept analysis. J Adv Nurs 2016;72:2644-53.  Back to cited text no. 23
Berra K, Miller NH, Jennings C. Nurse-based models for cardiovascular disease prevention: From research to clinical practice. J Cardiovasc Nurs 2011;26 4 Suppl:S46-55.  Back to cited text no. 24
Allen JK, Dennison Himmelfarb CR, Szanton SL, Frick KD. Cost-effectiveness of nurse practitioner/community health worker care to reduce cardiovascular health disparities. J Cardiovasc Nurs 2014;29:308-14.  Back to cited text no. 25
IOM (Institute of Medicine). The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.  Back to cited text no. 26
World Health Organization. Preparing a Workforce for the 21st Century: The Challenge of Chronic Conditions, Geneva; 2005. Available from: http://www.who.int/chp/knowledge/publications/workforce_report/en/. [Last accessed on 2017 Mar 23].  Back to cited text no. 27
Pruitt SD, Epping-Jordan JE. Preparing the 21st century global healthcare workforce. BMJ 2005;330:637-9.  Back to cited text no. 28
World Health Organization, Framework for Action on Interprofessional Education and Collaborative Practice. Geneva; 2010. Available from: http://www.who.int/hrh/resources/framework_action/en. [Last accessed on 2017 Mar 23].  Back to cited text no. 29
Hassmiller SB. The RWJF's investment in nursing to strengthen the health of individuals, families, and communities. Health Aff (Millwood) 2013;32:2051-5.  Back to cited text no. 30
Berra K, Franklin B, Jennings C. Community-Based Healthy Living Interventions. Prog Cardiovasc Dis 2017;59:430-9.  Back to cited text no. 31
High Level Expert Group Report on Universal Health Coverage for India. Planning Commission of India; 2011. Available from: http://planningcommission.nic.in/reports/genrep/rep_uhc0812.pdf. [Last accessed on 2017 Mar 23].  Back to cited text no. 32


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]

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