EDITOR’S PAGE gOVERVIEWj

Scorecard for NCDsAndrew E. Moran*, Jagat Narulay

New York, NY, USA

From the *Division ofGeneral Medicine, Depart-ment of Medicine,Columbia UniversityMedical Center, New York,NY, USA; yIcahn School of

Medicine at Mount Sinai,New York, NY, USA. Corre-spondence: J. Narula (jagat.narula@mountsinai.org).

GLOBAL HEART© 2013 Published byElsevier Ltd. on behalf ofWorld Heart Federation(Geneva).VOL. 8, NO. 2, 2013

Noncommunicable diseases (NCDs) have risen to bea top public health priority in high-, middle-, and low-income countries alike. Most of the risk factors and high-risk behaviors upstream of NCDs have no symptoms, andoften people do not associate today’s behavior choices withsubsequent disease. As the proportion of the populationunaware of NCD risk factors in population-based surveysattests, presence of NCD risk factors is often unknown to theaffected individuals and to the health system. In thecampaign to control NCDs, the high-income nations haveseveral advantages: a well developed health-delivery andrisk-factor surveillance infrastructure, adequate numbers ofqualified health professionals, and, increasingly, electronicmedical records used by health care practitioners for thepurposes of individual diagnosis and monitoring andsystem-wide surveillance. Disparities among nations inthese resources might lead to the conclusion that low-income nations need to be brought up to speed by adoptingthe NCD control tools of the high-income world.

However, innovations leading to better health need notalways flow from high- to low-income countries. Anexample is the community health worker movement,which originated in different forms in China, Sub-SaharanAfrica, Indonesia, and Latin America, only later becominga model for chronic disease management in high-incomenations [1]. In terms of delivering health care and healthpromotion by digital technology, low- and middle-incomenations have advantages: mobile cellular technology andsmart phones are becoming ubiquitous in these countries,and their younger populations are willing to adopt newtechnologies. Indeed, if citizens of low- and middle-incomenations are using mobile devices to do banking and requestgovernment services, then mobile health care, healtheducation, and health promotion will be adopted soon.Already, mobile applications are being used in low- andmiddle-income countries to allow patients to pay for clinicvisits, provide remote video conferencing with doctors,monitor pregnant women, and remind HIV patients to taketheir antiretroviral medication [2].

In this context, the Digital Health Scorecard intro-duced by Ratzan et al. in this issue of Global Heart repre-sents a new mobile software application for NCD educationand prevention [3]. Seven major NCD risk factors werechosen: overweight/obesity, low physical inactivity,tobacco use, harmful alcohol use, elevated cholesterol,blood pressure, and hyperglycemia. Risk factor levels andoverall NCD risk are presented to the user in simple colorcodes and a numeric scale. The relative importance of risk

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factors is tailored to specific geographic regions usinga weighting procedure based on the Global Burden ofDisease 2010 Study comparative risk assessment (CRA).The CRA combines region-specific risk factor relative risksand risk factor prevalence to calculate each region's pop-ulation-attributable fractions for diseases. It should benoted that the Digital Health Scorecard uses the NCDrelative risks from the CRA, not the regional prevalence,which is appropriate for the individual risk assessmentfunction of the scorecard. Risk factor prevalence in thelarger population should not be important for weightingrisk factors at the level of an individual. Additionally, thereis a surveillance function; risk factor information isuploaded (without compromising individual privacy) andaggregated at the population level. This risk factorsurveillance data might be biased (by self-selection of usersor selective reporting) and would require validation bypopulation-based risk factor surveys in the samepopulation.

A mobile NCD education and risk assessment applica-tion has the potential to expand the reach of the preven-tion strategy, and low- and middle-income nations maybe the proving ground; however, the consequence of thedirect-to-consumer health promotion and risk assessment ishard to anticipate where chronic disease care itself is unpre-dictable and not uniform. Where along the continuum fromrisk factor to disease should health professional monitoringbe introduced into the technology? Are privacy protectionsadequate to reassure individual users that his or herhealth information will be protected? How well will healthpromotion compete in a digital environment crowded withadvertisements promoting tobacco, alcohol, and unhealthyprocessed foods? These questions will likely be answeredrelatively soon as the promise of mobile health technologyexpands along with the global mobile phone network.We should, however, be cognizant that mobile technologywill complement functional health care delivery and riskfactor surveillance systems but will not replace them.

REFERENCES1. Lehmann U, Sanders D. Community health workers: what do we know

about them? The state of evidence on programmes, activities, costs

and impact on health outcomes of using community health workers.Geneva: World Health Organization; 2007.

2. Information and Communications for Development 2012: MaximizingMobile. Washington, DC: The World Bank; 2012.

3. Ratzan SC, Weinberger MB, Apfel F, Kocharian G. The Digital HealthScorecard: a new health literacy metric for noncommunicable disease

prevention and care. Glob Heart 2013;8:171–9.

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