About the CARMEN Initiative
In search for more efficient ways to prevent non-communicable diseases, PAHO developed the CARMEN concept in late 1995, as a practical tool to assist member countries to meet the challenge of achieving Health for All.
CARMEN was developed because there was an increasing awareness among PAHO member countries that non-communicable diseases (NCDs) account for nearly two-thirds of the total number of deaths in the Americas, and that, to a large extent, these diseases are dependent on risk factors and lifestyles which are amenable to modification. This is an area where countries realized that increased emphasis on prevention could lead to major health gains. Countries such as Argentina, Chile, and Uruguay were very interested in developing a similar approach to that successfully implemented by the North Karelia and the CINDI projects in Europe and Canada. Therefore, CARMEN has been adapted from the CINDI program, taking into account the specific characteristics of the counties of Latin America and the Caribbean.(Structure of the Pan American Network.)
The purpose of the CARMEN program is to improve the health status of the population by reducing the prevalence of the risk factors associated with non-communicable diseases (NCDs). This is attained through integrated health promotion and disease prevention at the community level and their health care services.
CARMEN addresses all risk factors associated with non-communicable diseases and non-intentional injuries. These include:
- Biological conditions: blood pressure and cholesterol, obesity, and diabetes.
- Unhealthy consumption behaviors: smoking, dietary habits, and excessive alcohol drinking.
- Absence of health promotive or protective behaviors: sedentary lifestyles and lack of seatbelt use.
- Lack of use of preventive or screening devices such as PAP smears.
- Psychosocial factors: stress, social support, and work environment.
- However, the specific risk factors that each CARMEN program addresses are based upon a situational analysis and the priorities of each country.
- CARMEN is based on the concept of integrated action. Integrated action implies intervention aimed at simultaneously reducing a set of risk factors common to NCDs, at the individual and community levels, through combined efforts of preventive health care services for high risk individuals and health promotion intervention directed towards the general population.
- Closely linked to integration is the need to foster collaboration for prevention by means of intersectoral action. CARMEN thus recognizes the need to involve various institutions and societal organizations, both inside and outside the health sector, and to coordinate these efforts.
- CARMEN builds a countrywide effort upon local demonstration areas , which apply existing prevention knowledge to set in motion the processes required to achieve the objectives of CARMEN and to learn more from these experiences to extend the lessons to the rest of the country. In order to learn from these experiences, CARMEN adopts a practical approach to impact and process evaluation.
- CARMEN also values international collaboration as a mechanism to exchange experiences among countries, and to raise visibility and priority of non-communicable diseases. To enhance international collaboration, PAHO has created a Pan-American network of CARMEN programs, which is linked to the international web of CINDI* projects.
* CINDI is the Countrywide Integrated Non-Communicable Diseases Intervention Programme sponsored by the European Regional Office for the World Health Organization. 20 countries in Europe and Canada belong to this network of integrated community national projects to prevent and control NCDs.
The following operational strategies are used to implement interventions:
- Policy development and legislation to attain consensus among relevant partners on the issues to be addressed and to coordinate their efforts.
- Development and implementation of national practice guidelines that lead to better and more cost-effective management of risk factors and early identification of disease by health professionals, predominantly at the primary care level.
- Professional education to improve their skills and to increase involvement in preventing non-communicable diseases, and to help reorient health services towards prevention.
- Public health education and social communication to advocate policy changes and support the implementation of lifestyle changes, the creation of healthy environments, and the reorientation of health services.
- Marketing of CARMEN to rally political, corporate and social support for the program.
- Development of a formal management structure for the program based on the concept of "partnership" characterizing the coalition approach.
- Monitoring, impact and process evaluation.
Interventions are targeted to specific audiences depending upon the precise aims of the intervention. These audiences can be:
CARMEN compliments the concepts that Healthy Cities and Safe Communities are based and broadens their scope. CARMEN adds to intersectoral and health promotion efforts developed locally under the concept of Healthy Cities, and:
- Focuses on preventing and controlling non-communicable diseases.
- Underscores the contribution of health services to community action and encourages their reorientation towards prevention as part of the heath sector reform.
- Stresses integration of population and individual prevention approaches, targets low-risk as well as high-risk populations, focuses on health determinants and risk factors.
- Emphasizes a formal process of planning and implementation of intervention under a national policy framework for the prevention of NCDs.
- Supplies a theoretical framework to understand the diffusion processes involved.
- Provides an evaluation and monitoring framework to assess the progress towards NCD prevention.
The effective planning and implementation of CARMEN depends on a timely evaluation of its impact and processes. The information system established to monitor impact of CARMEN emphasizes assessment of health effects of interventions within the society during an extended period of approximately fifteen years. The indicators to evaluate impact are grouped as essential, recommended, and optional. The following essential indicators are required to be collected every three to five years:
- Age/sex distribution of the population.
- Mortality data of malignant neoplasm, diabetes mellitus, diseases of the circulatory system, diseases of the respiratory system, and non-intentional injuries, according to the WHO B list.
- Population survey data on risk factors: total cholesterol, systolic/diastolic blood pressure, body weight and height, smoking, diet, alcohol consumption, and physical activity.
- The assessment of the impact of interventions in terms of mortality and prevalence of risk factors is the backbone of NCD prevention and practice. Relating those outcomes to program activities requires long periods of observation. In the mean time, it is necessary to learn about how programs work and how they can be implemented cost-effectively. Process evaluation is concerned with the documentation of interventions, their intensity, reach-out, cost, and short-term impact.
- Impact and process evaluations are conducted under protocols developed by CINDI and adapted for use by CARMEN in the Americas.
Any country can develop a CARMEN program. However, to be part of and gain the support of the Pan-American and international networks, countries must do the following:
- Present an official request by the government to become a member with a commitment to support a national CARMEN program for at least five years.
- Create an official structure to manage the program and appoint a national CARMEN director.
- Draft a national policy framework to prevent and control NCDs according to CARMEN strategies, reflective of consensus among relevant governmental and non-governmental partners.
- Design a three-year action plan to implement intervention at the national level and the demonstration area, including a detailed calendar of activities, a budget and funding plan, and a dissemination strategy beyond the demonstration phase.
- Devise an evaluation plan according to the CINDI protocol, including a detailed calendar of activities, a budget and funding plan.
- Submit to a site visit by official representatives of CARMEN/CINDI to assess the fulfillment of the above-mentioned requisites.