177 General discussion 7 generally less likely to meet targets: for example, 74.7% of patients with primary education compared to 84.9%, of patients with secondary or tertiary education met the target for smoking in lower middle-income countries. Attendance to cardiac rehabilitation was higher among patients with secondary or tertiary education in HICs (63.3% vs 79.7%, p=0.001) and upper middle-income countries (7.4% vs 26.6%, p=0.001) (Chapter 6). Patients present with multiple characteristics that can potentially be related to health inequities, and therefore it is necessary to not study these factors in isolation but to consider their intersections. The few studies that have reported health inequalities in secondary prevention with an intersectional approach focus on sex and educational level, and show that female patients with lower educational level present a lower levels of risk factor target attainment (17,33). This thesis shows that the burden of and sex differences in the presence of multiple risk factors are larger among subjects with lower education: 57.1% of men and 60.8% of women with CHD in the CESCAS Study had 5 or more risk factors, but these estimates were higher (59.7% of men and 70.5% of women) among those with a lower educational level (33). Surveys capture information on multiple factors related to potential health inequalities, and there is a need and potential to further research and report disparities in secondary prevention with an intersectional approach. Collecting data on patients’ characteristics allows researchers to identify health disparities, that eventually can support the strategies to reduce them. Survey representativeness Secondary prevention surveys in clinical settings collect data from patients attending a selected sample of health centers. To allow for survey results to be applicable to a wide range of patients, it is important that they include a representative sample of patients that reflects the population targeted by preventive strategies and clinical guidelines. In this section, we address representativeness in surveys and its shortcomings by discussing geographical coverage at international level, including a case example of secondary prevention in South America, and diversity of centers within countries. Further, we reflect on how surveys can improve representativeness and discuss examples of strategies that surveys have implemented for this purpose. Representativeness at global level The burden of CHD and cardiovascular risk factors is not distributed equally, and low-and middle income countries, especially in East and Central Asia, Oceania and the North Africa and middle East face the highest burden (2,27). The largest recent surveys in secondary prevention of CHD have variable geographical coverage and have made efforts to include a wide range of countries and regions: the most recent EUROASPIRE survey was conducted in 27 countries (Chapter 5), most of which were located in Europe; SURF CHD II was conducted in 29 countries (Chapter 6); PURE included 20 high, middle and low-income countries (49); and INTERASPIRE is being conducted in 17 countries from the six regions (55). However, some regions are largely missed in surveys, for example, only two countries from the Sub-Saharan Africa region are included in PURE and INTERASPIRE. Surveys in secondary
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