Population effects on individual systolic blood pressure: A multilevel analysis of the World Health Organization MONICA project

Individuals from the same population share a number of contextual circumstances that may condition a common level of blood pressure over and above individual characteristics. Understanding this population effect is relevant for both etiologic research and prevention strategies. Using multilevel regression analyses, the authors quantified the extent to which individual differences in systolic blood pressure (SBP) could be attributed to the population level. They also investigated possible cross-level interactions between the population in which a person lived and pharmacological (antihypertensive medication) and nonpharmacological (body mass index) effects on individual SBP. They analyzed data on 23,796 men and 24,986 women aged 35-64 years from 39 worldwide Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) study populations participating in the final survey of this World Health Organization project (1989-1997). SBP was positively associated with low educational achievement, high body mass index, and use of antihypertensive medication and, for women, was negatively associated with smoking. About 7-8% of all SBP differences between subjects were attributed to the population level. However, this population effect was particularly strong (i.e., 20%) in antihypertensive medication users and overweight women. This empirical evidence of a population effect on individual SBP emphasizes the importance of developing population-wide strategies to reduce individual risk of hypertension.

Assessing the quality of risk factor survey data: lessons from the WHO MONICA Project

Background and purpose Survey data quality is a combination of the representativeness of the sample, the accuracy and precision of measurements, data processing and management with several subcomponents in each. The purpose of this paper is to show how, in the final risk factor surveys of the WHO MONICA Project, information on data quality were obtained, quantified, and used in the analysis. Methods and results In the WHO MONICA (Multinational MONItoring of trends and determinants in CArdiovascular disease) Project, the information about the data quality components was documented in retrospective quality assessment reports. On the basis of the documented information and the survey data, the quality of each data component was assessed and summarized using quality scores. The quality scores were used in sensitivity testing of the results both by excluding populations with low quality scores and by weighting the data by its quality scores. Conclusions Detailed documentation of all survey procedures with standardized protocols, training, and quality control are steps towards optimizing data quality. Quantifying data quality is a further step. Methods used in the WHO MONICA Project could be adopted to improve quality in other health surveys.

Is the increase in coronary events on Mondays an artifact?

Background: The aim of this article was to investigate the size and possible causes of the reported excess in coronary events on Mondays. Methods: We conducted a metaanalysis of data from the World Health Organization (WHO) MONICA Project, which monitored trends and determinants in cardiovascular disease. The MONICA Project was undertaken in 21 countries from 1980 to 1995. Results: We found a small overall excess rate of coronary events on Mondays. In a population experiencing 100 events per week, we estimate there would be approximately I more event on Monday than on any other day. Hierarchical logistic regression showed that the Monday excess was greater in centers with less thorough data collection procedures. Conclusions: The excess of coronary events on Mondays is probably an artifact resulting from events with uncertain dates being coded as taking place on Mondays.

Effect on trend estimates of the difference between survey respondents and non-respondents: Results from 27 populations in the WHO MONIICA Project

Introduction: In the World Health Organization (WHO) MONICA (multinational MONItoring of trends and determinants in CArdiovascular disease) Project considerable effort was made to obtain basic data on non-respondents to community based surveys of cardiovascular risk factors. The first purpose of this paper is to examine differences in socio-economic and health profiles among respondents and non-respondents. The second purpose is to investigate the effect of non-response on estimates of trends. Methods:Socio-economic and health profile between respondents and non-respondents in the WHO MONICA Project final survey were compared. The potential effect of non-response on the trend estimates between the initial survey and final survey approximately ten years later was investigated using both MONICA data and hypothetical data. Results: In most of the populations, non-respondents were more likely to be single, less well educated, and had poorer lifestyles and health profiles than respondents. As an example of the consequences, temporal trends in prevalence of daily smokers are shown to be overestimated in most populations if they were based only on data from respondents. Conclusions: The socio-economic and health profiles of respondents and non-respondents differed fairly consistently across 27 populations. Hence, the estimators of population trends based on respondent data are likely to be biased. Declining response rates therefore pose a threat to the accuracy of estimates of risk factor trends in many countries.

Cold periods and coronary events: an analysis of populations worldwide

Study objective: To investigate the association between cold periods and coronary events, and the extent to which climate, sex, age, and previous cardiac history increase risk during cold weather. Design: A hierarchical analyses of populations from the World Health Organisation's MONICA project. Setting: Twenty four populations from the WHO's MONICA project, a 21 country register made between 1980 and 1995. Patients: People aged 35 - 64 years who had a coronary event. Main results: Daily rates of coronary events were correlated with the average temperature over the current and previous three days. In cold periods, coronary event rates increased more in populations living in warm climates than in populations living in cold climates, where the increases were slight. The increase was greater in women than in men, especially in warm climates. On average, the odds for women having an event in the cold periods were 1.07 higher than the odds for men (95% posterior interval: 1.03 to 1.11). The effects of cold periods were similar in those with and without a history of a previous myocardial infarction. Conclusions: Rates of coronary events increased during comparatively cold periods, especially in warm climates. The smaller increases in colder climates suggest that some events in warmer climates are preventable. It is suggested that people living in warm climates, particularly women, should keep warm on cold days.

Estimating trends and seasonality in coronary heart disease

We present two methods of estimating the trend, seasonality and noise in time series of coronary heart disease events. In contrast to previous work we use a non-linear trend, allow multiple seasonal components, and carefully examine the residuals from the fitted model. We show the importance of estimating these three aspects of the observed data to aid insight of the underlying process, although our major focus is on the seasonal components. For one method we allow the seasonal effects to vary over time and show how this helps the understanding of the association between coronary heart disease and varying temperature patterns. Copyright (C) 2004 John Wiley Sons, Ltd.

E-health and the Universitas 21 organization: 2. Telemedicine and underserved populations

Telemedicine activities in underserved communities were reviewed as part of the Universitas 21 (U21) e-health project. A SWOT analysis (strengths, weaknesses, opportunities, threats) was conducted on 12 articles identified in a literature review, supplemented by expertise from U21 members. The analysis showed that threats include the reluctance of populations to use telemedicine services, and a general absence of infrastructure and resources to sustain them. Opportunities centre around potential research, including cost-effectiveness analyses and quantitative assessments of existing telemedicine services. The great strength of telemedicine is that it can improve access to health services among those most in need. However, its greatest weakness is the lack of evidence supporting its clinical and cost advantages relative to traditional services. This represents an important opportunity for research on telemedicine initiatives among underserved populations.