Socio-economic, migrant and geographic differentials in coronary heart disease occurrence in New South Wales

Objective: This study examines the variation in coronary heart disease (CHD) mortality and acute myocardial infarction (AMI) by socio-economic status (SES), country of birth (COB) and geography (urban/rural) in the total population of New South Wales (Australia) in 1991-95. Method: CHD deaths and AMI are from complete enumerations of deaths and hospital admissions, respectively; and population denominators are from census information. Data are examined separately by sex, and comparisons of SES groups (based on municipalities), COB and region are analysed using Poisson regression, after adjustment for age. Results: The study identified higher risk for AMI admissions and CHD mortality in lower SES populations with significant linear trends, for both sexes, adjusted for age, region and COB. According to the population attributable fractions (PAF), 23-41% of the risk of CHD occurrence is due to SES lower than the highest quartile. The higher age-adjusted risk for CHD occurrence in rural and remote populations for both sexes, compared with urban communities, was lessened by adjustment for COB, and all but abolished when also adjusted for SES. COB analysis indicated significantly lower age-adjusted AMI admissions and CHD mortality compared with the Australian-born, Conclusions: Higher risks for CHD in rural populations compared with the capital city (Sydney) are due, in part, to lower SES, lesser migrant composition. Implications: Strategies for reducing CHD differentials should consider demographic factors and the fundamental need to reduce socio-economic inequalities, as well as targeting appropriate prevention measures.

Injuries and noncommunicable diseases: emerging health problems of children in developing countries

The present article identifies, for children living in developing countries, the major causes of ill-health that are inadequately covered by established health programmes. Injuries and noncommunicable diseases, notably asthma, epilepsy, dental caries, diabetes mellitus and rheumatic heart disease, are growing in significance. In countries where resources are scarce it is to be expected that increasing importance will be attached to the development and implementation of measures against these problems. Their control may benefit from the application of elements of programmes directed against infectious, nutritional and perinatal disorders, which continue to predominate.

Women's health Australia: On the progress of the main cohort studies

More than 41,000 women aged 18-23, 45-50, and 70-75 years in 1996 are participating in the Australian Longitudinal Study on Women's Health (Women's Health Australia). Baseline surveys were conducted for all three cohorts in 1996, and the first follow-up survey of the mid-age group in 1998 has achieved a response rate exceeding 90%. The main findings so far reflect the large differences in the life experiences of the three cohorts. The young women report high levels of stress. The physical and mental health of those with young children is worse than for those without children, but confounding by sociodemographic characteristics may account for the differences. Two thirds of young women in the healthy weight or underweight range would like to weigh less, and early onset of dieting is associated with poorer physical and mental health. Most of the women in the mid-age group have multiple roles-in paid work, home duties, and caring for children and other dependents. The potential of the study to investigate the long-term impact of such busy lives on health outcomes is considerable. At this stage, the main health issues for these women relate to tiredness, weight gain, and menopause. The older cohort presents a picture of positive aging. These women are heavier users of health services than the mid-age and younger women, and they are also more satisfied with these services. Although their physical health is poorer, their mental health is better, and they report less stress than women in the other two cohorts. The follow-up survey of this group, planned for 1999, will focus on the coping strategies used by these women. An overall goal of the project is to understand the interactions among social roles, life events, and women's health in order to provide a basis for improved health policies and services. Analysis of these interactions, which relies on both quantitative and qualitative data, poses many challenges that will be addressed as the longitudinal data become available.

Tuberculosis and health sector reform: experience of integrating tuberculosis services into the district health system in rural South Africa

SETTING: Hlabisa health district, South Africa. OBJECTIVE: To describe the integration of a vertical tuberculosis control programme into an emerging 'horizontal' district health system, within the context of health sector reform. DESIGN: Descriptive account of the process of integration of the programme into the health system. RESULTS: A highly 'vertical' system of delivering tuberculosis treatment (with poor programme outcomes) was converted into a (horizontal' team, integrated within the district health system, that used available resources such as village clinics and community health workers, with improved programme outcomes. CONCLUSIONS: In some settings at least, integration of tuberculosis 'programmes' into the district health system as tuberculosis 'teams' is feasible, and may produce highly cost-effective outcomes.

Do simple prudent health behaviours protect men from myocardial infarction?

Background We tested whether behaviours such as discarding obvious fat on meat, cessation of smoking, avoidance of passive smoking, habitual use of reduced fat milk, prudent consumption of alcohol and regular but moderate physical exercise are associated with a reduction of cardiovascular risk. Methods This was a population-based case-control study done in Perth, Western Australia. The cases (n = 336) were men aged 27-64 years with a first-ever acute myocardial infarction (AMI) during the period 1992-1993, and who survived at least 28 days. The controls (n = 735) were participants in a population-based survey of cardiovascular risk factors conducted during May-November 1994. Both groups completed the same questionnaire and the data were analysed with multiple logistic regression using backward elimination technique. Results Among men aged 27-64 years simple measures such as participation in non-vigorous exercise (odds ratio [OR] = 0.5, 95% CI : 0.4-0.7), and avoidance of added salt (OR = 0.6, 95% CI : 0.4-0.9) are associated with significant and Important protection from AMI. Conclusion After 25 years of falling mortality in Australia, lifestyles can still be significantly improved to reduce heart disease even further.

Diagnosis and treatment of mental disorders: a survey of Singapore mental health professionals

Background: A series of surveys of mental health literacy have been undertaken in Australia, involving members of the general public as well as general practitioners and mental health professionals, whereby respondents consider vignettes of depression and of schizophrenia, offer a diagnosis and rate a series of possible interventions for their judged helpfulness. A similar survey was undertaken in Singapore and is reported in this paper. Methods: The survey was undertaken at a large state psychiatric hospital with staff (psychiatrists, allied health professionals, psychiatrically and generally trained nursing staff) rating a vignette of mania, in addition to the vignettes derived in Australia for depression and schizophrenia, and with the Australian intervention options extended somewhat to respect Singapore facilities. Results: Responses of those in the four professional groups were compared. The psychiatrists were highly accurate in generating diagnoses, other staff somewhat less so for diagnosing depression (with a percentage instead choosing a diagnosis of stress) and mania (with a percentage instead diagnosing a schizophrenic condition). Reported helpfulness ratings identified those interventions judged consensually as likely to be helpful or harmful, as well as establishing some differences across the four professional groups. Conclusions: The consensus decisions of helpful treatments for depression and schizophrenia revealed very similar findings to judgements made by Australian professionals. The treated outcome of schizophrenia was judged as somewhat worse than that for mania and depression. While non-medical staff differed from psychiatrists in judging the comparative utility of some drug interventions and lifestyle issues, there was clear evidence of a relatively dominant 'medical model' to recommended treatments, while traditional healing practices and services were rated as distinctly unhelpful.

Life-cycle preferences over consumption and health: when is cost-effectiveness analysis equivalent to cost-benefit analysis?

This paper studies life-cycle preferences over consumption and health status. We show that cost-effectiveness analysis is consistent with cost-benefit analysis if the Lifetime utility function is additive over time, multiplicative in the utility of consumption and the utility of health status, and if the utility of consumption is constant over time. We derive the conditions under which the lifetime utility function takes this form, both under expected utility theory and under rank-dependent utility theory, which is currently the most important nonexpected utility theory. If cost-effectiveness analysis is consistent with cost-benefit analysis, it is possible to derive tractable expressions for the willingness to pay for quality-adjusted life-years (QALYs). The willingness to pay for QALYs depends on wealth, remaining life expectancy, health status, and the possibilities for intertemporal substitution of consumption. (C) 1999 Elsevier Science B.V. All rights reserved.

Endorsement of CIDI psychosis screening items in the Australian Survey of Mental Health and Well being

This paper presents preliminary analysis of the endorsement of the CIDI Psychosis Screening items in a large Australian community sample. CIDI interviews were completed on a representative sample of 10,641 individuals living in private dwellings in Australia. The items examined constructs related to thought control/interference (G1), ideas of reference (G2), and special powers (G3). If endorsed, each item had a follow-up probe (G1A telepathy; G2A things arranged with special meaning; G3A -- group acceptability). The final item (G4) asked if the respondent had been told that they had schizophrenia. This paper presents the frequency of endorsement, and examines the impact of age and sex on these items. Endorsement of the items was G1 =5.86°/,,, G1A=0.70%, G2=4.84%, G2A=l.31%, G3=3.41%, G3A=2.65%, and G4=0.65%. If screen-positives are defined as two or more 'hits', then 0.41% of the sample met this criterion. Younger participants were significantly more likely to be screen-positive. Items G1, G1A, G2 and G2A were endorsed more frequently by younger participants while there were no significant age effects identified in items G3 or G4. There was a nonsignificant trend for females to endorse item G1 more frequently than males (p = 0.07), but there were no signficant gender differences on the other items. Many individuals who were 'screen-negative' for psychosis endorsed CIDI items related to thought controls, ideas of reference and special powers, suggesting that there may be a 'continuum' of experiences in the population. The impact of age on the distribution of these measures suggests either differential biological vulnerability to these experiences and/or differential cultural factors influencing endorsement of the items. The implications of these findings on our understanding of the symptoms of psychosis will be discussed. The survey was funded by the Commonwealth Dept. of Health and Family Services. The Stanley Foundation supported this project.

Alcohol- and drug-use disorders in Australia: implications of the National Survey of Mental Health and Wellbeing

Objective: This study reports the prevalence and correlates of ICD-10 alcohol- and drug-use disorders in the National Survey of Mental Health and Wellbeing (NSMHWB) and discusses their implications for treatment. Method: The NSMHWB was a nationally representative household survey of 10 641 Australian adults that assessed participants for symptoms of the most prevalent ICD-10 and DSM-IV mental disorders, including alcohol- and drug-use disorders. Results: In the past 12 months 6.5% of Australian adults met criteria for an ICD-10 alcohol-use disorder and 2.2% had another ICD-10 drug-use disorder. Men were at higher risk than women of developing alcohol- and drug-use disorders and the prevalence of both disorders decreased with increasing age. There were high rates of comorbidity between alcohol- and other drug-use disorders and mental disorders and low rates of treatment seeking. Conclusions: Alcohol-use disorders are a major mental health and public health issue in Australia. Drug-use disorders are less common than alcohol-use disorders, but still affect a substantial minority of Australian adults. Treatment seeking among persons with alcohol- and other drug-use disorders is low. A range of public health strategies (including improved specialist treatment services) are needed to reduce the prevalence of these disorders.