Changes in estimated coronary risk in the 1980s: data from 38 populations in the WHO MONICA Project

The World Health Organization (WHO) MONICA Project is a 10-year study monitoring trends and determinants of cardiovascular disease in geographically defined populations. Data were collected from over 100 000 randomly selected participants in two risk factor surveys conducted approximately 5 years apart in 38 populations using standardized protocols. The net effects of changes in the risk factor levels were estimated using risk scores derived from longitudinal studies in the Nordic countries. The prevalence of cigarette smoking decreased among men in most populations, but the trends for women varied. The prevalence of hypertension declined in two-thirds of the populations. Changes in the prevalence of raised total cholesterol were small but highly correlated between the genders (r = 0.8). The prevalence of obesity increased in three-quarters of the populations for men and in more than half of the populations for women. In almost half of the populations there were statistically significant declines in the estimated coronary risk for both men and women, although for Beijing the risk score increased significantly for both genders. The net effect of the changes in the risk factor levels in the 1980s in most of the study populations of the WHO MONICA Project is that the rates of coronary disease are predicted to decline in the 1990s.

Sources of information about HIV/AIDS and perceived risk of infection among heterosexual young adults: 1989 and 1994

This paper reports a study of sources of information about HIV/AIDS and trust of the sources among heterosexuals in 1989 (113 females and 91 males) and 1994 (185 females and 66 males). We also examined whether perceived personal risk of HIV infection was predicted by sources of information about HIV/AIDS, trust of the sources, how informed about AIDS people believed they were, and perceived risk of infection to others, as well as whether there was a relationship between perceived personal risk and safe sex behaviour Participants received most of their information about AIDS/HIV from magazines, newspapers, and television, but placed most trust on sources such as doctors and HIV/AIDS organisations. Perceived personal risk was influenced most by perceived risk to friends and to people with the same sexual practices. In the 1994 sample, perceived personal risk was correlated with the amount of condom use among participants with sexual experience. These results indicate ther has been. relative stability across a five-year period. They also point to the continuing discrepancy among young heterosexuals between the most-used and most-trusted sources of information, as well as to the importance of peer influence on perceptions of personal risk of HIV infection.

Refining the risk-benefit equation for thrombolysis: How to identity the low risk patient before administering thrombolytic therapy

In view of the relative risk of intracranial haemorrhage and major bleeding with thrombolytic therapy, it is important ro identify as early as possible the low risk patient who may not have a net clinical benefit from thrombolysis in the setting of acute myocardial infarction. An analysis of 5434 hospital-treated patients with myocardial infarction in the Perth MONICA study showed that age below 60 and absence of previous infarction or diabetes, shock, pulmonary oedema, cardiac arrest and Q-wave or left bundle branch block on the initial ECG identified a large group of patients with a 28 day mortality of only 1%, and one year mortality of only 2%. Identification of baseline risk in this way helps refine the risk-benefit equation for thrombolytic therapy, and may help avoid unnecessary use of thrombolysis in those unlikely to benefit.

Long-term risk of first recurrent stroke in the Perth Community Stroke Study

Background and Purpose-Few community-based studies have examined the long-term risk of recurrent stroke after an acute first-ever stroke. This study aimed to determine the absolute and relative risks of a first recurrent stroke over the first 5 years after a first-ever stroke and the predictors of such recurrence in a population-based series of people with first-ever stroke in Perth, Western Australia. Methods-Between February 1989 and August 1990, all people with a suspected acute stroke or transient ischemic attack of the brain who were resident in a geographically defined region of Perth, Western Australia, with a population of 138 708 people, were registered prospectively and assessed according to standardized diagnostic criteria. Patients were followed up prospectively at 4 months, 12 months, and 5 years after the index event. Results-Three hundred seventy patients with a first-ever stroke were registered, of whom 351 survived >2 days. Data were available for 98% of the cohort at 5 years, by which time 199 patients (58%) had died and 52 (15%) had experienced a recurrent stroke, 12 (23%) of which were fatal within 28 days. The 5-year cumulative risk of first recurrent stroke was 22.5% (95% confidence limits [CL], 16.8%, 28.1%). The risk of recurrent stroke was greatest in the first 6 months after stroke, at 8.8% (95% CL, 5.4%, 12.1%). After adjustment for age and sex, the prognostic factors for recurrent stroke were advanced, but not extreme, age (75 to 84 years) (hazard ratio [HR], 2.6; 95% CL, 1.1, 6.2), hemorrhagic index stroke (HR, 2.1; 95% CL, 0.98, 4.4), and diabetes mellitus (HR, 2.1; 95% CL, 0.95, 4.4). Conclusions-Approximately 1 in 6 survivors (15%) of a first-ever stroke experience a recurrent stroke over the next 5 years, of which 25% are fatal within 28 days. The pathological subtype of the recurrent stroke is the same as that of the index stroke in 88% of cases. The predictors of first recurrent stroke in this study were advanced age, hemorrhagic index stroke, and diabetes mellitus, but numbers of recurrent events were modest. Because the risk of recurrent stroke is highest (8.8%) in the first 6 months after stroke, strategies for secondary prevention should be initiated as soon as possible after the index event.

Suicide in urban New South Wales, Australia 1985-1994: Socio-economic and migrant interactions

Variation of suicide with socio-economic status (SES) in urban NSW (Australia) during 1985-1994, by sex and country or region of birth, was examined using Poisson regression analysis of vital statistics and population data (age greater than or similar to 15 yr). Quintiles of SES were defined by municipality of residence and comparisons of suicide by SES were adjusted for age and country (or region) of birth (COB), and examined by COB. Risk of suicide in females was 28% that of males for all adults and 21% for youth (age 15-24 yr). Suicide risk was lower in males from southern Europe, Middle East and Asia, and higher in northern and eastern European males, compared to the Australian-born. Risks for suicide increased significantly with decreasing SES in males, but not in females. The relationship of male suicide and SES was stronger when controlled for COB. For males, the relative risk of suicide, adjusted for age and COB, was 66% higher in the lowest SES quintile compared to the highest quintile, and 39% higher for youth (age 15-24 yr). For male suicide, the population attributable fraction for SES (less than the highest quintile) was 27%. Analysis of SES differentials in male suicide according to COB indicated a significant inverse suicide gradient in relation to SES for the Australian-born and those burn in New Zealand and the United Kingdom or fire. but not in non-English speaking COB groups, except for Asia. For Australian-born males, suicide risk was 71% higher in the lowest SES group (compared to the highest), adjusted for age. These findings indicate that SES plays an important role in male suicide rates among the Australian-born and migrants from English-speaking countries and Asia, and among youth; but not in female suicide, nor suicide in most non-English speaking migrant groups. Reduction in SES differentials through economic and social policies may reduce male suicide in lower SES groups and should be seen to be at least as important as individual level interventions. (C) 1998 Elsevier Science Ltd. All rights reserved.

Reducing coronary heart disease in the Australian Coalfields: evaluation of a 10-year community intervention

Coronary heart disease is a leading cause of death in Australia with the Coalfields district of New South Wales having one of the country's highest rates. Identification of the Coalfields epidemic in the 1970's led to the formation of a community awareness program in the late 1980's (the healthy heart support group) followed by a more intense community action program in 1990, the Coalfields Healthy Heartbeat (CHHB). CHHB is a coalition of community members, local government officers, health workers and University researchers. We evaluate the CHHB program, examining both the nature and sustainability of heart health activities undertaken, as well as trends in risk factor levels and rates of coronary events in the Coalfields in comparison with nearby local government areas. Process data reveal difficulties mobilising the community as a whole; activities had to be selected for interested subgroups such as families of heart disease patients, school children, retired people and women concerned with family nutrition and body maintenance. Outcome data show a significantly larger reduction in case fatality for Coalfields men (although nonfatal heart attacks did not decline) while changes in risk factors levels were comparable with surrounding areas. We explain positive responses to the CHHB by schools, heart attack survivors and women interested in body maintenance in terms of the meaning these subgroups find in health promotion discourses based on their embodied experiences. When faced with a threat to one's identity, health discourse suddenly becomes meaningful along with the regimens for health improvement. General public disinterest in heart health promotion is examined in the context of historical patterns of outsiders criticising the lifestyle of miners, an orientation toward communal lather than individual responsibility for health (i.e, community 'owned' emergency services and hospitals) and anger about risks from environmental hazards imposed by industrialists. (C) 1999 Elsevier Science Ltd. All rights reserved.

Rapid reduction in coronary risk for those who quit cigarette smoking

The objective of this study was to determine the rate of the decline in risk of a major coronary event after quitting cigarette smoking. It was a population-based case-control study of men and women aged 35 to 69 years in Newcastle, Australia, and men and women aged 35 to 64 years in Auckland, New Zealand, between 1986 and 1994. Cases were 5,572 people identified in population registers of coronary events and controls were 6,268 participants in independent community-based risk factor prevalence surveys from the same study populations. There was a rapid reduction in risk after quitting cigarette smoking. The risk of suffering a major coronary event for men who were current cigarette smokers was 3.5 (95% CI 3.0-4.0) times higher than the risk for never smokers but this fell to 1.5 (95% CI 1.1-1.9) for men who had quit for 1-3 years. Women who were current cigarette smokers were 4.8 (95% CI 4.0-5.9) times more likely to suffer a major coronary event than never smokers and this fell to 1.6 (95% CI 1.0-2.5) for women who had quit for 1-3 years. Those who had quit cigarette smoking for 4-6 years or more had a similar risk to never smokers. These results reinforce the importance of smoking cessation. The public health message is that the benefit of giving up smoking occurs rapidly.

Risk premiums and benefit measures for generalized-expected-utility theories

Standard tools for the analysis of economic problems involving uncertainty, including risk premiums, certainty equivalents and the notions of absolute and relative risk aversion, are developed without making specific assumptions on functional form beyond the basic requirements of monotonicity, transitivity, continuity, and the presumption that individuals prefer certainty to risk. Individuals are not required to display probabilistic sophistication. The approach relies on the distance and benefit functions to characterize preferences relative to a given state-contingent vector of outcomes. The distance and benefit functions are used to derive absolute and relative risk premiums and to characterize preferences exhibiting constant absolute risk aversion (CARA) and constant relative risk aversion (CRRA). A generalization of the notion of Schur-concavity is presented. If preferences are generalized Schur concave, the absolute and relative risk premiums are generalized Schur convex, and the certainty equivalents are generalized Schur concave.

Adolescent reputation enhancement: Differentiating delinquent, nondelinquent, and at-risk youths

This research reports the findings of two studies conducted to measure and then investigate differences between delinquent, nondelinquent, and at-risk youths' orientations towards reputation enhancement. In the first study, concerning item selection and scale development, the factor structure and content validity of a potential Reputation Enhancement Scale were tested by examining the item responses of the scale completed by 230 high-school students. In the second study, the scale was validated by comparing the item responses of 80 delinquent, 90 at-risk, and 90 nondelinquent adolescents with the responses of the original students. The instrument was found to be reliable (alphas from .64 to .92), indicating that the factors are dependable across different samples, and the coefficients of congruence were sufficiently high to investigate meaningful group differences. Three second-order factors (Conforming Reputation, Nonconforming Reputation, Self-presentation) were derived from the 15 first-order factors. Although multivariate analyses revealed significant differences between the reputational orientations of delinquent, at-risk, and nondelinquent participants, the self-presentation second-order factor did not differentiate the three groups.

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.

Urban and rural suicide differentials in migrants and the Australian-born, New South Wales, Australia 1985-1994

We estimated risk of suicide in adults in New South Wales (NSW) by sex, country of birth and rural/urban residence, after adjusting for age; we also examined youth suicide (age 15-24 years). The study population was the entire population of NSW, Australia, aged greater than or equal to 15 years during the period 1985-1994. Poisson regression was used to examine the relationship between predictor variables and the risk of suicide, with the focus on migrant status and area of residence. A significantly higher risk of suicide was found in male migrants from Northern Europe and Eastern Europe/former USSR, compared to Australian-born males; a significantly lower suicide risk occurred in males from Southern Europe, the Middle East and Asia. In female migrants, those from UK/Eire, Northern Europe, Eastern Europe/former USSR and New Zealand exhibited a significantly higher risk of suicide compared to Australian-born females. A significantly lower risk of suicide occurred in females from the Middle East. Male migrants overall were at significantly lower risk of suicide than the Australian-born, while female migrants overall had a significantly higher risk of suicide than Australian-born females. Among migrant males overall, the rural-urban suicide risk differential was significantly higher for those living in non-metropolitan areas (RR = 1.9; 95% CI: 1.7-2.1). Suicide risk was significantly higher in non-metropolitan male immigrants from the UK/Eire (RR = 1.4; 95% CI: 1.1-1.7), Southern Europe (RR = 1.7; 95% CI: 1.2-2.4), Northern/Western Europe (1.5; 95% CI: 1.2-1.9), the Middle East (RR = 3.8; 95% CI: 1.9-7.8), New :Zealand (RR = 1.4; 95% CI: 1.0-1.8) and 'other' (RR = 2.6; 95% CI: 1.9-3.5), when compared to their urban counterparts. There was no statistically significant difference in suicide risk between rural and urban Australian-born males. For female suicide, significantly lower risk was found in female immigrants living in non-metropolitan areas who were from Northern/Western Europe (RR = 0.7; 95% CI: 0.4-0.96), as well as the Australian-born (RR = 0.7; 95% CI: 0.6-0.8), when compared to their urban counterparts. The non-metropolitan/metropolitan relative risk for suicide in female migrants overall was not significantly different from one. Among male youth there was a significantly higher suicide risk in non-metropolitan areas, with a relative risk estimate of 1.4 for Australian-born youth (95% CI: 1.2-1.5) and 1.7 for migrant youth (95% CI: 1.2-2.4), when compared with metropolitan counterparts. We conclude that suicide among migrant males living in non-metropolitan areas accounts for most of the excess of male suicide in rural NSW, and the significantly lower risk of suicide for non-metropolitan Australian-born women does not apply to migrant women. (C) 1999 Published by Elsevier Science Ltd. All rights reserved.

HIV risk behaviour and prevention in prison: a bleach programme for inmates in NSW

One hundred and eighty-one inmates in AIDS education courses were surveyed about their risk behaviour and access to disinfectants for syringe cleaning in 1993, Overall, 40% of respondents reported HIV risk behaviour in prison. One-quarter of respondents reported injecting, of whom three-quarters reported sharing syringes in prison. Most respondents who shared syringes reported cleaning them with disinfectants (96%), even though only one-third reported having easy access to disinfectants. One-sixth of respondents reported sharing tattooing equipment, of whom two-thirds reported using a disinfectant to clean the tattoo needle. Few respondents reported fellatio (8%) or anal intercourse (4%) in prison. Although some respondents faced difficulty in obtaining disinfectants, almost all respondents cleaned syringes with bleach when sharing. High levels of risk behaviour in prison might be reduced by methadone maintenance and condom programmes. A trial of strict one-for-one syringe exchange warrants consideration.