An effectiveness hierarchy of preventive interventions: Neglected paradigm or self-evident truth?

© The Author 2017. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. Non-communicable disease prevention strategies usually target the four major risk factors of poor diet, tobacco, alcohol and physical inactivity. Yet, the most effective approaches remain disputed. However, increasing evidence supports the concept of an effectiveness hierarchy. Thus entive activities targeting individuals (such as 1:1 personal advice, health education, 'nudge' or primary prevention medications) consistently achieve a smaller population health impact than interventions aimed further 'upstream' (for instance, smoke-free legislation, alcohol minimum pricing or regulations eliminating dietary transfats). These comprehensive, policy-based interventions reach all parts of the population and do not depend on a sustained 'agentic' individual response. They thus tend to be more effective, more rapid, more equitable and also cost-saving. This effectiveness hierarchy is self-evident to many professionals working in public health. Previously neglected in the wider world, this effectiveness hierarchy now needs to be acknowledged by policy makers

Road traffic accidents in Libya: An undeclared War

To The Editor: In his outstanding article regarding Road Traffic Accidents (RTAs) in Libya [1], Dr Abdulmajid Ali has raised awareness and started a debate about this extremely important issue. Before responding to some points in Dr Ali’s article, I would like to tell a real story of a tragic accident that happened last week, which highlights several issues related to RTAs in Libya. A 55 year old driver left after Fajr prayer to the vegetable market to buy a few things for his daughter’s wedding lunch. While trying to avoid a big pothole in the middle of the road, he was hit by a truck without headlights coming from the opposite direction. The truck driver continued driving as if nothing had happened. None of the road users cared to help the victim but he was able to contact his son by mobile phone to come and help him out of the wreckage. His son took him to the main Trauma Hospital in Tripoli. The patient had no external injuries. He was admitted for observation only. A few hours later the patient died as a result of major internal haemorrhage. Further information revealed that the truck driver had no driving licence and the truck was not road worthy.This story is not unique However, it highlights the complex and intermingled issues that need to be addressed to have any real impact on this disastrous problem in Libya. The specific points I would like to add to Dr Ali’s article are:There is no doubt that RTAs are a major killer in Libya especially in the young age group. The annual reporting of road causalities is considered to be the yard stick to measure the effectiveness of any national traffic policy,; in the UK for example the target is to reduce fatalities from RTAs by 50% by 2010 [2]. It is a disgrace not to have accurate official statistics published at least annually of fatalities, injuries, disabilities and the economic consequences of this undeclared war in Libya. There is evidence to support that there could be a positive impact when national health challenges are tackled systematically [3-5]. It is perplexing not to have a Libyan National Traffic Policy to deal with this very serious issue comprehensively.The majority of serious accidents in Libya occur on motorways. Internationally, motorways are organised in such a way that traffic can only leave or join the motorway through specified junctions. In contrast, in Libyan motorways, other vehicles can join the motorway unpredictably at any point, left or right and sometimes from above or below! Personally I think that the lack of a Highway Code or its implementation is a major contributing cause for serious RTAs.The Libyan Traffic Police Force needs a shakeup to root out the few corrupt officers who brought what used to be a highly regarded force into disrepute because of their indiscipline. The force needs support, respect and incentives, one of which is to link their pay rise to the national reduction of RTAs.To be slightly provocative, I would like to call for a public inquiry into the issue of RTAs in Libya. This is a very robust way to learn lessons and implement corrective changes (please see www.hse.gov.uk Railway Public inquiries). Dr Ali touched on the importance of ATLS. As we can learn from the above story the issue is not as simple as we think. I will not scratch the issue of the role of Blood transfusion Service in this situation. Suffice it to say this is a colossal national challenge and deserves equal resources.I would like to express my disagreement with Dr Ali’s suggestion to exert our pressure on the Libyan Ministry of Health. I do not believe that we have any power to exert over the politicians

Relation between socioeconomic deprivation and death from a first myocardial infarction in Scotland: population based analysis

No abstract available

Short-term and long-term outcomes in 133 429 emergency patients admitted with angina or myocardial infarction in Scotland, 1990-2000: population-based cohort study

Objective: To analyse short- and long-term outcomes and prognostic factors in a large population-based cohort of unselected patients with a first emergency admission for suspected acute coronary syndrome between 1990 and 2000 in Scotland. Methods: All first emergency admissions for acute myocardial infarction (AMI) and all first emergency admissions for angina (the proxy for unstable angina) between 1990 and 2000 in Scotland (population 5.1 million) were identified. Survival to five years was examined by Cox multivariate modelling to examine the independent prognostic effects of diagnosis, age, sex, year of admission, socioeconomic deprivation and co-morbidity. Results: In Scotland between 1990 and 2000, 133 429 individual patients had a first emergency admission for suspected acute coronary syndrome: 96 026 with AMI and 37 403 with angina. After exclusion of deaths within 30 days, crude five-year case fatality was similarly poor for patients with angina and those with AMI (23.9% v 21.6% in men and 23.5% v 26.0% in women). The longer-term risk of a subsequent fatal or non-fatal event in the five years after first hospital admission was high: 54% in men after AMI (53% in women) and 56% after angina (49% in women). Event rates increased threefold with increasing age and 20–60% with different co-morbidities, but were 11–34% lower in women. Conclusions: Longer-term case fatality was similarly high in patients with angina and in survivors of AMI, about 5% a year. Furthermore, half the patients experienced a fatal or non-fatal event within five years. These data may strengthen the case for aggressive secondary prevention in all patients presenting with acute coronary syndrome

Population assessment of future trajectories in coronary heart disease mortality.

Background: Coronary heart disease (CHD) mortality rates have been decreasing in Iceland since the 1980s, largely reflecting improvements in cardiovascular risk factors. The purpose of this study was to predict future CHD mortality in Iceland based on potential risk factor trends. Methods and findings: The previously validated IMPACT model was used to predict changes in CHD mortality between 2010 and 2040 among the projected population of Iceland aged 25–74. Calculations were based on combining: i) data on population numbers and projections (Statistics Iceland), ii) population risk factor levels and projections (Refine Reykjavik study), and iii) effectiveness of specific risk factor reductions (published meta-analyses). Projections for three contrasting scenarios were compared: 1) If the historical risk factor trends of past 30 years were to continue, the declining death rates of past decades would level off, reflecting population ageing. 2) If recent trends in risk factors (past 5 years) continue, this would result in a death rate increasing from 49 to 70 per 100,000. This would reflect a recent plateau in previously falling cholesterol levels and recent rapid increases in obesity and diabetes prevalence. 3) Assuming that in 2040 the entire population enjoys optimal risk factor levels observed in low risk cohorts, this would prevent almost all premature CHD deaths before 2040. Conclusions: The potential increase in CHD deaths with recent trends in risk factor levels is alarming both for Iceland and probably for comparable Western populations. However, our results show considerable room for reducing CHD mortality. Achieving the best case scenario could eradicate premature CHD deaths by 2040. Public health policy interventions based on these predictions may provide a cost effective means of reducing CHD mortality in the future

National survey of the prevalence, incidence, primary care burden, and treatment of heart failure in Scotland

Objective: To examine the epidemiology, primary care burden, and treatment of heart failure in Scotland, UK. Design: Cross sectional data from primary care practices participating in the Scottish continuous morbidity recording scheme between 1 April 1999 and 31 March 2000. Setting: 53 primary care practices (307 741 patients). Subjects: 2186 adult patients with heart failure. Results: The prevalence of heart failure in Scotland was 7.1 in 1000, increasing with age to 90.1 in 1000 among patients 85 years. The incidence of heart failure was 2.0 in 1000, increasing with age to 22.4 in 1000 among patients 85 years. For older patients, consultation rates for heart failure equalled or exceeded those for angina and hypertension. Respiratory tract infection was the most common co-morbidity leading to consultation. Among men, 23% were prescribed a ß blocker, 11% spironolactone, and 46% an angiotensin converting enzyme inhibitor. The corresponding figures for women were 20% (p = 0.29 versus men), 7% (p = 0.02), and 34% (p < 0.001). Among patients < 75 years 26% were prescribed a β blocker, 11% spironolactone, and 50% an angiotensin converting enzyme inhibitor. The corresponding figures for patients 75 years were 19% (p = 0.04 versus patients < 75), 7% (p = 0.04), and 33% (p < 0.001). Conclusions: Heart failure is a common condition, especially with advancing age. In the elderly, the community burden of heart failure is at least as great as that of angina or hypertension. The high rate of concomitant respiratory tract infection emphasises the need for strategies to immunise patients with heart failure against influenza and pneumococcal infection. Drugs proven to improve survival in heart failure are used less frequently for elderly patients and women

Modelling Future Coronary Heart Disease Mortality to 2030 in the British Isles.

OBJECTIVE: Despite rapid declines over the last two decades, coronary heart disease (CHD) mortality rates in the British Isles are still amongst the highest in Europe. This study uses a modelling approach to compare the potential impact of future risk factor scenarios relating to smoking and physical activity levels, dietary salt and saturated fat intakes on future CHD mortality in three countries: Northern Ireland (NI), Republic of Ireland (RoI) and Scotland. METHODS: CHD mortality models previously developed and validated in each country were extended to predict potential reductions in CHD mortality from 2010 (baseline year) to 2030. Risk factor trends data from recent surveys at baseline were used to model alternative future risk factor scenarios: Absolute decreases in (i) smoking prevalence and (ii) physical inactivity rates of up to 15% by 2030; relative decreases in (iii) dietary salt intake of up to 30% by 2030 and (iv) dietary saturated fat of up to 6% by 2030. Probabilistic sensitivity analyses were then conducted. RESULTS: Projected populations in 2030 were 1.3, 3.4 and 3.9 million in NI, RoI and Scotland respectively (adults aged 25-84). In 2030: assuming recent declining mortality trends continue: 15% absolute reductions in smoking could decrease CHD deaths by 5.8-7.2%. 15% absolute reductions in physical inactivity levels could decrease CHD deaths by 3.1-3.6%. Relative reductions in salt intake of 30% could decrease CHD deaths by 5.2-5.6% and a 6% reduction in saturated fat intake might decrease CHD deaths by some 7.8-9.0%. These projections remained stable under a wide range of sensitivity analyses. CONCLUSIONS: Feasible reductions in four cardiovascular risk factors (already achieved elsewhere) could substantially reduce future coronary deaths. More aggressive polices are therefore needed in the British Isles to control tobacco, promote healthy food and increase physical activity

Sex differences in incidence, mortality, and survival in individuals with stroke in Scotland, 1986 to 2005

<p><b>Background and Purpose:</b> The aim of this study was to examine the effect of sex across different age groups and over time for stroke incidence, 30-day case-fatality, and mortality.</p> <p><b>Methods:</b> All first hospitalizations for stroke in Scotland (1986 to 2005) were identified using linked morbidity and mortality data. Age-specific rate ratios (RRs) for comparing women with men for both incidence and mortality were modeled with adjustment for study year and socioeconomic deprivation. Logistic regression was used to model 30-day case-fatality.</p> <p><b>Results:</b> Women had a lower incidence of first hospitalization than men and size of effect varied with age (55 to 64 years, RR=0.65, 95% CI 0.63 to 0.66; 85 years, RR=0.94, 95% CI 0.91 to 0.96). Women aged 55 to 84 years had lower mortality than men and again size of effect varied with age (65 to 74 years, RR=0.79, 95% CI 0.76 to 0.81); 75 to 84 years, RR=0.94, 95% CI 0.92 to 0.95). Conversely, women aged 85 years had 15% higher stroke mortality than men (RR=1.15, 95% CI 1.12 to 1.18). Adjusted risk of death within 30 days was significantly higher in women than men, and this difference increased over the 20-year period in all age groups (adjusted OR in 55 to 64 year olds 1.23, 95% CI 1.14 to 1.33 in 1986 and 1.51, 95% CI 1.39 to 1.63 in 2005).</p> <p><b>Conclusions:</b> We observed lower rates of incidence and mortality in younger women than men. However, higher numbers of older women in the population mean that the absolute burden of stroke is greater in women. Short-term case-fatality is greater in women of all ages and, worryingly, these differences have increased from 1986 to 2005.</p&gt

Use of evidence to support healthy public policy: a policy effectiveness-feasibility loop

Public policy plays a key role in improving population health and in the control of diseases, including non-communicable diseases. However, an evidence-based approach to formulating healthy public policy has been difficult to implement, partly on account of barriers that hinder integrated work between researchers and policy-makers. This paper describes a “policy effectiveness–feasibility loop” (PEFL) that brings together epidemiological modelling, local situation analysis and option appraisal to foster collaboration between researchers and policy-makers. Epidemiological modelling explores the determinants of trends in disease and the potential health benefits of modifying them. Situation analysis investigates the current conceptualization of policy, the level of policy awareness and commitment among key stakeholders, and what actually happens in practice, thereby helping to identify policy gaps. Option appraisal integrates epidemiological modelling and situation analysis to investigate the feasibility, costs and likely health benefits of various policy options. The authors illustrate how PEFL was used in a project to inform public policy for the prevention of cardiovascular diseases and diabetes in four parts of the eastern Mediterranean. They conclude that PEFL may offer a useful framework for researchers and policy-makers to successfully work together to generate evidence-based policy, and they encourage further evaluation of this approach

Analyzing Recent Coronary Heart Disease Mortality Trends in Tunisia between 1997 and 2009.

BACKGROUND: In Tunisia, Cardiovascular Diseases are the leading causes of death (30%), 70% of those are coronary heart disease (CHD) deaths and population studies have demonstrated that major risk factor levels are increasing. OBJECTIVE: To explain recent CHD trends in Tunisia between 1997 and 2009. METHODS: DATA SOURCES: Published and unpublished data were identified by extensive searches, complemented with specifically designed surveys. ANALYSIS: Data were integrated and analyzed using the previously validated IMPACT CHD policy model. Data items included: (i)number of CHD patients in specific groups (including acute coronary syndromes, congestive heart failure and chronic angina)(ii) uptake of specific medical and surgical treatments, and(iii) population trends in major cardiovascular risk factors (smoking, total cholesterol, systolic blood pressure (SBP), body mass index (BMI), diabetes and physical inactivity). RESULTS: CHD mortality rates increased by 11.8% for men and 23.8% for women, resulting in 680 additional CHD deaths in 2009 compared with the 1997 baseline, after adjusting for population change. Almost all (98%) of this rise was explained by risk factor increases, though men and women differed. A large rise in total cholesterol level in men (0.73 mmol/L) generated 440 additional deaths. In women, a fall (-0.43 mmol/L), apparently avoided about 95 deaths. For SBP a rise in men (4 mmHg) generated 270 additional deaths. In women, a 2 mmHg fall avoided 65 deaths. BMI and diabetes increased substantially resulting respectively in 105 and 75 additional deaths. Increased treatment uptake prevented about 450 deaths in 2009. The most important contributions came from secondary prevention following Acute Myocardial Infarction (AMI) (95 fewer deaths), initial AMI treatments (90), antihypertensive medications (80) and unstable angina (75). CONCLUSIONS: Recent trends in CHD mortality mainly reflected increases in major modifiable risk factors, notably SBP and cholesterol, BMI and diabetes. Current prevention strategies are mainly focused on treatments but should become more comprehensive