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 METHODS: DATA SOURCES: Published and unpublished data were identified by extensive searches, complemented with specifically designed surveys.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

Sustaining modified behaviours learnt in a diabetes prevention program in regional Australia : the role of social context

BackgroundThe Greater Green Triangle diabetes prevention program was conducted in primary health care setting of Victoria and South Australia in 2004--2006. This program demonstrated significant reductions in diabetes risk factors which were largely sustained at 18 month follow-up. The theoretical model utilised in this program achieved its outcomes through improvements in coping self-efficacy and planning. Previous evaluations have concentrated on the behavioural components of the intervention. Other variables external to the main research design may have contributed to the success factors but have yet to be identified. The objective of this evaluation was to identify the extent to which participants in a diabetes prevention program sustained lifestyle changes several years after completing the program and to identify contextual factors that contributed to sustaining changes.MethodsA qualitative evaluation was conducted. Five focus groups were held with people who had completed a diabetes prevention program, several years later to assess the degree to which they had sustained program strategies and to identify contributing factors.ResultsParticipants value the recruitment strategy. Involvement in their own risk assessment was a strong motivator. Learning new skills gave participants a sense of empowerment. Receiving regular pathology reports was a means of self-assessment and a motivator to continue. Strong family and community support contributed to personal motivation and sustained practice.ConclusionsFamily and local community supports constitute the contextual variables reported to contribute to sustained motivation after the program was completed. Behaviour modification programs can incorporate strategies to ensure these factors are recognised and if necessary, strengthened at the local level.<br /

Association Between Cognition, Health Related Quality of Life, and Costs in a Population at Risk for Cognitive Decline

Background: The association between health-related quality of life (HRQoL) and care costs in people at risk for cognitive decline is not well understood. Studying this association could reveal the potential benefits of increasing HRQoL and reducing care costs by improving cognition. Objective: In this exploratory data analysis we investigated the association between cognition, HRQoL utilities and costs in a well-functioning population at risk for cognitive decline. Methods: An exploratory data analysis was conducted using longitudinal 2-year data from the FINGER study (n= 1,120). A change score analysis was applied using HRQoL utilities and total medical care costs as outcome. HRQoL utilities were derived from the Short Form Health Survey-36 (SF-36). Total care costs comprised visits to a general practitioner, medical specialist, nurse, and days at hospital. Analyses were adjusted for activities of daily living (ADL) and depressive symptoms. Results: Although univariable analysis showed an association between cognition and HRQoL utilities, multivariable analysis showed no association between cognition, HRQoL utilities and total care costs. A one-unit increase in ADL limitations was associated with a -0.006 (p Conclusion: The level of cognition in people at-risk for cognitive decline does not seem to be associated with HRQoL utilities. Future research should examine the level at which cognitive decline starts to affect HRQoL and care costs. Ideally, this would be done by means of cross-validation in populations with various stages of cognitive functioning and decline.Peer reviewe

Joint effects of alcohol use, smoking and body mass index as an explanation for the alcohol harm paradox : causal mediation analysis of eight cohort studies

Background and aims Lower socio-economic status (SES) is associated with higher alcohol-related harm despite lower levels of alcohol use. Differential vulnerability due to joint effects of behavioural risk factors is one potential explanation for this 'alcohol harm paradox'. We analysed to what extent socio-economic inequalities in alcohol-mortality are mediated by alcohol, smoking and body mass index (BMI), and their joint effects with each other and with SES. DesignCohort study of eight health examination surveys (1978-2007) linked to mortality data. Setting Finland.ParticipantsA total of 53 632 Finnish residents aged 25+ years.MeasurementsThe primary outcome was alcohol-attributable mortality. We used income as an indicator of SES. We assessed the joint effects between income and mediators (alcohol use, smoking and BMI) and between the mediators, adjusting for socio-demographic indicators. We used causal mediation analysis to calculate the total, direct, indirect and mediated interactive effects using Aalen's additive hazards models. Findings During 1 085 839 person-years of follow-up, we identified 865 alcohol-attributable deaths. We found joint effects for income and alcohol use and income and smoking, resulting in 46.8 and 11.4 extra deaths due to the interaction per 10 000 person-years. No interactions were observed for income and BMI or between alcohol and other mediators. The lowest compared with the highest income quintile was associated with 5.5 additional alcohol deaths per 10 000 person-years (95% confidence interval = 3.7, 7.3) after adjusting for confounders. The proportion mediated by alcohol use was negative (-69.3%), consistent with the alcohol harm paradox. The proportion mediated by smoking and BMI and their additive interactions with income explained 18.1% of the total effect of income on alcohol-attributable mortality. Conclusions People of lower socio-economic status appear to be more vulnerable to the effects of alcohol use and smoking on alcohol-attributable mortality. Behavioural risk factors and their joint effects with income may explain part of the alcohol harm paradox.Peer reviewe

Fit for what?: towards explaining Battlegroup inaction

The thrust of this paper concerns the case of the European Battlegroup (BG) non-deployment in late 2008, when the United Nations requested European military support for the United Nations Organisation Mission peacekeeping force in the Democratic Republic of the Congo (DRC). The argument is built on the fact that when, in official documents, the EU approaches the European security and ESDP/CSDP's military crisis management policy and interventions, it makes strong references to the United Nations and the UN Charter Chapter VII's mandate of restoring international peace and security. Such references make it seem that supporting the UN when it deals with threats and crises is a primary concern of the EU and the member states. These allusions lead to the main contention of this paper, that there is much ambivalence in these indications. The paper develops its argument from one key hypothesis; namely, that the non-deployment of a European BG in the DRC, at the end of 2008, constitutes a useful case study for detecting a number of ambiguities of the EU in respect of its declarations in the official documents establishing the European military crisis management intervention structure