Effect of Patients’ Awareness of CVD Risk Factors on Health-Related Behaviors:

Knowledge of cardiovascular diseases and associated risk factors in the general adult population of Jeddah, Saudi Arabia: A cross-sectional study examining gender disparities

To assess knowledge about cardiovascular diseases (CVD) among the general population, we emphasized gender-related disparities and other lifestyle and health-related factors. This cross-sectional study was conducted among 395 individuals from the general population of Jeddah, Saudi Arabia. An online questionnaire was administered to assess knowledge of CVD types, symptoms, and risk factors. The majority of participants identified coronary heart disease (73.7%) as having CVD, with no sex effect. Males had higher knowledge regarding cerebrovascular disease (44% vs 31.5%) and congenital heart diseases (60% vs 51.9%) as being part of CVD, while they had lower knowledge of peripheral arterial disease (44% vs 50.7%) than females, respectively (P < .05). Males exhibited better knowledge of heart attack and stroke symptoms than females. Knowledge was optimal for major CVD risk factors, such as smoking (90.6%) and high low-density lipoprotein cholesterol levels (85.1%); however, gaps were observed in recognizing diabetes (56.2%) and stress (69.4%) as factors for CVD. The mean overall knowledge score was 16.33 ± 5.72 25, with no difference between sexes (P = .239). Predictors of good CVD knowledge included university-level education, daily healthy food consumption, and perceived life as highly stressful; nonetheless, sex showed no significant effect. While the general population displayed a suboptimal understanding of CVD, notable sex disparities were observed, highlighting the need for tailored public health interventions. Emphasizing cognitive and behavioral aspects can foster better prevention and management strategies, given the evident gender disparities.

The independent and joint associations of cardiorespiratory fitness and adiposity with cardiometabolic risk factors and metabolic syndrome in United States college students

Objective To examine the association of CRF and adiposity with cardiometabolic risk factors and metabolic syndrome among emerging adults. Participants: 5681 (60.1% Men; 21 ± 1years) college students from a large university located in the northeast of the United States. Methods: Participants completed an objective health assessment that involved the assessment cardiometabolic risk factors, CRF, and adiposity. Data of 5681 students' (60.1% Men; 21 ± 1years) who had CRF, adiposity, all risk factors necessary to determine metabolic syndrome evaluated were analyzed using logistic regression analyses. Results: Poor CRF and elevated adiposity were associated with cardiometabolic risk factors and metabolic syndrome regardless of sex, with the association between adiposity and risk factors found to be stronger compared to CRF. Conclusions: Targeted and tailored screening and interventions are urgently needed to reduce adiposity and increase CRF to avoid serious short and long-term negative health outcomes in this population.

Knowledge, attitudes, and beliefs of cardiovascular disease prevention in young adults in the country of Georgia

INTRODUCTION

Cardiovascular disease (CVD) accounts for 46% of all mortality in the country of Georgia (former Soviet Union). Young adults in that country have not been studied regarding CVD and a need exists to understand lifestyle modifications to promote cardiovascular health.

DESIGN

An interpretive description qualitative design was used to explore Georgian young adults' knowledge, attitudes, and beliefs of CVD preventative practices and life experiences.

METHODS

A convenience sample of 19 ethnic Georgian participants (18-40 years old) who were fluent in either English, Georgian, or Russian from a local private university was used. Semi-structured interviews were conducted via video conferencing utilizing an interpreter.

RESULTS

Four themes were identified: (1) CVD and risk factor knowledge, (2) prevention attitudes, beliefs, and gender differences, (3) health literacy influences, and (4) culture and societal impacts. CVD knowledge was limited and influenced by health literacy and the current healthcare system in Georgia.

CONCLUSION

Cultural and societal gender norms influence cardiovascular health behaviors.

CLINICAL IMPLICATIONS

Georgian nurses can play a key role in CVD education and screening for young adults in Georgia.

How to optimize the adherence to a guideline-directed medical therapy in the secondary prevention of cardiovascular diseases: a clinical consensus statement from the European Association of Preventive Cardiology

A key factor to successful secondary prevention of cardiovascular disease (CVD) is optimal patient adherence to treatment. However, unsatisfactory rates of adherence to treatment for CVD risk factors and CVD have been observed consistently over the last few decades. Hence, achieving optimal adherence to lifestyle measures and guideline-directed medical therapy in secondary prevention and rehabilitation is a great challenge to many healthcare professionals. Therefore, in this European Association of Preventive Cardiology clinical consensus document, a modern reappraisal of the adherence to optimal treatment is provided, together with simple, practical, and feasible suggestions to achieve this goal in the clinical setting, focusing on evidence-based concepts.

Communication about physical activity to reduce vascular erectile dysfunction - A qualitative interview study among men in cardiac rehabilitation

BACKGROUND

Physical activity, a core intervention in cardiac rehabilitation, can reduce vascular erectile dysfunction (ED). ED is a common sensitive problem for men with cardiac diseases, decreasing their quality of life. Cardiac health professionals rarely provide information about ED or its relation to physical activity. Developing health professionals' communicative component of the complex intervention 'Physical Activity to reduce Vascular Erectile Dysfunction' (PAVED) is important. Understanding the receiver needs is essential in designing a complex intervention.

AIM

To elucidate men's perspectives on cardiac health professionals' communication about PAVED.

ETHICAL ISSUES

An Institutional Data Protection Agency approved the study.

METHODS

An interpretive data-driven thematic analysis was applied to individual, qualitative semi-structured interviews with 20 Danish men attending cardiac rehabilitation.

RESULTS

The men wanted health professionals' communicating about ED, as it was perceived as a major problem diminishing masculinity and tabooed by health professionals. Men wanted help for self-help, which may be possible with the aid of competent health professionals' communication about how to prevent, reduce and cope with ED - including information about PAVED. The men wanted health professionals' communication about ED in various contexts: general information in groups, sexual counselling for individuals and couples and written material.

STUDY LIMITATIONS

Recruitment was done from a Danish municipality's cardiac rehabilitation, and the transferability of the results may be limited to similar contexts.

CONCLUSION

Erectile dysfunction was experienced as a major biopsychosocial problem for the men and their partners. The men had a need for health professionals' communication about sexuality, ED and information about PAVED as well as about prevention, reduction and management of ED. The men had a need for professional communication about sexual health.

Modelling knowledge, health beliefs, and health-promoting behaviours related to cardiovascular disease prevention among Malaysian university students

Background

Healthy lifestyle habits formed during young adulthood may have a sustaining impact on health across later life. The current study aimed to test the theoretical model of factors (selected demographic variables, knowledge of heart disease, health belief related to cardiovascular disease (CVD), self-efficacy, cues to action, and screening intention) influencing health-promoting behaviours among Malaysian university students.

Methods

In a cross-sectional survey, the undergraduate students in Universiti Sains Malaysia were invited to complete the self-administered questionnaires. Participants were selected using a purposive sampling method. The proposed hypothesised model was analysed using a structural equation modelling with Mplus 7.3 program. A total of 788 (70.7% female) undergraduate students with a mean age of 20.2 (SD = 1.02) participated in the study. The primary outcome of knowledge, health beliefs, and health-promoting behaviours related to CVD were measured by questionnaires namely: Knowledge of Heart Disease, Health Beliefs Related to CVD, and Health Promoting Lifestyle Profiles-II.

Results

The final hypothetical structural model showed a good fit to the data based on several fit indices: with comparative fit index (CFI) at .921, standardised root mean square residual (SRMR) at .037, and root mean square error of approximation (RMSEA) at .044 (90% CI: .032, .054). The final structural model supported 13 significant path estimates. These variables explained 12% of the total variance in health-promoting behaviours. Through perceived benefits, total knowledge had an indirect effect on health-promoting behaviours.

Conclusion

The results suggest that perceived barriers, perceived benefits, family history of CVD, and screening intention enable young adults to engage in health-promoting behaviours.

Rural-urban differences in college students' cardiovascular risk perceptions

Objective: To examine rural-urban differences in college students' cardiovascular risk perceptions. Participants: College students in rural (n = 61) and urban (n = 57) Kentucky counties were recruited from November 2012 to May 2014. Methods: This was a secondary data analysis of a cross-sectional study examining rural-urban differences in cardiovascular risk factors. Students rated their risk for developing high blood pressure, diabetes, high cholesterol, heart disease, having a stroke, and gaining excess weight. Chi-square and logistic regression were used for data analysis. Results: Rural students had lower odds of perceived high risk for developing high blood pressure compared to urban students (odds ratio (OR): 0.32, 95% CI: 0.11-0.96) after adjusting for race, sex, and body mass index. This association was not observed after adjusting for healthcare access variables. No other significant differences were observed. Conclusions: Efforts to raise perceived risk for developing hypertension among rural college students may be warranted.

Patients' knowledge on cardiovascular risk factors and associated lifestyle behaviour in Ethiopia in 2018: A cross-sectional study

BACKGROUND

Cardiovascular disease (CVD) is posing a major public health challenge globally. Evidence reports significant gaps in knowledge of cardiovascular risk factors among patients with CVD. Despite the growing burden of cardiovascular disease in developing countries, there is limited data available to improve the awareness of this area, which is crucial for the implementation of prevention programs.

METHODS

A cross-sectional survey was conducted in two referral hospitals in Eastern Ethiopia from June-September 2018. Outpatients with a confirmed diagnosis cardiovascular conditions were eligible for participation in the study. A convenience sampling technique was used. The primary outcome of the study was knowledge of cardiovascular risk factors among patients with cardiovascular disease. The knowledge of cardiovascular disease risk factors was measured using a validated instrument (heart disease fact questionnaire). A score less than 70% was defined as suboptimal knowledge. Multivariable linear regression was used to examine the relationship between knowledge of cardiovascular risk factors and explanatory variables.

RESULTS

A total of 287 patients were enrolled in the study. Mean age was 47±11yrs and 56.4% of patients were females. More than half of patients (54%) had good knowledge on cardiovascular risk factors (scored>70%), whilst 46% demonstrated suboptimal knowledge levels in this area. Urban residency was associated with higher cardiovascular risk factors knowledge scores, whereas, never married and no formal education or lower education were identified as predictors of lower knowledge scores. There was no statistically significant association between knowledge of cardiovascular risk factors and actual cumulative risk behaviour.

CONCLUSION

Almost half of CVD patients in Ethiopia have suboptimal knowledge regarding cardiovascular risk factors. Residence, education level and marital status were associated with knowledge of cardiovascular risk factors. Implementation of innovative interventions and structured, nurse-led lifestyle counselling would be required to effectively guide patients in developing lifestyle modification and achieve sustainable behaviour change.

Association Between Self-Reported Hypertension and Antihypertensive Medication Use and Cardiovascular Disease-Related Events and Expenditures Among Patients Diagnosed With Hypertension

OBJECTIVES

Research suggests that persons who are aware of the risk factors for cardiovascular disease (CVD) are more likely to engage in healthy behaviors than persons who are not aware of the risk factors. We examined whether patients whose insurance claims included an International Classification of Diseases, Ninth Revision (ICD-9) code associated with hypertension who self-reported high blood pressure were more likely to fill antihypertensive medication prescriptions and less likely to have CVD-related emergency department visits and hospitalizations (hereinafter, CVD-related events) and related medical expenditures than patients with these codes who did not self-report high blood pressure.

METHODS

We used a large convenience sample from the MarketScan Commercial Database linked with the MarketScan Health Risk Assessment (HRA) Database to identify patients aged 18-64 in the United States whose insurance claims included an ICD-9 code associated with hypertension and who completed an HRA from 2008 through 2012 (n = 111 655). We used multivariate logistic regression analysis to examine the association between self-reported high blood pressure and (1) filling prescriptions for antihypertensive medications and (2) CVD-related events. Because most patients with hypertension will not have a CVD-related event, we used a 2-part model to analyze medical expenditures. The first part estimated the likelihood of a CVD-related event, and the second part estimated expenditures.

RESULTS

Patients with an ICD-9 code of hypertension who self-reported high blood pressure had a significantly higher predicted probability of filling antihypertensive medication prescriptions (26.5%; 95% confidence interval, 25.7-27.3; P < .001), had a significantly lower predicted probability of a CVD-related event (0.6%, P < .001), and on average spent significantly less on CVD-related events ($251, P = .01) than patients who did not self-report high blood pressure.

CONCLUSION

This study affirms that self-knowledge of high blood pressure, even among patients who are diagnosed and treated for hypertension, can be improved. Interventions that improve patients' awareness of their hypertension may improve antihypertensive medication use and reduce adverse CVD-related events.

Should information about sexual health be included in education directed toward men with cardiovascular diseases?

BACKGROUND

Modifiable risk factors contribute to the pathogenesis of cardiovascular disease (CVD) and erectile dysfunction (ED). We aimed to compare the knowledge about the contribution of modifiable risk factors to the pathogenesis of CVD and ED. The impact of patients' having modifiable risk factors on the awareness of their negative influence on the development of CVD and ED was examined.

METHODS

To this multicenter cohort study, we included 417 patients with CHD who had been hospitalized in the cardiology or cardiac surgery department during the previous six weeks and underwent cardiac rehabilitation in one of the five centers. Knowledge about modifiable risk factors was collected. ED was assessed by an abridged IIEF-5 questionnaire. Comparisons between groups were conducted using the Student's t-test, Mann-Whitney U test, and Kruskal-Wallis test. Relationships were analyzed with Spearman's rank correlation coefficient.

RESULTS

The mean number of correctly identified risk factors for CVD was significantly higher than those for ED (3.71 ± 1.87 vs. 2.00 ± 1.94; p < .0001). Smoking was the most recognized risk factor both for CVD and ED. Dyslipidemia was least frequently identified as a risk factor for CVD. Sedentary lifestyle was the only risk factor whose incidence did not affect the level of patient knowledge.

CONCLUSIONS

Cardiac patients with ED know more about risk factors for CVD than ED. It is necessary to include information about the negative impact of modifiable risk factors on sexual health into education programs promoting healthy lifestyles in men with cardiovascular diseases.

Accuracy of self-perceived risk for common conditions

Background:

Accurate awareness of common disease risk is necessary to promote healthy lifestyles and to prevent unnecessary anxiety and evaluation. Our objective is to identify characteristics of patients who do not accurately perceive their risk of developing coronary heart disease (CHD), diabetes (DM), breast cancer (BC) and colorectal cancer (CRC).

Methods:

Using personalized disease risk reports and risk perception surveys, subjects (n = 4703) were classified as high or low/average risk and high or low/average perceived risk for each condition. Models were used to examine factors associated with risk under-estimation by high risk patients and risk over-estimation by low/average risk patients.

Results:

Patients at high risk for DM, BC and CRC often (60%−75% of the time) under-estimated their risk, while low/average risk patients overestimated their risk 13%−40% of the time. For CHD, under-estimation by high risk individuals approximated over-estimation by low/average individuals. Compared to normal weight patients at high risk for cancer, obese patients were more likely to under-estimate their risk for BC (OR 3.1, CI 1.9–5.0) and CRC (2.6, 1.5–4.5) as were overweight patients. Overweight and obese patients at low/average risk of DM or CHD were more likely than normal weight patients to over-estimate their risk. Low/average risk women were more likely than men to over-estimate their risk of DM (1.3, 1.1–1.5) and CHD (1.8, 1.5–2.1).

Conclusions:

Our data show that body mass index is the factor most consistently associated with incorrect risk perceptions for several common conditions.

Risk Knowledge and Awareness of Coronary Heart Disease, and Health Promotion Behaviors Among Adults in Oman

Background and Purpose:

The purpose of this study was to assess the relationships between an individual’s characteristics and experiences (age, gender, level of education, income, and employment), knowledge of coronary heart disease (CHD) risk factors, perception of health status, awareness of CHD, and health promotion behaviors among adult Omanis.

Methods:

Using Pender’s health promotion model, a cross-sectional and correlational survey design was employed. A self-administered questionnaire was distributed to 180 participants in Muscat, the capital of Oman. Descriptive and multivariate linear regression analyses were employed.

Results:

Increasing age was associated with high levels of awareness about CHD. Participants who were employed and knowledgeable about CHD risk factors were more likely to have lower perceptions of health. The regression model showed that knowledge of CHD risk factors and awareness of CHD had positive associations with health promotion behaviors. Meanwhile, employed participants had lower health promotion behaviors scores.

Implications for Practice:

Interventions to increase health promotion behaviors should include application of behavioral change strategies that are suitable for age and employment status. The strategies must focus on providing information to enhance knowledge and awareness about CHD.

Persistence of socioeconomic inequalities in the knowledge of cardiovascular risk factors five years after coronary angiography

BACKGROUND

Cardiovascular diseases are important causes of death, morbidity, and years of potential life lost in most developed countries.

AIMS

The purpose of this study was to assess trends in knowledge of cardiovascular risk factors among patients five years after coronary angiography and to investigate the impact of educational level on knowledge level.

METHODS

The study included 1289 of 4391 patients admitted for cardiac events in 2008/2009 at the National Institute for Cardiac Surgery and Interventional Cardiology, Luxembourg. A follow-up study was conducted by post five years later (2013/2014). Data were obtained from 1837 of the contacted patients (with 548 reported deaths) (response rate=42%). Logistic regression models were used to evaluate the association between educational level and knowledge of cardiovascular risk factors. Educational level was used as a surrogate for socioeconomic status.

RESULTS

In total, 39.9% of patients could list at least three risk factors in 2013/2014, a much higher percentage than the 8.5% observed during the initial survey. In both sexes, knowledge of cardiovascular risk factors increased between 2008/2009 and 2013/2014. Patients with higher educational levels were more likely (odds ratio=2.33, 95% confidence interval: 1.63-3.34) to cite at least three risk factors than patients with lower education levels.

CONCLUSION

Knowledge level was associated with educational level, and improved for all educational groups five years after coronary angiography. Educational differences in knowledge persisted, but the gaps decreased. Improving knowledge of cardiovascular risk factors among patients with cardiovascular disease will help increase awareness and promote lifestyle changes.

Association Between the Awareness of Dyslipidemia and Health Behavior for Control of Lipid Levels Among Korean Adults with Dyslipidemia

Background

Dyslipidemia is a major risk factor contributing to cardiovascular disease and its prevalence is steadily rising. Although screening tests are readily accessible, dyslipidemia remains undertreated. Evaluating health behavior patterns after diagnosis may help improve lifestyle interventions for the management of dyslipidemia.

Methods

Data from the fifth Korean National Health and Nutrition Examination Survey 2010–2012 were used. A total of 6,624 dyslipidemia patients over 20 years old were included according to National Cholesterol Education Program-Adult Treatment Panel III guidelines. Logistic regression analysis was completed using a weighted method to determine whether awareness of dyslipidemia was associated with health behavior. Health behavior was divided into two categories: behavioral factors (smoking, alcohol consumption, exercise) and nutritional factors (adequate intake of fiber, carbohydrate, fat, protein).

Results

There were no significant differences in health behavior among dyslipidemia patients according to awareness after adjustment for covariates, diabetes and hypertension. Awareness in women was associated with decreased smoking (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.32 to 0.94), but when adjusted for diabetes and hypertension the result was not significant (OR, 0.61; 95% CI, 0.35 to 1.06). The same pattern applied to intake of carbohydrate in men (OR, 1.28; 95% CI, 0.99 to 1.67) and protein in women (OR, 1.22; 95% CI, 0.98 to 1.50). In subgroup analysis, awareness of dyslipidemia in men without hypertension or diabetes was associated with adequate intake of carbohydrate (OR, 1.70; 95% CI, 1.06 to 2.72).

Conclusion

Increasing awareness alone may not be enough to improve healthy behavior in patients with dyslipidemia. Efforts including patient education and counseling through a multi-team approach may be required.

Potential contribution of lifestyle and socioeconomic factors to healthy user bias in antihypertensives and lipid-lowering drugs

Objectives

Healthy user bias arises when users of preventive medications such as lipid-lowering drugs (LLDs), hormone replacement therapy and antihypertensive (AH) medications are healthier than non-users due to factors other than medication effects, making the medications appear more beneficial in observational studies of effectiveness and safety. The purpose of the study is to examine factors contributing to healthy user effect in patients taking AHs or LLDs.

Methods

Among patients with hypertension or hyperlipidaemia in a population-based sample from the National Health and Nutrition Examination Survey (1999–2010), we assessed the association between socioeconomic and lifestyle factors and the use of AHs/LLDs by logistic regression with adjustment for demographics and comorbidities in a cross-sectional study.

Results

When 9715 AH/LLD users were compared with 3725 non-users, AH/LLD users were more likely to be: highly educated (OR 1.2, 95% CI 1.2 to 1.3), non-impoverished (OR 1.3, 95% CI 1.2 to 1.4), current non-smokers (OR 1.2, 95% CI 1.1 to 1.4), physically active (OR 1.1, 95% CI 1.0 to 1.2) and consume more calcium (OR 1.1, 95% CI 1.0 to 1.3) but less likely to have normal body mass index (OR 0.6, 95% CI 0.6 to 0.7) or to meet dietary sodium recommendations (OR 0.8, 95% CI 0.7 to 0.9).

Conclusions

We identified several salutary lifestyle factors associated with AH/LLD use in a representative US population. Healthy user effect may be partly explained by better socioeconomic profiles and lifestyles in AH/LLD users compared with non-users.

Cohort profile: the Baependi Heart Study-a family-based, highly admixed cohort study in a rural Brazilian town

PURPOSE

Cardiovascular disease (CVD) is a major challenge to global health. The same epidemiological transition scenario is replayed as countries develop, but with variations based on environment, culture and ethnic mixture. The Baependi Heart Study was set up in 2005 to develop a longitudinal family-based cohort study that reflects on some of the genetic and lifestyle-related peculiarities of the Brazilian populations, in order to evaluate genetic and environmental influences on CVD risk factor traits.

PARTICIPANTS

Probands were recruited in Baependi, a small rural town in the state of Minas Gerais, Brazil, following by first-degree and then increasingly more distant relatives. The first follow-up wave took place in 2010, and the second in 2016. At baseline, the study evaluated 1691 individuals across 95 families. Cross-sectional data have been collected for 2239 participants.

FINDINGS TO DATE

Environmental and lifestyle factors and measures relevant to cardiovascular health have been reported. Having expanded beyond cardiovascular health outcomes, the phenotype datasets now include genetics, biochemistry, anthropometry, mental health, sleep and circadian rhythms. Many of these have yielded heritability estimates, and a shared genetic background of anxiety and depression has recently been published. In spite of universal access to electricity, the population has been found to be strongly shifted towards morningness compared with metropolitan areas.

FUTURE PLANS

A new follow-up, marking 10 years of the study, is ongoing in 2016, in which data are collected as in 2010 (with the exception of the neuropsychiatric protocol). In addition to this, a novel questionnaire package collecting information about intelligence, personality and spirituality is being planned. The data set on circadian rhythms and sleep will be amended through additional questionnaires, actimetry, home sleep EEG recording and dim light melatonin onset (DLMO) analysis. Finally, the anthropometric measures will be expanded by adding three-dimensional facial photography, voice recording and anatomical brain MRI.

Awareness of Cardiovascular Disease and Preventive Behaviors Among Overweight Immigrant Latinas

BACKGROUND AND OBJECTIVES

Low-income Latina women face increased risk for cardiovascular disease (CVD) due to high rates of obesity, diabetes, and other comorbidities. Language barriers, lack of health insurance, and lack of access to preventive health messages may further increase their risk. The purpose of this study was to evaluate knowledge about CVD of overweight, immigrant Latinas who spoke little or no English and participated in an educational intervention.

METHODS

Ninety participants completed a CVD knowledge questionnaire before and after 8 educational sessions based upon Su Corazón, Su Vida. The curriculum focused on understanding risk factors of CVD and prevention through heart-healthy diets, physical activity, and weight control. The questionnaire evaluated general CVD knowledge (eg, heart disease is the leading cause of death in women) and prevention measures (eg, physical activity can lower a woman's risk for getting heart disease). Data were analyzed using generalized estimating equations and correlational statistics.

RESULTS

Participants were middle-aged, overweight Latinas, predominantly of Mexican descent, with low education and acculturation. Baseline knowledge that heart disease is the leading cause of death in women was low. A comparison of preintervention and postintervention scores on the questionnaire showed a significant change (P < 0.001), with means of 7.9 and 9.4, respectively. Scores for individual items correctly answered significantly improved for 9 of the 11 items, including questions about portion control to lose weight, physical activity, overweight, and risk for heart disease. Most participants did not recognize that men and women may experience different symptoms of a heart attack. Knowledge was not significantly related to background characteristics, body mass index, or lifestyle behaviors.

CONCLUSIONS

Despite campaigns to increase CVD awareness, many Spanish-speaking, immigrant Latinas remain unaware that heart disease is the leading cause of death. Educational interventions may significantly improve their CVD knowledge; nonetheless, continued cardiovascular health promotion efforts are needed for this population.