Documenting the Full Value of Vaccination: A Systematic Review of Value Frameworks

OBJECTIVES

Economic evaluations of vaccination may not fully account for nonhealth patient impacts on families, communities, and society (ie, broader value elements). Omission of broader value elements may reflect a lack of established measurement methodology, lack of agreement over which value elements to include in economic evaluations, and a lack of consensus on whether the value elements included should vary by vaccination type or condition. We conducted a systematic review of value frameworks to identify broader value elements and measurement guidance that may be useful for capturing the full value of vaccination.

METHODS

We searched Ovid MEDLINE, PubMed, Embase, and the gray literature to identify value frameworks for all health interventions, and we extracted information on each framework's context, value elements, and any available guidance on how these elements should be measured. We used descriptive statistics to analyze and compare the prevalence of broader value elements in vaccination value frameworks and other healthcare-related value frameworks.

RESULTS

Our search identified 62 value frameworks that met inclusion criteria, 9 of which were vaccination specific. Although vaccination frameworks included several broader value elements, such as reduced transmissibility and public health benefits, the elements were represented inconsistently across the frameworks. Vaccination frameworks omitted several value elements included in nonvaccination-specific frameworks, including dosing and administration complexity and affordability. In addition, guidance for measuring broader value elements was underdeveloped.

CONCLUSIONS

Future efforts should further evaluate inclusion of broader value elements in economic evaluations of vaccination and develop standards for their subsequent measurement.

The Thai Health Promotion Foundation: Two Decades of Joint Contributions to Addressing Noncommunicable Diseases and Creating Healthy Populations

Globally, the current investment in preventive care is inadequate and ineffective for addressing noncommunicable diseases and their causes. The Thai Health Promotion Foundation, with its sustainable funding from 2% levies on tobacco and alcohol, together with partners, has been used to address noncommunicable diseases effectively.

Behavioral economic and wellness-based approaches for reducing alcohol use and consequences among diverse non-student emerging adults: study protocol for Project BLUE, a randomized controlled trial

BACKGROUND

Emerging adults (EAs) who are not 4-year college students nor graduates are at elevated risk for lifetime alcohol use disorder, comorbid drug use, and mental health symptoms, compared to college graduates. There is a need for tailored brief alcohol intervention (BAI) approaches to reduce alcohol risk and to facilitate healthy development in this high-risk population. Most BAIs include a single session focused on discussing risks associated with drinking and correcting normative beliefs about drinking rates. EAs may benefit from additional elements that enhance general wellness. The substance-free activity session (SFAS) aims to clarify life goals and values and increase goal-directed activities that provide alternatives to alcohol use, and the relaxation training (RT) session teaches relaxation and stress reduction skills.

METHODS

The present study is a randomized 3-group (BAI + SFAS vs. RT + SFAS vs. education control) trial with 525 EAs (175 per group; estimated 50% women and 50% African American) who report recent risky drinking and who are not students or graduates of 4-year colleges. Participants will have the option of completing the intervention sessions in person or via a secure video teleconference. Levels of drinking and alcohol-related problems will be evaluated at baseline and 1, 3, 6, and 12 months post-intervention. The primary hypothesis is that both BAI + SFAS and RT + SFAS participants will report significantly greater reductions in alcohol use and problems relative to education control participants, with no differences in outcomes between the two active treatment conditions.

DISCUSSION

The results of this study will inform alcohol prevention efforts for high-risk community dwelling emerging adults.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04776278.

Behavioral Economic and Wellness-based Approaches for Reducing Alcohol Use and Consequences Among Diverse Non-Student Emerging Adults: Study Protocol for Project BLUE, a Randomized Controlled Trial

Background

Emerging adults (EAs) who are not 4-year college students nor graduates are at elevated risk for lifetime alcohol use disorder, comorbid drug use, and mental health symptoms, compared to college graduates. There is a need for tailored brief alcohol intervention (BAI) approaches to reduce alcohol risk and to facilitate healthy development in this high-risk population. Most BAIs include a single session focused on discussing risks associated with drinking and correcting normative beliefs about drinking rates. EAs may benefit from additional elements that enhance general wellness. The Substance-Free Activity Session (SFAS) aims to clarify life goals and values and increase goal-directed activities that provide alternatives to alcohol use, and the Relaxation Training (RT) session teaches relaxation and stress reduction skills.

Methods

The present study is a randomized 3-group (BAI+SFAS vs. RT+SFAS vs. education control) trial with 525 EAs (175 per group; estimated 50% women & 50% African American) who report recent risky drinking and who are not students or graduates of 4-year colleges. Participants will have the option of completing the intervention sessions in person or via a secure video teleconference. Levels of drinking and alcohol-related problems will be evaluated at baseline and 1, 3, 6, and 12-months post-intervention. The primary hypothesis is that both BAI+SFAS and RT+SFAS participants will report significantly greater reductions in alcohol use and problems relative to education control participants, with no differences in outcomes between the two active treatment conditions.

Discussion

The results of this study will inform alcohol prevention efforts for high-risk community dwelling emerging adults.

ClinicalTrialsgov Identifier

NCT04776278.

What Is Value in Health and Healthcare? A Systematic Literature Review of Value Assessment Frameworks

OBJECTIVES

This study aimed to investigate how value is defined and measured in existing value assessment frameworks (VAFs) in healthcare.

METHODS

We searched PubMed, Embase, the Cochrane Library, and Centre for Reviews and Dissemination from 2008 to 2019. We also performed backward citation chaining of included studies and previously published systematic reviews. Studies reporting the development of a VAF in healthcare were included. For each included framework, we extracted and compared the context, target users, intended use, methods used to identify value attributes, description of the attributes, and attribute scoring approaches.

RESULTS

Of the 8151 articles screened, 57 VAFs were included. The value attributes included in 55 VAFs were grouped into 9 categories: health benefits (n = 53, 96%), affordability (n = 45, 82%), societal impact (n = 42, 76%), burden of disease (n = 36, 65%), quality of evidence (n = 32, 58%), cost-effectiveness (n = 31, 56%), ethics and equity (n = 27, 49%), unmet needs (n = 21, 38%), and innovation (n = 15, 27%). The remaining 2 VAFs used broad attributes or user-defined attributes. Literature review was the main approach to identify value attributes in 36 VAFs. Patient or public was engaged through the development of only 11 VAFs. Weighting has been used to score 29 VAFs, of which 19 used the methods of multicriteria decision analysis.

CONCLUSIONS

There are substantial variations in defining and measuring value. A noticeable weakness of existing VAFs is that patient or public engagement was generally very limited or missing in framework development process. Existing VAFs tend to aggregate multiple value attributes into a single index for decision making.

Screening for Excessive Alcohol Consumption in Emergency Departments: A Nationwide Assessment of Emergency Department Physicians

OBJECTIVE

To assess current screening practices for excessive alcohol consumption, as well as perceived barriers, perceptions, and attitudes toward performing this screening among emergency department (ED) physicians.

DESIGN

A brief online assessment of screening practices for excessive drinking was disseminated electronically to a representative panel of ED physicians from November 2016 to January 2017. Descriptive statistics were calculated on the frequency of alcohol screening, factors affecting screening, and attitudes toward screening.

SETTING

An online assessment was sent to a national panel of ED physicians.

PARTICIPANTS

A panel of ED physicians who volunteered to be part of the American College of Emergency Physicians Emergency Medicine Practice Research Network survey panel.

MAIN OUTCOME MEASURE

The primary outcome measures were the percentage of respondents who reported screening for excessive alcohol consumption and the percentage of respondents using a validated excessive alcohol consumption screening tool.

RESULTS

Of the 347 ED physicians evaluated (38.6% response rate), approximately 16% reported "always/usually," 70% "sometimes," and 14% "never" screening adult patients (≥18 years) for excessive alcohol use. Less than 20% of the respondents who screened for excessive drinking used a recommended screening tool. Only 10.5% of all respondents (15.4% "always," 9.5% "sometimes" screened) received an electronic health record (EHR) reminder to screen for excessive alcohol use. Key barriers to screening included limited time (66.2%) and treatment options for patients with drinking problems (43.1%).

CONCLUSIONS

Only 1 in 6 ED physicians consistently screened their patients for excessive drinking. Increased use of EHR reminders and other systems interventions (eg, electronic screening and brief intervention) could help improve the delivery of screening and follow-up services for excessive drinkers in EDs.

Quality of Care and Preventive Screening Use in the CareFirst Patient-Centered Medical Home Program

Despite their value, comprehensive diabetes care and screening for common cancers remain underutilized. We examined the association between participation in a patient-centered medical home (PCMH) program with strong financial incentives and receipt of preventive care in the first 5 years after program launch. Using multivariate regression analysis, we compared outcomes for adults under the care of participating primary care providers (PCPs) with adults under the care of nonparticipating PCPs. Outcomes were breast, cervical and colorectal cancer screenings, and elements of diabetes care. The analytic sample included 818,623 adults living in Maryland, Virginia, or the District of Columbia, and enrolled with CareFirst for at least 1 year during 2010-2015. By Year 5, enrollees in the intervention group were 7.9 (95% confidence interval [CI]: 2.8-13.0), 6.1 (95% CI: 1.4-10.7), 3.1 (95% CI: 2.1-4.0), and 7.6 (95% CI: 7.0-8.2) percentage points more likely to undergo HbA1c tests, nephropathy examinations, breast, and cervical cancer screenings, respectively. We found no significant change in the propensity to receive colorectal cancer screening or an eye examination. Our study shows that a PCMH program with strong financial incentives can raise the provision of preventive care but could require additional adjustment.

Introducing a reserve waiting list initiative for elective general surgery at a District General Hospital

Cancelled operations represent a significant burden on the National Health Service in terms of theatre efficiency, financial implications and lost training opportunities. Moreover, they carry considerable physical and psychological effects to patients and their relatives. Evidence has shown that up to 93% of cancelled operations are due to patient-related factors. An analysis at our District General Hospital revealed that approximately 18 operations are cancelled on the day of surgery each month. This equates to 27 hours of allocated operating time valued by the trust as £67 500, not being used effectively. This retrospective quality improvement report aims to reduce unused theatre time due to cancelled elective operations in general surgery theatres-thereby improving theatre efficiency and patient care. To ascertain the baseline number of cancelled operations, an initial review of theatre cases was undertaken. Further review was then completed after implementation of two improvements-a short notice surgical waiting list and fast track pre-assessment clinics. The results showed that implementation of the reserve surgical waiting list reduced unused operating time by an average of 2.25 hours per month. By further adding in the fast track preassessment clinic, these figures increased to an average of 11.5 hours over the next 3 months. This precipitated a reutilisation of otherwise wasted theatre time. Economic impact of this time amounts around £28 750 a month, after implementation of both improvements. Simple protocol changes can lead to large improvements in the efficient running of theatres. The resultant change has improved patient satisfaction, led to greater training opportunities and improved theatre efficiency. Extrapolation of our results show better usage of previously underused theatre time, to the equivalent worth of £345 000. Further implementation of these improvements in other surgical specialities and hospitals would be beneficial.

Effectiveness of the YourCall™ text message intervention to reduce harmful drinking in patients discharged from trauma wards: protocol for a randomised controlled trial

BACKGROUND

Behavioural brief interventions (BI) can support people to reduce harmful drinking but multiple barriers impede the delivery and equitable access to these. To address this challenge, we developed YourCall™, a novel short message service (SMS) text message intervention incorporating BI principles. This protocol describes a trial evaluating the effectiveness of YourCall™ (compared to usual care) in reducing hazardous drinking and alcohol related harm among injured adults who received in-patient care.

METHODS/DESIGN

Participants recruited to this single-blind randomised controlled trial comprised patients aged 16-69 years in three trauma-admitting hospitals in Auckland, New Zealand. Those who screened positive for moderately hazardous drinking were randomly assigned by computer to usual care (control group) or the intervention. The latter comprised 16 informational and motivational text messages delivered using an automated system over the four weeks following discharge. The primary outcome is the difference in mean AUDIT-C score between the intervention and control groups at 3 months, with the maintenance of the effect examined at 6 and 12 months follow-up. Secondary outcomes comprised the health and social impacts of heavy drinking ascertained through a web-survey at 12 months, and further injuries identified through probabilistic linkage to national databases on accident insurance, hospital discharges, and mortality. Research staff evaluating outcomes were blinded to allocation. Intention-to-treat analyses will include assessment of interactions based on ethnicity (Māori compared with non-Māori).

DISCUSSION

If found to be effective, this mobile health strategy has the potential to overcome current barriers to implementing equitably accessible interventions that can reduce harmful drinking.

TRIAL REGISTRATION

Universal Trial Number (UTN) U1111-1134-0028. ACTRN12612001220853 . Submitted 8 November 2012 (date of enrolment of first participant); Version 1 registration confirmed 19 November 2012. Retrospectively registered.

Elephant (Elephas maximus) Health and Management in Asia: Variations in Veterinary Perspectives

There is a need to identify strategic investments in Asian elephant (Elephas maximus) health that will yield maximal benefits for overall elephant health and conservation. As an exploratory first step, a survey was administered to veterinarians from Asian elephant range countries at a workshop and via email to help prioritize health-related concerns that will mostly benefit elephants. Responses were received from 45 veterinarians from eight countries that had a range of experience with captive and wild elephants. The occurrence of medical conditions and responses to treatment varied among responses. However, injuries, parasitism, and gastrointestinal disease were reported as the most common syndromes responsible for elephant morbidity, whereas injury and infectious disease not due to parasitism were the most commonly reported sources of elephant mortality. Substandard nutrition, water quality and quantity deficiencies, and inadequate or absent shelter were among the factors listed as barriers to optimal elephant health. While this survey's results do not support definitive conclusions, they can be used to identify where and how subsequent investigations should be directed. Rigorous assessment of the relative costs and benefits of available options is required to ensure that investments in individual and population health yield the maximal benefits for elephants.

U.S. Preventive Services Task Force recommendations and cancer screening among female Medicare beneficiaries

BACKGROUND

Medicare covers several cancer screening tests not currently recommended by the U.S. Preventive Services Task Force (Task Force). In September 2002, the Task Force relaxed the upper age limit of 70 years for breast cancer screening recommendations, and in March 2003 an upper age limit of 65 years was introduced for cervical cancer screening recommendations. We assessed whether mammogram and Pap test utilization among women with Medicare coverage is influenced by changes in the Task Force's recommendations for screening.

METHODS

We identified female Medicare beneficiaries aged 66-80 years and used bivariate probit regression to examine the receipt of breast (mammogram) and cervical (Pap test) cancer screening reflecting changes in the Task Force recommendations. We analyzed 9,760 Medicare Current Beneficiary Survey responses from 2001 to 2007.

RESULTS

More than two-thirds reported receiving a mammogram and more than one-third a Pap test in the previous 2 years. Lack of recommendation was given as a reason for not getting screened among the majority (51% for mammogram and 75% for Pap). After controlling for beneficiary-level socioeconomic characteristics and access to care factors, we did not observe a significant change in breast and cervical cancer screening patterns following the changes in Task Force recommendations.

CONCLUSIONS

Although there is evidence that many Medicare beneficiaries adhere to screening guidelines, some women may be receiving non-recommended screening services covered by Medicare.

Priority-setting for evidence-based health outreach in community-based organizations: A mixed-methods study in three Massachusetts communities

Priority setting, or determining how to best allocate limited resources, is an important first step for evidence-based public health approaches in community-based organizations (CBOs), but guidance for such work is limited. This study aims to study drivers of priority setting and the way CBOs use data for this work. Data come from PLANET MassCONECT, a Community-Based Participatory Research project focused on knowledge translation among CBOs targeting the underserved in Boston, Lawrence, and Worcester, MA. We conducted four focus group discussions with CBO staff members (31 participants) in 2008 and a survey of 214 CBO staff members in 2009. Multiple, often competing factors appear to drive priority setting, including data, funding, partnerships, and community preferences. The process may be hindered by challenges related to finding, evaluating, and utilizing data for priority setting. Supporting CBOs in efforts to use data effectively and incorporate context into systematic priority-setting processes is vital.

Impact of Broadened Coverage of Smoking Cessation Treatments on Cardiovascular Disease

One third of all premature tobacco-attributable deaths are due to CVD and tobacco is the cause of approximately 15% of all CVD attributable. Primary and secondary prevention strategies that combine evidenced based tobacco dependence treatment programs along with cigarette taxes and media campaigns can result in hundreds of thousand of fewer excess deaths from smoking attributable CVD. Expanded insurance from both commercial and public insurers will be greatly expanded by the recently enacted federal health care reform but barriers to reducing the avoidable morbidity and mortality that is due to tobacco use is impacted by the potential for remaining financial barriers to full insurance coverage from Americans in regions of the country with the highest smoking prevalence rates.

A randomized controlled trial of a behavioral economic supplement to brief motivational interventions for college drinking

OBJECTIVE

Behavioral economic theory suggests that a reduction in substance use is most likely when there is an increase in rewarding substance-free activities. The goal of this randomized controlled clinical trial was to evaluate the incremental efficacy of a novel behavioral economic supplement (Substance-Free Activity Session [SFAS]) to a standard alcohol brief motivational interviewing (BMI) session for heavy-drinking college students.

METHOD

Participants were 82 first-year college students (50% female; 81.7% White/European American; M age = 18.5 years, SD = 0.71) who reported 2 or more past-month heavy drinking episodes. After completing a baseline assessment and an individual alcohol-focused BMI, participants were randomized to either the SFAS or to a Relaxation Training (RT) control session. The SFAS was delivered in an MI style and attempted to increase the salience of delayed academic and career rewards and the patterns of behavior leading to those rewards.

RESULTS

The combination of an alcohol BMI plus the SFAS was associated with significantly greater reductions in alcohol problems compared with an alcohol BMI plus RT at the 1-month and 6-month follow-up assessments (p = .015, ηp² = .07), an effect that was partially mediated by increases in protective behavioral strategies. BMI + SFAS was also associated with greater reductions in heavy drinking among participants who at baseline reported low levels of substance-free reinforcement or symptoms of depression.

CONCLUSION

These results are consistent with behavioral economic theory and suggest that a single session focused on increasing engagement in alternatives to drinking can enhance the effects of brief alcohol interventions.

Physical activity promotion in primary care targeting the older adult

PURPOSE

This integrative review identifies and examines research literature focused on physical activity promotion provided in primary care settings to older adult patients in order to evaluate the effectiveness of provider-delivered interventions on elders short- and long-term activity levels.

DATA RESOURCES

A comprehensive review of original research published in English from all countries through May 2010 was performed. Relevant literature was identified through MEDLINE, CINAHL, and ProQuest on-line databases. Data from 11 unique studies were systematically extracted and summarized in table format.

CONCLUSIONS

Activity interventions delivered in primary care can produce at least short term increases in activity; however, there is limited evidence to evaluate whether long-term changes can be achieved and thus making the case for future longitudinal studies.

IMPLICATIONS FOR PRACTICE

Tailored activity prescriptions should be provided after holistic patient assessment. Activity counseling requires recognition as a billable service and further study is needed to identify the most efficient intervention. Inclusion of health-economic evaluations in future research could reveal if efforts to improve physical activity levels are an efficient use of resources.

Data-Driven Decision Making in the Prevention of Substance-Related Harm: Results from the Strategic Prevention Framework State Incentive Grant Program

The Strategic Prevention Framework State Incentive Grant Program (SPF SIG) is a national public-health initiative in the United States to prevent and reduce substance-related harm. The model promotes data-driven decision making (DDDM), with an emphasis on using epidemiological data to help select prevention priorities and to allocate prevention resources. This article examines how well the first two cohorts of SPF SIG states (N = 26) implemented DDDM, and also explores what factors facilitated and hindered the process. Data were collected by reviewing and coding states' strategic plans, supplemented by interviews with state project directors, evaluators, and epidemiological workgroup chairs. Fidelity to the process was scored as high, medium, or low, based on transparency and support from relevant evidence. On selecting prevention priorities, 81% of states received high or medium scores on all priorities selected. On allocating prevention resources, 85% received a high or medium score. Facilitators included collaboration among stakeholders, training and technical assistance, and efforts of epidemiological workgroups and evaluators. However, states that lacked established data infrastructures for prevention were at a decided disadvantage in implementing the model. Future implications for SPF SIG states and ongoing challenges to DDDM in general are discussed.

A behavioral economic supplement to brief motivational interventions for college drinking

Basic behavioral and neurobiological research has demonstrated that deficiencies in naturally occurring substance-free rewards are both a cause and a consequence of substance abuse that are due in part to the systematic discounting of delayed substance-free rewards. Existing brief motivational interventions (BMIs) for alcohol abuse do not target this mechanism of change. The goal of this uncontrolled pilot study was to evaluate a behavioral economic Substance-Free Activity Session (SFAS) to traditional alcohol BMIs. Participants were 13 college freshmen who reported two or more heavy drinking episodes (>5/4 drinks in an occasion for men/ women) in the past month. All participants completed a baseline assessment and a BMI that addressed alcohol use. In addition, participants received the SFAS, a 50-min individual session that attempts to increase engagement in constructive alternatives to drinking by enhancing the salience of delayed rewards (academic and career success) and the patterns of behavior (academic and extracurricular engagement) leading to these outcomes. At the 1-month follow-up assessment, participants reported significant reductions in heavy drinking, and moderate to large effect size reductions in weekly drinking and peak blood alcohol levels. The results of this pilot study provide preliminary support for the efficacy of this behavioral economic intervention session as a supplement to traditional alcohol BMIs.

Impact and cost of a 2-week community-based screening and awareness program for diabetes and cardiovascular risk factors in a Swiss canton

BACKGROUND

Community-based diabetes screening programs can help sensitize the population and identify new cases. However, the impact of such programs is rarely assessed in high-income countries, where concurrent health information and screening opportunities are common place.

INTERVENTION AND METHODS

A 2-week screening and awareness campaign was organized as part of a new diabetes program in the canton of Vaud (population of 697,000) in Switzerland. Screening was performed without appointment in 190 out of 244 pharmacies in the canton at the subsidized cost of 10 Swiss Francs per participant. Screening included questions on risk behaviors, measurement of body mass index, blood pressure, blood cholesterol, random blood glucose (RBG), and A1c if RBG was ≥7.0 mmol/L. A mass media campaign promoting physical activity and a healthy diet was channeled through several media, eg, 165 spots on radio, billboards in 250 public places, flyers in 360 public transport vehicles, and a dozen articles in several newspapers. A telephone survey in a representative sample of the population of the canton was performed after the campaign to evaluate the program.

RESULTS

A total of 4222 participants (0.76% of all persons aged ≥18 years) underwent the screening program (median age: 53 years, 63% females). Among participants not treated for diabetes, 3.7% had RBG ≥ 7.8 mmol/L and 1.8% had both RBG ≥ 7.0 mmol/L and A1c ≥ 6.5. Untreated blood pressure ≥140/90 mmHg and/or untreated cholesterol ≥5.2 mmol/L were found in 50.5% of participants. One or several treated or untreated modifiable risk factors were found in 78% of participants. The telephone survey showed that 53% of all adults in the canton were sensitized by the campaign. Excluding fees paid by the participants, the program incurred a cost of CHF 330,600.

CONCLUSION

A community-based screening program had low efficiency for detecting new cases of diabetes, but it identified large numbers of persons with elevated other cardiovascular risk factors. Our findings suggest the convenience of A1c for mass screening of diabetes, the usefulness of extending diabetes screening to other cardiovascular risk factors, and the importance of a robust background communication campaign.

Divergent fifteen-year trends in traditional and cardiometabolic risk factors of cardiovascular diseases in the Seychelles

Objective

Few studies have assessed secular changes in the levels of cardiovascular risk factors (CV-RF) in populations of low or middle income countries. The systematic collection of a broad set of both traditional and metabolic CV-RF in 1989 and 2004 in the population of the Seychelles islands provides a unique opportunity to examine trends at a fairly early stage of the "diabesity" era in a country in the African region.

Methods

Two examination surveys were conducted in independent random samples of the population aged 25–64 years in 1989 and 2004, attended by respectively 1081 and 1255 participants (participation rates >80%). All results are age-standardized to the WHO standard population.

Results

In 2004 vs. 1989, the levels of the main traditional CV-RF have either decreased, e.g. smoking (17% vs. 30%, p < 0.001), mean blood pressure (127.8/84.8 vs. 130.0/83.4 mmHg, p < 0.05), or only moderately increased, e.g. median LDL-cholesterol (3.58 vs. 3.36 mmol/l, p < 0. 01). In contrast, marked detrimental trends were found for obesity (37% vs. 21%, p < 0.001) and several cardiometabolic CVD-RF, e.g. mean HDL-cholesterol (1.36 vs. 1.40 mmol/l, p < 0.05), median triglycerides (0.80 vs. 0.78 mmol/l, p < 0.01), mean blood glucose (5.89 vs. 5.22 mmol/l, p < 0.001), median insulin (11.6 vs. 8.3 μmol/l, p < 0.001), median HOMA-IR (2.9 vs. 1.8, p < 0.001) and diabetes (9.4% vs. 6.2%, p < 0.001). At age 40–64, the prevalence of elevated total cardiovascular risk tended to decrease (e.g. WHO-ISH risk score ≥10; 11% vs. 13%, ns), whereas the prevalence of the metabolic syndrome (which integrates several cardiometabolic CVD-RF) nearly doubled (36% vs. 20%, p < 0.001). Data on physical activity and on intake of alcohol, fruit and vegetables are also provided. Awareness and treatment rates improved substantially for hypertension and diabetes, but control rates improved for the former only. Median levels of the cardiometabolic CVD-RF increased between 1989 and 2004 within all BMI strata, suggesting that the worsening levels of cardiometabolic CVD-RF in the population were not only related to increasing BMI levels in the interval.

Conclusion

The levels of several traditional CVD-RF improved over time, while marked detrimental trends were observed for obesity, diabetes and several cardiometabolic factors. Thus, in this population, the rapid health transition was characterized by substantial changes in the patterns of CVD-RF. More generally, this analysis suggests the importance of surveillance systems to identify risk factor trends and the need for preventive strategies to promote healthy lifestyles and nutrition.