Enhancing global capacity in the surveillance, prevention, and control of chronic diseases: seven themes to consider and build upon

BACKGROUND

Chronic diseases are now a major health problem in developing countries as well as in the developed world. Although chronic diseases cannot be communicated from person to person, their risk factors (for example, smoking, inactivity, dietary habits) are readily transferred around the world. With increasing human progress and technological advance, the pandemic of chronic diseases will become an even bigger threat to global health.

METHODS

Based on our experiences and publications as well as review of the literature, we contribute ideas and working examples that might help enhance global capacity in the surveillance of chronic diseases and their prevention and control. Innovative ideas and solutions were actively sought.

RESULTS

Ideas and working examples to help enhance global capacity were grouped under seven themes, concisely summarised by the acronym "SCIENCE": Strategy, Collaboration, Information, Education, Novelty, Communication and Evaluation.

CONCLUSION

Building a basis for action using the seven themes articulated, especially by incorporating innovative ideas, we presented here, can help enhance global capacity in chronic disease surveillance, prevention and control. Informed initiatives can help achieve the new World Health Organization global goal of reducing chronic disease death rates by 2% annually, generate new ideas for effective interventions and ultimately bring global chronic diseases under greater control.

Self-reflections on health promotion in the UK and the USA

OBJECTIVES

To compare and contrast the past 30-40 years of health promotion in the UK and the USA, and to identify two critical issues that relate to health promotion research and practice in both countries.

METHODS

Historiography and self-reflection.

CONCLUSIONS

Although the USA and the UK share different histories of health promotion development, many of the critical issues that characterize the field are similar. Two issues are particularly notable: the concern with evidence; and the problem of translation of the science of health promotion to practice.

Strengthening the evidence base for health promotion

This paper describes the evidence debate from the many players currently attempting to define best practices in health promotion. Expert opinions on the purpose of collecting evidence range from those who view evidence as a western notion of little use in the developing world to those who choose to focus on opportunities to demonstrate the effectiveness of health promotion. There is also much disagreement on what constitutes evidence. Some view evidence as strict outcomes of randomized clinical trials (RCT) and others place greater value on other unpublished sources, not traditionally viewed as valuable information. A challenge for health promotion in the new century is to foster and develop high quality, widely recognized and acceptable standards for evidence-based evaluation.

Subgroup-specific effects of questionnaire wording on population-based estimates of mammography prevalence

OBJECTIVES

This study investigated whether an apparent downturn in prevalence rates of mammography use reported in the 1992 Behavioral Risk Factor Surveillance System (BRFSS) questionnaire resulted from a change in questionnaire wording.

METHODS

In a pretest-posttest design (1990-1991 vs 1992), piecewise linear regression analyses were based on monthly prevalence estimates of mammography use among female BRFSS respondents 40 years or older.

RESULTS

Self-reported mammography use was lower by 3.5 percentage points (95% confidence interval [CI] = 1.5, 5.5) overall--and lower by 13.6 percentage points (95% CI = 2.6, 24.6) among Black women with less than a high school education--when predicted from 1992 data than when predicted from 1990-1991 data.

CONCLUSIONS

A change in questionnaire wording in the BRFSS caused demographic-specific effects in population-based estimates of mammography use.

Developing an evidence-based Guide to Community Preventive Services--methods. The Task Force on Community Preventive Services

Systematic reviews and evidence-based recommendations are increasingly important for decision making in health and medicine. Over the past 20 years, information on the science of synthesizing research results has exploded. However, some approaches to systematic reviews of the effectiveness of clinical preventive services and medical care may be less appropriate for evaluating population-based interventions. Furthermore, methods for linking evidence to recommendations are less well developed than methods for synthesizing evidence. The Guide to Community Preventive Services: Systematic Reviews and Evidence-Based Recommendations (the Guide) will evaluate and make recommendations on population-based and public health interventions. This paper provides an overview of the Guide's process to systematically review evidence and translate that evidence into recommendations. The Guide reviews evidence on effectiveness, the applicability of effectiveness data, (i.e., the extent to which available effectiveness data is thought to apply to additional populations and settings), the intervention's other effects (i.e., important side effects), economic impact, and barriers to implementation of interventions. The steps for obtaining and evaluating evidence into recommendations involve: (1) forming multidisciplinary chapter development teams, (2) developing a conceptual approach to organizing, grouping, selecting and evaluating the interventions in each chapter; (3) selecting interventions to be evaluated; (4) searching for and retrieving evidence; (5) assessing the quality of and summarizing the body of evidence of effectiveness; (6) translating the body of evidence of effectiveness into recommendations; (7) considering information on evidence other than effectiveness; and (8) identifying and summarizing research gaps. Systematic reviews of and evidence-based recommendations for population-health interventions are challenging and methods will continue to evolve. However, using an evidence-based approach to identify and recommend effective interventions directed at specific public health goals may reduce errors in how information is collected and interpreted, identify important gaps in current knowledge thus guiding further research, and enhance the Guide users' ability to assess whether recommendations are valid and prudent from their own perspectives. Over time, all of these advantages could help to increase agreement regarding appropriate community health strategies and help to increase their implementation.

State- and sex-specific prevalence of selected characteristics--Behavioral Risk Factor Surveillance System, 1992 and 1993

PROBLEM/CONDITION

Much chronic disease and injury morbidity and mortality is associated with high-risk behaviors (e.g., cigarette smoking, excessive alcohol consumption, and physical inactivity) and with lack of preventive health care (e.g., screening for cancer). States use the Behavioral Risk Factor Surveillance System (BRFSS) to collect data about these modifiable health behaviors and to monitor trends and significant changes in their populations over time.

REPORTING PERIOD

1992 and 1993.

DESCRIPTION OF SYSTEM

The BRFSS is a state-based telephone survey of the civilian, noninstitutionalized, adult (persons > or = 18 years of age) population. In 1992, 48 states and the District of Columbia participated in the BRFSS; in 1993, 49 states and the District of Columbia participated. Several questions were added to the BRFSS in 1993.

RESULTS

As in previous years, state-specific variations occurred in the prevalence of high-risk behaviors, awareness of certain medical conditions, use of preventive health services, and health-care coverage. In 1993, 4.0% (range: 1.4% - 6.4%) of adults reported riding with a driver who had had too much alcohol to drink. The percentage of persons > or = 50 years of age who had ever had a proctoscopic examination ranged from 25.6% to 51.5% (median: 36.8%). Among adults > or = 65 years of age, 27.4% (range: 18.5 % - 40.0%) had ever had a pneumococcal vaccination, and 49.9% (range: 28.7% - 66.2%) had had an influenza vaccination within the past 1 year.

INTERPRETATION

The variations in prevalence across states likely reflect socioeconomic differences, differences in state laws enacted to discourage risky behaviors, different levels of effort to screen for certain types of cancer or risk factors for other diseases, and other factors. ACTION TAKEN: States will continue to use the BRFSS to collect data about health behaviors. Analysis of these data will enable states to monitor factors that may affect the rate of chronic disease and injury mortality and morbidity and to develop public health policies to address these problems.

Perceived risk of becoming infected with HIV by donating blood and changes in reported blood donation practice among the Scottish general public 1989-1992

A total of 17,537 respondents aged 18-60 and resident in Edinburgh and Glasgow were interviewed between January 1989 and May 1992 as part of a large scale continuous monitoring survey of lifestyles and health. A computer assisted telephone interview (CATI) system was used. Respondents were chosen randomly from households with telephones. The objective was to see whether concern about the risks of becoming infected with HIV by donating blood led to a change in the blood donating habits of existing blood donors. Results showed no change in the percentage of donors, ex-donors and non-donors between 1989 and 1992, but a recent decrease in the percentage of respondents who thought that you could become infected with HIV by donating blood was observed. The percentage of new donors and ex-donors balanced each other out, but in all years respondents reporting a decreased frequency of donation outweighed those reporting an increased frequency. The belief that you can become infected with HIV by donating blood was most prevalent among non-donors followed by ex-, current and new-donors in that order. There was some evidence that the belief that you can become infected with HIV by donating blood was adversely affecting blood donation habits.

Conceptions and misconceptions about transmission of HIV/AIDS among the Scottish general public, 1988-1992

Knowledge levels among the Scottish general public about so called 'casual' transmission of the AIDS virus were analysed using data collected by our Unit's survey using computer-assisted telephone interviewing methods. Five cross-sections of data from the period March to May of each year were analysed and compared to provide overall estimates of knowledge on four items relating to casual transmission between respondent groups and to provide an estimate of changes over time in knowledge levels from 1988 to 1992. The data show that significant differences in knowledge exist, with the lowest levels of knowledge found among the older and among the less educated respondents. There is evidence for a continuing increase in knowledge for all items studied and for most respondent groups, but little evidence that disparities in knowledge between respondent groups are lessening over time. Misconceptions about potential risks from donating blood and kissing persist at quite high levels.

Sexual behavior and exposure to HIV infection: estimates from a general-population risk index

OBJECTIVES

The spread of the human immunodeficiency virus (HIV) in the general population has been a much debated topic in the mass media. The aim of this study was to create an approach to estimating the risk of exposure to HIV resulting from sexual behaviors.

METHODS

A theoretical estimate was applied to data obtained from a large-scale risk factor survey carried out in Britain. An HIV infection-exposure risk index was constructed by ranking different sex-related categorizations derived from variables in the survey.

RESULTS

The risk index involved a Delphi-based assessment of self-reported behavioral factors associated with HIV exposure and subsequent transmission. Roughly 85% of the adult population aged 18 to 50 were estimated to be at some risk for behavioral exposure to HIV virus with regard to reported sexual behavior. Over time, those who could be considered at no risk have declined as a proportion of the population.

CONCLUSIONS

The estimates appear to refute commonplace assertions that exposure to HIV through sexual behavior is not a problem for general populations.

Anti-permissive attitudes to lifestyles associated with AIDS

AIDS is in the tradition of diseases which have given moral interpretations. One way in which this moralistic perspective may express itself is by members of the public holding high risk groups responsible for their (AIDS related) lifestyles and their considering AIDS to be a self-inflicted disease. A unique data source of 7000 verbatim comments recorded in the course of 25,000 structured Computer Assisted Telephone Interviews on Lifestyle and Health which contain a substantial component on AIDS--knowledge, attitudes, beliefs and sexual behaviour, was used to document negative attitudes to 'AIDS related lifestyles'. These comments revealed that despite evidence of concern about drug use, many respondents consider AIDS to be irrelevant to the majority of the population. There is some evidence that AIDS has contributed to reinforcing negative attitudes towards homosexuality and drug use, especially among older respondents. Extreme punitive attitudes towards high risk groups were expressed by a small minority (predominantly males).

Trends in Scottish cigarette smoking by gender, age and occupational status, 1984-1991

Data from the General Household Survey (GHS) for the period 1984-1988 and data from the RUHBC-CATI (Research Unit in Health and Behavioural Change - Computer Assisted Telephone Interview) survey for the period 1988 to 1991 are pooled to study changes in the cigarette smoking prevalence in Scotland. It is concluded that the Scottish smoking prevalence shows a slight downward trend for males and a slight upward trend for females. There is some evidence for an earlier decrease in smoking prevalence related to a lower smoking uptake among younger generations, however, the current pattern of smoking among the youngest age group shows an increase. The reported difference in smoking prevalence between those in manual and non-manual occupations seems to be increasing among females and decreasing among males.

Patterns of unhealthy eating behaviours in a middle aged Scottish population

This paper examines unhealthy eating in a middle aged Scottish population. Data from a 1989 survey of 500 Scottish men and women aged 45 to 59 years are used to explore inter-relations among five items of unhealthy eating, smoking and alcohol consumption. The results show that unhealthy eating behaviours are highly correlated, indicating strong links among certain nutrition habits. The findings also reveal that such patterns of unhealthy eating vary considerably between males and females. Finally, unhealthy eating behaviours were also found to be significantly associated with smoking and alcohol consumption. Implications of these findings for future research in epidemiology and health promotion are considered.

Assessing the qualitative data component in large-scale quantitative surveys: computer aided qualitative survey data management, retrieval and analysis

In a large-scale survey the qualitative component of the interview is often used either to refine the quantitative coding categories or to get a 'general feel' for the respondents' comments with no attempt at analysis. This article reports on an approach which has been developed for solving some of the problems of linkage of qualitative and quantitative components at the survey analysis stage. This approach is dependent on efficient methods of data management and text retrieval, and presupposes a system of data collection that produces computer-based text files to store the verbatim comments of study participants. The size of the data set necessitated using a mainframe computer for data management, text retrieval and analysis. The article provides illustrations of how the analysis of 11 000 files consisting of textual data was facilitated.

Changing patterns in reported sexual practices in the population: multiple partners and condom use

OBJECTIVE

To determine whether the pattern of change with regard to condom use and multiple sexual partners is influenced by gender or educational level.

DESIGN

Findings from data collected from 1987 to 1990 about changes in condom use and multiple-partner activities are presented, based on telephone interviews with 9416 participants aged 18 to 44 years resident in central Scotland, UK.

METHODS

Change in patterns over time were modelled in a multivariate logistic regression using a linear interactive modelling program.

RESULTS

Several models showing changes in the proportion of multiple-partner respondents and condom users yielded a complicated pattern of behavioural change in educational status and gender.

CONCLUSIONS

There is a large difference in reported condom use and multiple sexual partners by gender, but the difference is decreasing over time. Better educated respondents increased their use of condoms while less educated respondents showed a decrease in the proportion of multiple partners.

Leisure time physical activity in Scotland: trends 1987-1991 and the effect of question wording

In this article data collected between 1987 and 1991 is analyzed to identify changes in the proportion of sedentary individuals in Edinburgh and Glasgow. In the primary question, which asked the respondents about physical activity for exercise such as walking, running and swimming, a wording change deleting the prompt to specific activities is taken into consideration. The data were collected by telephone on 13,586 respondents. A considerable decrease in the proportion of sedentary individuals in both cities was observed between 1987 and 1991. This decrease could not be related to changes in specific sporting activities. The change to an unprompted question led to a 14% lower estimate of physical activity. This was almost fully explained by a change in the estimate of the proportion of walkers. Older respondents in particular were affected by the question change.

Leisure time physical activity behavior in three British cities

This article provides baseline information on leisure time physical activity. The data were collected in 1989 by telephone in the cities of London, Glasgow and Edinburgh. Twenty-eight percent of the respondents living in London reported that they engage in physical activity for exercise three or more times per week. For Glasgow and Edinburgh these figures are 24% and 28% respectively. Female respondents, respondents in the lower occupational categories and older respondents exercised on average less than male respondents, respondents from the higher occupational categories and younger respondents. Walking was the most popular form of physical activity for exercise in the three cities, for all age groups, all occupational groups and both sexes. Female respondents, respondents from the lower occupational categories and older respondents engaged in less strenuous physical activities. The differences between groups were independent of the stringency of the definition of exercise. The data showed that levels of leisure time physical activity for exercise do not meet standards which are advocated internationally. However, the levels and patterns found are similar to those found in North American studies. It would appear that the differences between the two Scottish cities and London are small.

Mobile breast screening: factors affecting uptake, efforts to increase response and acceptability

In 1986, a breast screening project was set up to assess the feasibility of mobile breast screening in rural areas near Edinburgh. Secondary objectives included a study of factors affecting uptake, ways in which uptake might be encouraged and a study of the acceptability of this form of screening. This paper deals with the results of studies dealing with secondary objectives. We found that response rates to opportunistic screening was poor, 5,631 attenders out of 23,229 eligible women (24.2%). This was especially so in older women. Distance proved to be the single most significant factor affecting uptake, but car and house ownership were also highly significantly correlated with response. Leaflet drops had no demonstrable effect on response, but personal invitation by general practitioners produced a 75% response rate in women 50-64 who had failed to attend on the van's previous visit. Attenders found this form of screening both convenient and acceptable.

Dental health-related behaviour in Scottish schoolchildren aged 11, 13 and 15 from Edinburgh city

The two most important individually-mediated factors for the control of dental decay and periodontal diseases are frequency of sugar consumption commonly in the form of sweets, and toothbrushing. Most dental health education efforts have therefore been concentrating on informing and motivating parents and children to restrict sugar intake and to brush their teeth twice a day. The present investigation was undertaken, as part of a wider survey of health related behaviour in Scottish schoolchildren, to determine the frequency of tooth brushing and sweet consumption in relation to age, gender and social background. Data was collected from 4,890 children aged 11, 13 and 15 years from independent and state schools in Lothian. Subjects completed a questionnaire, anonymously, in class.

China's impact on American medicine in the seventies: a limited and preliminary inquiry

A citation survey of the impact of Chinese medical ideas on Western medical literature is presented. In general it is argued that the diffusion of ideas was very rapid at the beginning of the decade, but has markedly slowed recently. Speculations on this 'loss of interest' are offered.

Alcohol consumption patterns among women in Baltimore

A telephone survey of women aged 18 + (N = 1084) in Baltimore during 1980 showed that 8.1% had a heavy alcohol intake (2 + drinks per day) and that 22.4% engaged in escape drinking. Age, race, marital status, maternal status, income, education, employment and degree of urbanization were examined for their relationships with the amount of alcohol consumption and the prevalence of escape drinking. Multivariate analysis showed that being married or widowed, lower educational attainment and less egalitarian sex-role attitudes were associated with lower alcohol consumption.

Detection and treatment of emotionally disturbed children in public schools: problems and theoretical perspectives

Examined the effect of selected socio-demographic, mental health resource, and school system variables on the identification and treatment of children as emotionally disturbed. An explanatory model is provided, and the Labeling and Social Movements perspectives are examined in terms of their explanatory power. The major finding is that emotionally disturbed children are significantly underdetected and underserved nationally in public school systems, and, specifically, in Maryland and Washington, D.C. Further, results indicate that the attitudes of school system officials and the community in general, as well as the availability of mental health professionals, determine whether school systems detect emotionally disturbed children. When such children are detected, more specialized and expensive services are provided in school districts with higher per capita income, school budget, and proportion of mental health professionals.

Social factors in the etiology of chronic disease: an overview

Our intention in this introductory article is to emphasize what we consider to be certain critical points in the current state of research into the social epidemiology of chronic disease. As will be outlined, these critical points need to be considered in future research. To begin with we provide a mild critique of research in this area which has had its tradition specified by social epidemiology, a term which has recently come into favor to describe research concerned with social factors in the etiology of chronic disease. Next we briefly summarize critical available evidence on an etiological relationship between social factors and cardiovascular disease, cancer and multiple disease outcomes. Following this a major emphasis will be placed on issues which directly relate to problems of methodology in social factors assessment. Finally, an emphasis will be given to the critical question of mechanisms which need to be clarified in this type of multivariate research.

Social factors in the etiology of multiple outcomes: the case of blood pressure and alcohol consumption patterns

The literature addressing the relationships between biological and social factors in the etiology of multiple chronic diseases occurring simultaneously is presented. The rationale for studying such multiple outcomes is presented in terms of providing a realistic appraisal of the development of chronic diseases from a clinical perspective; i.e. persons with chronic illnesses often have more than one illness at the same time. Social processes related to the development of one joint disease outcome, namely clinically elevated blood pressure and heavy alcohol consumption patterns, are discussed, and emphasis is given to elaborating the role of stress and social support in the etiologic process. Several alternative models are presented to account for the etiology of the joint outcome, and a research agenda is suggested.

Urban and rural Indian drinking patterns: the special case of the Lumbee

This paper reports the results of a study of 460 adult male Lumbee Indians in a rural and urban setting. The study sought to determine what factors would explain the differences in drinking patterns between the rural and urban settings. The major variables considered were: (1) quantity, frequency, and variability of drinking; (2) occupational prestige; (3) commitment to work; (4) status satisfaction; and (5) job satisfaction. The urban Lumbee show a mean drinking pattern that is heavier than that of the rural group. In general, low achievement, as measured by occupational prestige and status satisfaction, and low satisfaction, as measured by job satisfaction and commitment to work, predict more excessive drinking patterns. Implications of the findings for treatment and future research are discussed.

The diffusion of a mass genetic screening programme

This paper reports the diffusion of knowledge of screening for a genetic disorder (Tay–Sachs disease) in two fairly well defined, urban, Jewish populations in the Baltimore and Washington metropolitan areas, and on some of the sociological variables which influence the diffusion. Differences between the two populations are shown.

Reliability and validity of estimators of alcoholism prevalence

According to multivariate analyses of responses to four estimators of alcoholism prevalence, a questionnaire about "escape" drinking is the most reliable and the most valid.

Comparison of alcoholism prevalence rates obtained by survey and indirect estimators

Prevalence rates obtained by the Ledermann consumption model and the Jellinek estimation formula are similar to the rate of "heavy--escape drinking" obtained by a suvey using a quantity--frequency index and questions about "escape drinking".