The equity impact of brief opportunistic interventions to promote weight loss in primary care: secondary analysis of the BWeL randomised trial.

BACKGROUND: Guidelines recommend that clinicians should make brief opportunistic behavioural interventions to patients who are obese to increase the uptake of effective weight loss programmes. The objective was to assess the effect of this policy on socioeconomic equity. METHODS: One thousand eight hundred eighty-two consecutively attending patients with obesity and who were not seeking support for weight loss from their GP were enrolled in a trial. Towards the end of each consultation, GPs randomly assigned participants to one of two 30-s interventions. In the active intervention (support arm), the GP offered referral to a weight management group. In the control intervention (advice arm), the GP advised the patient that their health would benefit from weight loss. Agreement to attend a behavioural weight loss programme, attendance at the programme and weight loss at 12 months were analysed by socioeconomic status, measured by postcode using the Index of Multiple Deprivation (IMD). RESULTS: Mean weight loss was 2.43 kg (sd 6.49) in the support group and 1.04 kg (sd 5.50) for the advice only group, but these effects were moderated by IMD (p = 0.039 for the interaction). In the support arm, weight loss was greater in higher socioeconomic groups. Participants from lower socioeconomic backgrounds were more likely to accept the offer and equally likely to attend a weight loss referral but attended fewer sessions. Adjusting for these sequentially reduced the gradient for the association of socioeconomic status with weight loss from + 0.035 to - 0.001 kg/IMD point. In the advice only arm, 10% took effective action to promote weight loss. The decision to seek support for weight loss outside of the trial did not differ by socioeconomic status, but weight loss among deprived participants who used external support was greater than among more affluent participants (p = 0.025). CONCLUSION: Participants' responses to GPs' brief opportunistic interventions to promote weight loss differed by socioeconomic status and trial arm. In the support arm, more deprived people lost less weight because they attended fewer sessions at the programme. In the advice arm, more deprived people who sought and paid for support for weight loss themselves lost more weight than more affluent people who sought support. TRIAL REGISTRATION: This trial is registered with the ISRCTN registry, number ISRCTN26563137 . Date of registration: January 3, 2013; date of first participant recruited: June 4, 2014.

Systematic review: chronic obstructive pulmonary disease and work-related outcomes.

Background: Several studies have assessed the impact of chronic obstructive pulmonary disease (COPD) on work ability and work productivity; however, this relationship is poorly understood. Aims: To undertake a systematic review to assess the effects of COPD on employment, absenteeism and presenteeism. Methods: A comprehensive search using CINAHL, Embase, MEDLINE and the Cochrane Library was conducted to include epidemiological studies from 1937 to August 2017. One reviewer screened all citations. Shortlisted full-text articles were independently assessed by a second reviewer. Data were extracted by one reviewer with a random sample of papers (45%) checked by a second reviewer. Results: Forty-four studies were included; the majority of evidence was from cross-sectional studies, and some cohort studies. COPD patients had lower employment rates than those without COPD. Among those in work, most studies showed patients with COPD took more time off work than those without and reported poorer work performance (presenteeism), although evidence for this association was weaker. The influence of disease severity on these outcomes was unclear; however, it appeared that increasing severity of airflow obstruction was associated with reduced likelihood of being employed. A number of methodological limitations were found among the evidence, including the lack of adjustment for important confounders. Conclusions: Future studies are required which assess the impact of COPD on presenteeism using validated presenteeism instruments and consistent reporting methods. Robust studies are now needed to identify modifiable factors associated with these poorer working outcomes to inform future interventions aimed at improving work productivity among those with COPD.

Process evaluation results of a cluster randomised controlled childhood obesity prevention trial: the WAVES study.

BACKGROUND: Increasing prevalence of childhood obesity and its related consequences emphasises the importance of developing and evaluating interventions aimed at prevention. The importance of process evaluation in health intervention research is increasingly recognised, assessing implementation and participant response, and how these may relate to intervention success or failure. A comprehensive process evaluation was designed and undertaken for the West Midlands ActiVe lifestyle and healthy Eating in School children (WAVES) study that tested the effectiveness of an obesity prevention programme for children aged 6-7 years, delivered in 24 UK schools. The four intervention components were: additional daily school-time physical activity (PA); cooking workshops for children and parents; Villa Vitality (VV), a 6-week healthy lifestyle promotion programme run by a local football club; and signposting to local PA opportunities. METHODS: Data relating to six dimensions (Fidelity, Reach, Recruitment, Quality, Participant Responsiveness, Context) were collected via questionnaires, logbooks, direct observations, focus groups and interviews. Multiple data collection methods allowed for data triangulation and validation of methods, comparing research observations with teacher records. The 6-stage WAVES study model ((i) Data collection, (ii) Collation, (iii) Tabulation, (iv) Score allocation and discussion, (v) Consultation, (vi) Final score allocation) was developed to guide the collection, assimilation and analysis of process evaluation data. Two researchers independently allocated school scores on a 5-point Likert scale for each process evaluation dimension. Researchers then discussed school score allocations and reached a consensus. Schools were ranked by total score, and grouped to reflect low, medium or high intervention implementation. RESULTS: The intervention was predominantly well-implemented and well-received by teachers, parents and children. The PA component was identified as the most challenging, VV the least. Median implementation score across schools was 56/75 (IQR, 51.0 - 60.8). Agreement between teacher logbooks and researcher observations was generally high, the main discrepancies occurred in session duration reporting where in some cases teachers' estimations tended to be higher than researchers'. CONCLUSIONS: The WAVES study model provides a rigorous and replicable approach to undertaking and analysing a multi-component process evaluation. Challenges to implementing school-based obesity prevention interventions have been identified which can be used to inform future trials. TRIAL REGISTRATION: ISRCTN97000586 . 19 May 2010.

Obesity prevention in English primary schools: headteacher perspectives.

Schools are seen as important contributors to obesity prevention, yet face barriers in fulfilling this function. This qualitative study investigates headteacher views on the primary school role in preventing obesity. Semi-structured interviews were held with 22 headteachers from ethnically and socio-economically diverse schools in the West Midlands, UK. Data analysis was conducted using the framework approach. Two over-arching categories were identified: 'School roles and responsibilities' and 'Influencing factors'. Participants agreed that although schools contribute towards obesity prevention in many ways, a moral responsibility to support children's holistic development was the principal motivator, rather than preventing obesity per se. The perceived impact on learning was a key driver for promoting health. Parents were believed to have the main responsibility for preventing obesity, but barriers were identified. Whilst headteachers recognized the advantageous position of schools in offering support to parents, opinion varied on the degree to which schools could and should take on this role. Headteachers serving more deprived areas reported adopting certain responsibilities that elsewhere were fulfilled by parents, and were more likely to view working with families on healthy lifestyles as an important school function. Several factors were perceived as barriers to schools doing more to prevent obesity, including academic pressure, access to expert support and space. In conclusion, school leaders need more support, through resources and government policy, to enable them to maximize their role in obesity prevention. Additionally, school-based obesity prevention should be an integral part of the education agenda rather than bolt-on initiatives.

Effect of obstructive sleep apnoea on diabetic retinopathy and maculopathy: a systematic review and meta-analysis.

AIMS: To summarize the association between obstructive sleep apnoea and diabetic retinopathy and diabetic maculopathy, and to examine the effects of oxygen desaturation index, mean and minimum oxygen saturation and time spent with < 90% oxygen saturation on diabetic retinopathy and diabetic maculopathy. METHODS: A systematic search was performed for papers published from inception to January 2014 in MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews using indexed terms and free text. Additional searches were carried out for grey literature. Two authors conducted the study selection and quality assessment. Data extraction was performed by the main author and checked by the other authors. RESULTS: One cohort study and 15 cross-sectional studies were included for narrative synthesis and three for meta-analyses. There was no convincing evidence that obstructive sleep apnoea was associated with diabetic retinopathy, although some evidence suggested that obstructive sleep apnoea was associated with greater severity of diabetic retinopathy and advanced diabetic retinopathy in people with Type 2 diabetes. Only six studies examined the impact of obstructive sleep apnoea on diabetic maculopathy and our narrative review suggests there is an association in Type 2 diabetes. Oxygen desaturation index, mean oxygen saturation or time spent with < 90% oxygen saturation were not associated with diabetic retinopathy, and insufficient evidence was available to draw conclusions on their effects on diabetic maculopathy; however, there was evidence from both narrative synthesis and meta-analysis that minimum oxygen saturation had an impact on diabetic retinopathy (pooled odds ratio 0.91, 95% CI 0.87-0.95; I(2) = 0%). CONCLUSIONS: There is a need for large cohort studies with long-term follow-up data to examine the long-term effects of obstructive sleep apnoea and other sleep variables on advanced retinal disease in diabetes.

Contributors to childhood obesity in Iran: the views of parents and school staff.

OBJECTIVE: To explore the contextual influences on childhood obesity in Tehran, Iran to inform future development of an obesity prevention intervention for Iranian primary school children. STUDY DESIGN: Qualitative study. METHODS: Focus groups and interviews with parents and school staff were convened to explore their perceptions of the causes of childhood obesity. Eleven focus groups and three interviews were held with parents and school staff (88 participants in total) from three different socio-economic areas in Iran's capital city, Tehran. All the discussions were transcribed verbatim in Persian. An iterative thematic approach was used for data analysis. RESULTS: Overall, the causes of childhood obesity were perceived to relate to macro-level policy influences, the school environment, sociocultural factors, and family and individual behavioural factors, acting in combination. A key emergent theme was the pervasive influence of Government policies on children's food intake and physical activity. Another key theme was the political and sociocultural context that does not support girls and women in Iran in having active lifestyles. CONCLUSION: The findings suggest that parents and school staff have sophisticated views on the possible causes of childhood overweight and obesity which encompassed behavioural, structural and social causes. A prominent emerging theme was the need for state level intervention and support for a healthy environment. Any local initiatives in Iran are unlikely to be successful without such support. WHAT IS KNOWN ON THIS SUBJECT: Childhood obesity is growing in Iran and it is seen as one of the features of the nutrition transition in developing countries. Findings from cross-sectional studies suggest a range of lifestyle factors contribute to obesity in the Iranian population. WHAT THIS STUDY ADDS: This qualitative study explores the socioenvironmental changes contributing to childhood obesity in primary school-aged children in Iran. Findings have provided important contextual data on the perceived contributors to childhood obesity in Iran, such as macro-level policy influences on accessibility to healthy food and physical activity, competing priorities at school level, sociocultural influences on diet and physical activity and limited knowledge and skills of parents. This has laid the foundation for the development of appropriate childhood obesity prevention interventions.

Accuracy and economic evaluation of screening tests for undiagnosed COPD among hypertensive individuals in Brazil.

In Brazil, prevalence of diagnosed COPD among adults aged 40 years and over is 16% although over 70% of cases remain undiagnosed. Hypertension is common and well-recorded in primary care, and frequently co-exists with COPD because of common causes such as tobacco smoking, therefore we conducted a cross-sectional screening test accuracy study in nine Basic Health Units in Brazil, among hypertensive patients aged ≥40 years to identify the optimum screening test/combinations to detect undiagnosed COPD. We compared six index tests (four screening questionnaires, microspirometer and peak flow) against the reference test defined as those below the lower limit of normal (LLN-GLI) on quality diagnostic spirometry, with confirmed COPD at clinical review. Of 1162 participants, 6.8% (n = 79) had clinically confirmed COPD. Peak flow had a higher specificity but lower sensitivity than microspirometry (sensitivity 44.3% [95% CI 33.1, 55.9], specificity 95.5% [95% CI 94.1, 96.6]). SBQ performed well compared to the other questionnaires (sensitivity 75.9% [95% CI 65.0, 84.9], specificity 59.2% [95% CI 56.2, 62.1]). A strategy requiring both SBQ and peak flow to be positive yielded sensitivity of 39.2% (95% CI 28.4, 50.9) and specificity of 97.0% (95% CI 95.7, 97.9). The use of simple screening tests was feasible within the Brazilian primary care setting. The combination of SBQ and peak flow appeared most efficient, when considering performance of the test, cost and ease of use (costing £1690 (5554 R$) with 26.7 cases detected per 1,000 patients). However, the choice of screening tests depends on the clinical setting and availability of resources.ISRCTN registration number: 11377960.

Airflow obstruction and metabolic syndrome: the Guangzhou Biobank Cohort Study.

There is some evidence that chronic obstructive pulmonary disease (COPD) and metabolic syndrome may be related, perhaps through systemic inflammation, which is common to both. However, the association between the two conditions has not yet been clearly shown. The present study involved 7,358 adults aged > or =50 yrs from a population-based survey who underwent spirometry, a structured interview and measurement of fasting metabolic marker levels. Airflow obstruction (forced expiratory volume in 1 s/forced vital capacity ratio of less than the lower limit of normal) was present in 6.7%, and the International Diabetes Federation metabolic syndrome criteria were met by 20.0%. The risk of metabolic syndrome was higher in those with airflow obstruction than in those without (odds ratio (OR) 1.47; 95% confidence interval (CI) 1.12-1.92), after controlling for potential confounders. Of the five components of metabolic syndrome, only central obesity was significantly associated with airflow obstruction (OR 1.43; 95% CI 1.09-1.88) after adjusting for body mass index. A similar association was observed in both never and current smokers. In this Chinese sample, airflow obstruction was associated with metabolic syndrome, and, in particular, its central obesity component. This may help explain the increased risk of cardiovascular diseases in COPD, and so could guide future clinical practice.

Leg length and age of puberty among men and women from a developing population: the Guangzhou Biobank Cohort study.

OBJECTIVES: Leg length and relative leg length are considered to be reliable markers of prepubertal living conditions. Cessation of leg growth, driven by estrogen, occurs earlier in puberty in girls than boys. We hypothesized that leg length and relative leg length, as sitting height to leg ratio, might have sex-specific associations with age of puberty. METHODS: We used multivariable linear regression in 10,046 older (>or=50 years) Chinese from the Guangzhou Biobank Cohort Study (Phase 3) to examine the associations of recalled age of puberty (women: age of menarche, and men: mean age of first nocturnal emission, voice breaking, and first pubic hair) with subischeal leg length, sitting height to leg ratio, and sitting height. RESULTS: Leg length and sitting height to leg ratio had different associations with age of puberty in men and women (P-values for interaction <0.001), but sitting height did not. Per year earlier puberty, legs were longer among men by 0.09 cm (95% confidence interval (CI) 0.01-0.18) and shorter among women by -0.16 cm (95% CI -0.20 to -0.12). Further adjustment for age, hip size (as a marker of buttock fat), and several markers of childhood conditions did not obviate the difference in association by sex. CONCLUSIONS: Adult leg length and relative leg length (sitting height to leg ratio) may be biomarkers of different exposures in men and women, with corresponding implications for their interpretation as a biomarker of early life exposures.

Accuracy of Vitalograph lung monitor as a screening test for COPD in primary care.

Microspirometry may be useful as the second stage of a screening pathway among patients reporting respiratory symptoms. We assessed sensitivity and specificity of the Vitalograph® lung monitor compared with post-bronchodilator confirmatory spirometry (ndd Easy on-PC) among primary care chronic obstructive pulmonary disease (COPD) patients within the Birmingham COPD cohort. We report a case-control analysis within 71 general practices in the UK. Eligible patients were aged ≥40 years who were either on a clinical COPD register or reported chronic respiratory symptoms on a questionnaire. Participants performed pre- and post-bronchodilator microspirometry, prior to confirmatory spirometry. Out of the 544 participants, COPD was confirmed in 337 according to post-bronchodilator confirmatory spirometry. Pre-bronchodilator, using the LLN as a cut-point, the lung monitor had a sensitivity of 50.5% (95% CI 45.0%, 55.9%) and a specificity of 99.0% (95% CI 96.6%, 99.9%) in our sample. Using a fixed ratio of FEV1/FEV6 < 0.7 to define obstruction in the lung monitor, sensitivity increased (58.8%; 95% CI 53.0, 63.8) while specificity was virtually identical (98.6%; 95% CI 95.8, 99.7). Within our sample, the optimal cut-point for the lung monitor was FEV1/FEV6 < 0.78, with sensitivity of 82.8% (95% CI 78.3%, 86.7%) and specificity of 85.0% (95% CI 79.4%, 89.6%). Test performance of the lung monitor was unaffected by bronchodilation. The lung monitor could be used in primary care without a bronchodilator using a simple ratio of FEV1/FEV6 as part of a screening pathway for COPD among patients reporting respiratory symptoms.

Passive smoking exposure and risk of COPD among adults in China: the Guangzhou Biobank Cohort Study.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality in China, where the population is also exposed to high levels of passive smoking, yet little information exists on the effects of such exposure on COPD. We examined the relation between passive smoking and COPD and respiratory symptoms in an adult Chinese population. METHODS: We used baseline data from the Guangzhou Biobank Cohort Study. Of 20 430 men and women over the age of 50 recruited in 2003-06, 15,379 never smokers (6497 with valid spirometry) were included in this cross-sectional analysis. We measured passive smoking exposure at home and work by two self-reported measures (density and duration of exposure). Diagnosis of COPD was based on spirometry and defined according to the GOLD guidelines. FINDINGS: There was an association between risk of COPD and self-reported exposure to passive smoking at home and work (adjusted odds ratio 1.48, 95% CI 1.18-1.85 for high level exposure; equivalent to 40 h a week for more than 5 years). There were significant associations between reported respiratory symptoms and increasing passive smoking exposure (1.16, 1.07-1.25 for any symptom). INTERPRETATION: Exposure to passive smoking is associated with an increased prevalence of COPD and respiratory symptoms. If this association is causal, we estimate that 1.9 million excess deaths from COPD among never smokers could be attributable to passive smoking in the current population in China. Our findings provide strong evidence for urgent measures against passive smoking in China.

Weight status, cardiorespiratory fitness and high blood pressure relationship among 5-12-year-old Chinese primary school children.

Cardiorespiratory fitness (CRF) and adiposity contribute to high blood pressure (HBP) in adults and children. However, their relative importance as risk factors is unknown. We examined the relationships between weight status, CRF and HBP among Chinese primary school children. A cross-sectional study was conducted with 4926 school children aged 5-12 years. CRF was estimated from a modified Cooper test, body mass index z-scores and weight categories were calculated from objective height and weight measurements and BP was measured using an electronic sphygmomanometer. HBP was defined as >95th percentile based on reference cutoffs for Chinese boys and girls. Generalised Linear Mixed models, adjusting for age, pubertal status and height, were developed for boys and girls to explore the independent and combined associations between fitness, weight status and HBP. Seven hundred and fifty-two (15.3%) children had HBP, with a higher prevalence in obese (40.5% and 45.9% in boys and girls, respectively) and overweight (27.6% and 30.2% in boys and girls, respectively) compared with non-overweight (9.0% and 13.8% in boys and girls, respectively) children. HBP prevalence was lower in boys with higher CRF (odds ratio (OR) for the highest vs lowest CRF quartile in boys 0.64; 95% confidence interval (CI) 0.46-0.89). This association was not seen in girls. With weight status and CRF in the same model, weight status, but not CRF, remained significantly associated with HBP (obesity in boys: OR 4.19; 95% CI 2.63-6.67; in girls: OR 2.49; 95% CI 1.19-5.19). The interaction effect for CRF and weight status was non-significant. Overweight/obesity was significantly associated with HBP among children. There was no evidence of modification of this relationship by CRF.

Association of the metabolic syndrome with vascular disease in an older Chinese population: Guangzhou Biobank Cohort Study.

OBJECTIVE: To assess the prevalence of the metabolic syndrome (MS) and relative associations with vascular disease in an older Chinese population using the US National Cholesterol Education Program: Adult Treatment Panel (NCEP: ATP III) and International Diabetes Federation (IDF) definitions. DESIGN: Cross-sectional study. SUBJECTS: A total of 3035 men and 7291 women aged 50 to 85 yr recruited from Guangzhou, China. MEASUREMENTS: All participants received a full medical check-up including measurement of blood pressure, obesity indices, fasting total, LDL-, HDL-cholesterol, triglycerides (TG) and glucose levels. Demographic information and self-reported history of physician-diagnosed coronary heart disease (CHD), stroke and myocardial infarction (MI) were collected through standardized interview. RESULTS: The estimates under the two definitions differed substantially, with the age standardized prevalence of MS 15.57% using the NCEP: ATP III definition and 25.81% using the IDF definition. Among all participants, 80.23% were similarly classified using both definitions. The association between self-reported CHD, stroke and MI and the MS defined by the IDF definition was stronger than that by the NCEP: ATP III. CONCLUSIONS: The IDF compared to the ATP III definition shows a stronger association with the MS and associated vascular disease in Chinese. The prevalence of the MS is alarmingly high in this older Chinese population. Comprehensive strategies are needed for prevention and treatment of the MS to reduce the increased societal burden of cardiovascular disease in China.

Secondhand smoke and respiratory ill health in current smokers.

BACKGROUND: Numerous studies have concluded that secondhand smoke (SHS) is harmful to non-smokers but controversy persists regarding its effects on smokers. The impact of SHS exposure on the acute respiratory health of current active smokers was examined using a cross sectional design. METHODS: 9923 uniformed staff in the Hong Kong Police Force completed a standardised questionnaire on current and past smoking, SHS exposure at home and at work, acute respiratory symptoms, and recent physician consultation. 3999 male current smokers were included in the analysis. RESULTS: About 5% of the smokers were exposed to SHS at home only, 53% were exposed at work only, and 30% were exposed both at home and at work. The prevalence ratios for respiratory symptoms (throat and nasal problems, cough, phlegm, and wheeze), physician consultation, and self medication were higher for those who were exposed to SHS at home or at work. The odds ratios of reporting one or more respiratory symptoms, for SHS exposures at home or at work, were 1.33 (95% confidence interval (CI) 1.12 to 1.59) and 1.66 (95% CI 1.36 to 2.02) respectively, after adjusting for age, marital status, education, rank and duties, exposure to self perceived dusty or polluted environment in previous job, and total dose of active smoking. The adjusted odds ratios showed significant positive dose-response gradients with SHS exposure at home, at work, and at both places combined. CONCLUSIONS: SHS exposure is strongly associated with increased acute respiratory symptoms and recent outpatient service utilisation in current smokers. If the association is causal, public health action to limit SHS exposure could also benefit smokers.

Randomised controlled trial of the effect of evidence based information on women's willingness to participate in cervical cancer screening.

STUDY OBJECTIVE: To assess whether providing women with additional information on the pros and cons of screening, compared with information currently offered by the NHS, affects their intention to attend for screening. DESIGN: Randomised controlled trial. Participants were randomly assigned to receive either the control, (based on an NHS Cervical Screening Programme leaflet currently used), or the intervention leaflet (containing additional information on risks and uncertainties). SETTING: Three general practices in Birmingham. PARTICIPANTS: 300 women aged 20 to 64 attending the practices during a one month period. MAIN OUTCOME MEASURES: Intention to attend for screening. MAIN RESULTS: 283 women (94.3%) completed the study. Fewer women in the intervention (79%) than the control group (88%) expressed intention to have screening after reading the information leaflet (difference between groups 9.2%, 95% confidence intervals (CI) 3.2% to 21.7%). The crude odds ratio (OR) and 95% CI was 0.50 (0.26 to 0.97). After adjusting for other factors, the trend persisted (OR 0.60, 95% CI 0.28 to 1.29). Having a previous Pap smear was the only significant predictor of intention to have screening (adjusted OR 2.54, 95% CI 1.03 to 6.21). Subgroup analysis showed no intervention effect in intended uptake between women at higher and lower risk of cervical cancer (p=0.59). CONCLUSIONS: Providing women with evidence based information on the risks, uncertainties, and the benefits of screening, is likely to deter some, but not differentially those at higher risk.

Passive smoking at work: the short-term cost.

STUDY OBJECTIVE: To estimate the impact of passive smoking at work on use of health care services and absenteeism. DESIGN: Cross sectional survey. SETTING: A workforce in Hong Kong. PARTICIPANTS: 5142 never-smoking police officers in a total sample of 9926. MAIN RESULTS: A consistently strong association was found among men between length of time exposed to passive smoking at work and self reported consultations with a doctor, use of medicines and time off work. Results for women were similar but most were not statistically significant. CONCLUSIONS: The exposure of healthy adults to passive smoking at work is related to utilisation of health care services and extra time off work. This results in costs to the health services, to employers and to those exposed.

Informed consent for breast screening: what should we tell women?

OBJECTIVE: To illustrate visually the lifetime probabilities of the principal outcomes of the UK breast screening programme in a readily understandable format. METHODS: We derived prognostic data from a modelling exercise using published effectiveness data and routine data sources. We calculated the probability that a woman will survive to the age of 75 if she chooses to participate fully in breast screening from age 50 to 64 and if she chooses not to participate. We also calculated her probability of being referred for assessment, undergoing fine-needle biopsy and undergoing open biopsy. We present these data in two alternative decision aid formats. These alternative formats illustrate visually the outcomes for 1000 women and 100 women choosing each alternative: breast screening or no breast screening. RESULTS: A woman participating in breast screening from age 50 to 64 increases her chances of surviving to age 75 by 0.6%. She has a 21.8% probability of surviving to age 75 and being referred for assessment but no further investigation. She has a 5.7% probability of undergoing core biopsy and a 0.9% probability of undergoing open biopsy. This information can easily be presented visually. CONCLUSIONS: We can provide realistic estimates of the effects of the breast screening programme on mortality in a readily understandable format. If we wish women to make an informed choice about breast screening they must be given this information.

Is population coronary heart disease risk screening justified? A discussion of the National Service Framework for coronary heart disease (Standard 4).

Standard 4 of the National Service Framework (NSF) for coronary heart disease (CHD) describes population cardiovascular risk screening at primary care level. General practitioners (GPs) are expected to deliver this standard and have their performance monitored as part of their clinical governance programme. Although CHD is an important preventable health problem in the United Kingdom (UK), the effectiveness of primary prevention screening programmes are minimal, even within clinical trial settings, and their cost-effectiveness is not clear. The National Screening Committee has identified clear standards for establishing a screening programme in the UK and the activities described in Standard 4 do not fulfill many of these criteria. Specifically, there are no plans for central organisation and co-ordination, no agreed quality assurance standards, and no uniform system for performance management. The clinical, social, and ethical acceptability of the interventions mandated have not been established, and GPs are left to consider how to redirect resources to achieve the standard. We argue that the benefits of population cardiovascular screening must be established through properly conducted trials and, if a programme is introduced, adequate resources and management structures must first be identified.

Exercise and health---new imperatives for public health policy in Hong Kong.

Physical inactivity is an important and largely avoidable cause of incapacity. Regular physical activity protects against several chronic diseases, including cardiovascular disease---one of the major causes of death in Hong Kong. Significant benefits can be achieved by regular participation in moderate amounts of either recreational or general lifestyle physical activities. Even more is gained from increasing the frequency, duration, and vigour of exercise. In Hong Kong, 59% of all adults lead a fairly sedentary lifestyle and only one in three exercise at levels that are thought to offer significant health benefits. An even more disturbing fact is that Hong Kong probably has the most inactive primary level schoolchildren in the world. The prevalence of these risk behaviours should make schoolchildren a priority for any public health prevention programme.

Preventing avoidable death: the case of cervical cancer in Hong Kong.

Cervical cancer remains an important cause of avoidable morbidity and mortality in Hong Kong. This paper briefly reviews the epidemiology of cervical cancer and explores the evidence on the effectiveness of screening. The essential components of a successful cervical cancer screening programme, based on international experience, are discussed. The present situation in Hong Kong is then examined and the options outlined for the way ahead.