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Agreement between data for awareness and treatment of high cholesterol collected by questionnaire and data obtained from medical records is over 75%. The agreement is better for women and for younger age groups. (1)
The MONICA Manual (2) has four questions about the awareness and treatment of high cholesterol.
| 1. | "Have you ever been told by a doctor or other health worker that you have high
blood cholesterol?" 1 = yes 2 = no (if no, record 8 in Question 2 and Question 3) 9 = insufficient data |
|__| |
| 2. | "Are you on special diet prescribed by a doctor or other health worker to lower
your blood cholesterol level?" 1 = yes 2 = no 3 = uncertain 8 if Question 1 = 2 9 = insufficient data |
|__| |
| 3. | "Are you taking (in the last two weeks) pills or other medicine prescribed by a
doctor to lower your blood cholesterol level?" 1 = yes 2 = no 3 = uncertain 8 if Question 1 = 2 9 = insufficient data |
|__| |
| 4. | "Have you had your blood cholesterol measured in the last year?" 1 = yes 2 = no 9 = insufficient data |
|__| |
For the Question 2, the MONICA Manual (2) gives the additional instructions:
Code 1 if yes
Code 2 if no
Code 3 if the person is following a special diet but he/she is not sure whether the diet
is for cholesterol lowering purposes.
Code 8 if the person has never been told by a doctor or other health worker that he/she
has high blood cholesterol (Question 1 = 2).
Code 9 if insufficient information is available to use the other codes.
For the Question 3 the additional instructions are:
Code 1 if yes
Code 2 if no.
Code 3 if the use of cholesterol lowering drugs is reported but the person in question is
not sure whether these have been used during the last two weeks or he/she is not sure
whether the drugs used were for lowering cholesterol.
Code 8 if the person has never been told that he/she has high blood cholesterol (Question
1 = 2).
Code 9 if insufficient information is available to use the other codes.
In the Monitoring Project on Cardiovascular Disease Risk Factors in the Netherlands, the questions on high cholesterol used during the period 1987 to 1991 (3, 4) were:
| 1. | Have you ever been diagnosed with hypercholesterolemia? 1. Yes 2. No |
|__| |
| If yes: | ||
| 2a. | When was the first time (year)? | |__||__||__||__| |
| 2b. | Who made the diagnosis? 1. General practitioner 2. Specialist 3. Company doctor ... |
|__| |
| 2c. | Do you have a diet for this at present? 1. Yes 2. No |
|__| |
| 2d. | If yes, what kind of diet? 1. Fat reduced 2. Cholesterol reduced ... |
|__| |
| 2e. | If yes, who provided the dietary advice? 1. Doctor 2. Dietician 3. Own initiative ... |
|__| |
| 2f. | Do you use antihypercholesterolemia medication? 1. Yes 2. No |
|__| |
In the MORGEN-project the following questions were used for awareness and treatment of high cholesterol (4):
| 1. | Have you ever been diagnosed with hypercholesterolemia? 1. Yes 2. No 3. Don't know |
|__| |
| 2. | If yes, do you use medication at present? 1. Yes 2. No |
|__| |
In the REGENBOOG project the following questions about the awareness and treatment of high cholesterol were included to the questionnaire (5):
| 1. | Is your cholesterol elevated at the moment? 1. Yes 2. No 3. I don't know |
|__| |
| 2. | Do you use drugs to lower your cholesterol? 1. Yes 2. No |
|__| |
| 3. | Are you on a diet to lower your blood cholesterol? 1. Yes 2. No |
|__| |
The questionnaire for the German Federal Health Survey 1998 (6) included high cholesterol among a long list of possible answers to the question
Which one of the following diseases did you ever have:
| Yes | No | Don't know | |
| High blood lipids, elevated cholesterol | |__| | |__| | |__| |
The informant's response was further clarified in a subsequent physician interview, when information on the use of pharmacological agents was collected. These were then grouped into 34 categories depending on their indication (7). The question asked whether, during the past 12 months, medications of a particular drug category were used :
daily, or several times per week, or 1-2 times per week, or less than once a week, or 1-3 times per month, or seldom, or never.
One of the drug category was "for lowering of blood lipids".
Question used in 1998 Health Survey for England (8):
| 1. | Have you ever had your blood cholesterol level measured by a doctor or
nurse? 1. Yes (Go to Question 2) 2. No |
|__| |
| 2. | When was the last time your blood cholesterol level was measured by a
doctor or nurse? 1. During the last 12 months 2. At least a year but less than 3 years ago 3. At least 3 years but less than 5 years ago 4. Five years ago or more |
|__| |
| 3. | Last time your blood cholesterol was measured, were you told it was 1. Normal (alright/fine) 2. Higher than normal 3. Lower than normal 4. Were you not told anything |
|__| |
The following questions about the awareness and treatment of high cholesterol were asked during the home visit from adults (9):
| 1. | Have you ever had your blood cholesterol checked? 1. Yes 2. No |
|__| |
| 2. | Have you ever been told by a doctor or other health professional that
your blood cholesterol level was high? 1. Yes 2. No |
|__| |
| 3. | Because of your high blood cholesterol, have you ever been told by a
doctor or other health professional to 1=Yes, 2=No a. eat fewer high fat or high cholesterol foods? b. control your weight or lose weight? c. exercise? d. take prescribed medicine? |
|__| |__| |__| |__| |
| 4. | To lower your blood cholesterol, are you now following this advice to 1=Yes, 2=No a. eat fewer high fat or high cholesterol foods? d. take prescribed medicine? |
|__| |__| |
| 5. | To lower your blood cholesterol, have you made any lasting and major
changes on your own? Specifically 1=Yes, 2=No b. have you controlled your weight or lost weight? c. do you exercise more? |
|__| |__| |
More detailed instruction for above questions are:
Question 1. Enter Code 1 (YES) if respondent has ever had his/her blood cholesterol checked by anyone.
For Code 2 (NO) skip questions concerning the SP's efforts to lower his or her blood cholesterol on his/her own (Question 5).
Question 3. Enter Code 1 (YES) if the respondent has ever been advised by a doctor or other health professional to follow one or more of the treatments listed. Enter Code 2 (NO) if the respondent has not been advised to follow one or more of the above treatments or if s/he has been advised to do so for any condition other that high cholesterol.
Note that "prescribed medication" may include pills, powders, or liquids, and must be purchased by prescription.
Question 4. Mark Code 1 (YES) if the person is currently following the treatment either on a regular or irregular basis.
Question 5. In this question you will only ask about those treatments that were not recommended by a doctor to lower the SP's cholesterol in Question 3. Therefore if a doctor has advised the SP to make all four changes in Question 3, this question will be skipped.
The questionnaire section on awareness of high cholesterol preceded the section on diabetes.
| 1. | Has a doctor or other health professional ever told you that
you have high cholesterol? 1. Yes 2. No (go to section on diabetes) 3. Insufficient data (go to section on diabetes) |
|__| |
| 2. | Do you eat a special diet, prescribed by a physician or
other health professional, to lower cholesterol? 1. Yes 2. No 3. Uncertain |
|__| |
| 3. | During the past two weeks, have you taken medication,
prescribed by a physician, to lower cholesterol? 1. Yes 2. No (go to section on diabetes) 3. Uncertain (go to section on diabetes) |
|__| |
| 4. | How many types of medications have you taken? | |__| |
| Medication 1 | ||
| 5. | Name of medication | |__________________| |
| 6. | Do you take it daily? | Yes No |
| 7. | Number of pills per day Number of pills per week |
|__| |__||__| |
| Medication 2 | ||
| 8. | Name of medication | |__________________| |
| 9. | Do you take it daily? | Yes No |
| 10. | Number of pills per day Number of pills per week |
|__| |__||__| |
| Medication 3 | ||
| 11. | Name of medication | |__________________| |
| 12. | Do you take it daily? | Yes No |
| 13. | Number of pills per day Number of pills per week |
|__| |__||__| |
The questions used in the National Cardiovascular Screening for high cholesterol were (10):
| 1. | Do you use medication for treatment of high cholesterol at present? 1. Yes 2. No |
|__| |
Questionnaire also has other questions about the age when person has started to use these medications, the reason for treatment and the name and dose of the drug.
WHO MONICA Project
The detailed description about the availability and quality of the data on awareness and treatment of high cholesterol is given in the Quality Assessment of Data on Awareness and Treatment of High Cholesterol in the WHO MONICA Project (11).
Awareness of high cholesterol
In many populations which included the question about the awareness of the high cholesterol the expression "told by a doctor or other health worker" was omitted (11). This omission will bias the response to the actual question asked in MONICA.
Dietary treatment of high cholesterol
There were a few centres where the local question about the dietary treatment of the high cholesterol could bias the response to the actual MONICA question. In these centres, the expression "prescribed by a doctor or other health worker" was omitted and some centres did not asked the question if the person was complying the prescribed diet. (11)
Drug treatment of high cholesterol
There were a few centres where the local question about the drug treatment of the high cholesterol could bias response to the actual MONICA question. In these centres, the expression "prescribed by a doctor or other health worker" was omitted or the question asked in general terms about the treatment for high cholesterol without defining whether it is drug or dietary treatment. There were also discrepancies between MONICA and local questions on the time period when the medication was taken . The MONICA question asked about the use during the "last two weeks" . The local questionnaires varied in their specification of the period from "preceding week" to "few months". (11)
Cholesterol measurement within the last year
The questions on cholesterol measurement within the last year were in most centres as suggested by the MONICA manual. Some had the questions formulated differently but the exact MONICA data could still be extracted from them. (11)
No information is available on retrospective quality assessment of the cholesterol questions for Risk factor monitoring in the Netherlands, Risk factor monitoring in Germany, UK National Health Surveys, and NHANES III.
Indicators where the measured cholesterol level and treatment status for the high cholesterol are combined were discussed in Chapter 5. Here, we will list other indicators used in different studies to describe the awareness and treatment of high cholesterol in populations.
WHO MONICA Project
In the WHO MONICA Project the results about the awareness and treatment of high cholesterol are reported using proportions of persons told about the high cholesterol, and four categories of treatment to lower blood cholesterol (12). These four categories are proportion of the persons aware of their high cholesterol status:
Risk factor monitoring in Germany
The German Federal Health Survey 1998 reported prevalence of medication use by drug categories and ranked them by prevalence for men and women and for the old and new states (7).
No information on treatment indicators are available for Risk factor monitoring in the Netherlands, UK National Health Surveys, and NHANES III.
Most surveys considered here have asked if a person has ever had his/her blood cholesterol measured or whether it was measured within the past year by a health professional. The exception is the German Federal Health Survey 1998 where a less specific question was used.
References
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