1. Project Partners: 計劃夥伴： Funded by: 捐助機構： Gap of Health Care for Midlife Women: Controlling Risk Factors of Stroke as Example Chau Pui Hing CADENZA Project, Faculty of Social Sciences, The University of Hong Kong

2. Project Partners: 計劃夥伴： Funded by: 捐助機構： 22 Our Team Members Prof Jean Woo Prof Susanne C Ho Prof William B Goggins

3. Project Partners: 計劃夥伴： Funded by: 捐助機構： 3 Background There is a tendency to assume that men have a worse cardiovascular risk factor profile than women  More effort may have been directed towards men Women generally have a healthier lifestyle than men  Further lead to possible gaps in health promotion efforts among women

4. Project Partners: 計劃夥伴： Funded by: 捐助機構： 4 An Illustration Here, we use cerebrovascular disease (stroke) as an example to illustrate possible gaps in health care, especially among midlife women

5. Project Partners: 計劃夥伴： Funded by: 捐助機構： 5 The Impact of Stroke Lead to disability and functional limitation, resulting in long term residential care (Woo et al. 1992a; Woo et al. 1998a) The leading cause of hospital admissions particularly among the older Hong Kong population, accounting for the largest number of bed days (Department of Health 2004) Economic burden of elderly stroke patients was about US$250 million in 2001 (Woo et al. 1997) The 4th leading cause of deaths in Hong Kong and accounted for about 8% of all deaths (Department of Health, 2010) Among the avoidable causes of mortality, stroke ranked first in Hong Kong compared with Paris, Manhattan, New York and Inner London (Chau et al. 2010)

6. Project Partners: 計劃夥伴： Funded by: 捐助機構： 6 Risk Factors for Stroke Hypertension, hypercholesterolemia, smoking, diabetes mellitus, overweight, etc. Different stroke subtypes have different risk factors Hypertension is a common risk factor for both ischemic and hemorrhagic strokes Smoking increases the risk of stroke for both subtypes, but is more associated with ischemic stroke

7. Project Partners: 計劃夥伴： Funded by: 捐助機構： 7 Stroke Prevention Risk factor reduction, such as anti-smoking, blood pressure and diabetes detection and control, is promoted as preventive measure

8. Project Partners: 計劃夥伴： Funded by: 捐助機構： 8 Stroke is emphasized

9. Project Partners: 計劃夥伴： Funded by: 捐助機構： 9 Stroke is not emphasized

10. Project Partners: 計劃夥伴： Funded by: 捐助機構： 10 Our Study Examine trends in some of the risk factors in relation to the stroke trends in Hong Kong based on evidences drawn from different studies Aim to identify some possible gaps in public health strategy for controlling risk factors in achieving reductions in stroke incidence among women

11. Project Partners: 計劃夥伴： Funded by: 捐助機構： 11 Incidence of Hemorrhagic Stroke in HK (2005-07) Remarks: Incidence rates were calculated based on hospital admission statistics Hemorrhagic stroke was identified by ICD9: 431-432 Women had lower incidence rates than men for all age groups

12. Project Partners: 計劃夥伴： Funded by: 捐助機構： 12 Incidence of Ischemic Stroke in HK (2005-07) Remarks: Incidence rates were calculated based on hospital admission statistics Ischemic stroke was identified by ICD9: 433, 434, 436 and 437 Women had lower incidence rates than men for all age groups

13. Project Partners: 計劃夥伴： Funded by: 捐助機構： 13 Prevalence of Daily Cigarette Smokers (2010) Source: Tobacco Control Office, Department of Health Women had lower prevalence rates than men for all age groups

14. Project Partners: 計劃夥伴： Funded by: 捐助機構： 14 Prevalence of Hypertension (2003-04) Remarks: Hypertension was defined as a systolic blood pressure ≥140mmHg or a diastolic blood pressure ≥90mmHg Source: Population Health Survey 2003/04 Women had lower or similar prevalence rates as their male counterparts

15. Project Partners: 計劃夥伴： Funded by: 捐助機構： 15 Prevalence of Overweight (2004-05) Remarks: Overweight was defined as a BMI ≥ 25kg/m 2 Source: Heart Health Survey 2004/05 Women had lower prevalence rates than men for most age groups

16. Project Partners: 計劃夥伴： Funded by: 捐助機構： 16 Prevalence of Diabetes Mellitus (2004-05) Remarks: DM was defined by self-report history or diagnosed by OGTT (fasting glucose ≥7.0mmol/L or 2-hour glucose ≥11.1mmol/L) Source: Heart Health Survey 2004/05 Women had higher prevalence rates than men for the middle aged and elderly

17. Project Partners: 計劃夥伴： Funded by: 捐助機構： 17 Prevalence of High Blood Cholesterol (2004-05) Remarks: High blood cholesterol was defined as a plasma cholesterol ≥5.2mmol/L Source: Heart Health Survey 2004/05 Women had higher prevalence rates than men among the middle aged and elderly

18. Project Partners: 計劃夥伴： Funded by: 捐助機構： 18 Good enough? How about the trends?

19. Project Partners: 計劃夥伴： Funded by: 捐助機構： 19 Trends in Stroke Incidence (Aged 35-44) Remarks: Incidence rates were calculated based on hospital admission statistics Hemorrhagic stroke was identified by ICD9: 431-432 Ischemic stroke was identified by ICD9: 433, 434, 436 and 437 Source: Chau et al. (2011)

20. Project Partners: 計劃夥伴： Funded by: 捐助機構： 20 Trends in Stroke Incidence An overall decreasing trend was shown for ischemic stroke, but this pattern did not apply to the middle aged population (aged 35-44) Hemorrhagic stroke incidence increased among the middle aged Remarks: Trends (2005-7 vs 2002-4 and 2002-4 vs 1999-2001) were tested with Poisson regression analysis (  =5%)

21. Project Partners: 計劃夥伴： Funded by: 捐助機構： 21 Trends in Male Daily Cigarette Smokers Prevalence Source: Tobacco Control Office, Department of Health

22. Project Partners: 計劃夥伴： Funded by: 捐助機構： 22 Trends in Female Daily Cigarette Smokers Prevalence Source: Tobacco Control Office, Department of Health

23. Project Partners: 計劃夥伴： Funded by: 捐助機構： 23 Trends in Daily Cigarette Smokers Prevalence From 1982 to 2010, prevalence rate of daily cigarette smokers was decreasing among men of all ages, but that among young and middle aged women (aged <40) has been increasing until recently

24. Project Partners: 計劃夥伴： Funded by: 捐助機構： 24 Trends in Hypertension Prevalence Remarks: Hypertension was defined as a systolic blood pressure ≥140mmHg or a diastolic blood pressure ≥90mmHg Sources: Cardiovascular Risk Factor Study 1995-1996; Population Health Survey 2003/04

25. Project Partners: 計劃夥伴： Funded by: 捐助機構： 25 Trends in Hypertension Prevalence Prevalence of hypertension in 2003-2004 increased as compared to 1995-1996 The increase in hypertension prevalence rate was steeper for the young and midlife population Although the increase in prevalence rates among women was slower than their male counterparts, the prevalence rates of hypertension among women aged 35-44 nearly tripled

26. Project Partners: 計劃夥伴： Funded by: 捐助機構： 26 Trends in Overweight Prevalence Remarks: Overweight was defined as a BMI ≥ 25kg/m 2 Sources: Cardiovascular Risk Factor Prevalence Study 1995-1996; Heart Health Survey 2004/05

27. Project Partners: 計劃夥伴： Funded by: 捐助機構： 27 Trends in Diabetes Mellitus Prevalence Remarks: DM was defined by self-report history or diagnosed by OGTT (fasting glucose ≥7.0mmol/L or 2-hour glucose ≥11.1mmol/L) 10-year age groups (instead of 5-years) were used in Cardiovasular Risk Factor Prevalence Study 1995/6 Sources: Cardiovascular Risk Factor Prevalence Study 1995-1996; Heart Health Survey 2004/05

28. Project Partners: 計劃夥伴： Funded by: 捐助機構： 28 Trends in Hypercholesterolemia Prevalence Remarks: High blood cholesterol was defined as a plasma cholesterol ≥5.2mmol/L Source: Cardiovascular Risk Factor Study 1995-1996; Heart Health Survey 2004/05

29. Project Partners: 計劃夥伴： Funded by: 捐助機構： 29 Trends in Overweight, Diabetes Mellitus and Hypercholesterolemia Fortunately, the trends in these risk factors were decreasing among women For the young and midlife women, the reduced stroke risk related to the decline in these factors perhaps was offset by the increase in the prevalence of other risk factors Nevertheless, the prevalence of hypercholesterolemia in women was still higher than men in the middle and elderly age groups

30. Project Partners: 計劃夥伴： Funded by: 捐助機構： 30 Discussions Stroke is one of the illnesses that women have lower incidence rates than men Women also have lower prevalence rates of some of the risk factors like smoking, hypertension and overweight These possibly are related to less emphasis on stroke prevention and risk factors reduction among women

31. Project Partners: 計劃夥伴： Funded by: 捐助機構： 31 Alarming Trends Increasing hemorrhagic stroke incidence rate and non-decreasing ischemic stroke incidence rate are observed not only in midlife men, but also midlife women Probably related to Increasing prevalence rates of hypertension, particularly the faster increase among the young and middle aged population Increasing prevalence rates of smoking among young and middle aged women

32. Project Partners: 計劃夥伴： Funded by: 捐助機構： 32 Implications Despite the lower risk of stroke among women, there is room for improvement in health promotion efforts in controlling the risk factors, particularly hypertension and smoking These strategies should be implemented at population level, in addition to the individual level control measures Improvement in control may prevent the mid age rise in incidence of hemorrhagic stroke and may lead to a decline in the incidence of ischemic stroke

33. Project Partners: 計劃夥伴： Funded by: 捐助機構： 33 Way Forward It is acknowledged that secondary data analyses are subject to certain limitations, further research based on primary data is necessary to explore how to strengthen public health strategy

34. Project Partners: 計劃夥伴： Funded by: 捐助機構： 34 Acknowledgments Data provision The Strategy and Planning Division of the Hospital Authority Prof Sarah M McGhee

35. Project Partners: 計劃夥伴： Funded by: 捐助機構： 35 Acknowledgments This study was supported by “CADENZA: A Jockey Club Initiative for Seniors” funded by The Hong Kong Jockey Club Charities Trust, and the Health and Health Services Research Fund (HHSRF: 06070451), Food and Health Bureau, Hong Kong SAR Government

36. Project Partners: 計劃夥伴： Funded by: 捐助機構： 36