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
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Our Team Members
Prof Jean Woo
Prof Susanne C Ho
Prof William B Goggins
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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
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An Illustration
Here, we use cerebrovascular disease (stroke)
as an example to illustrate possible gaps in
health care, especially among midlife women
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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)
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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
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Stroke Prevention
Risk factor reduction, such as anti-smoking,
blood pressure and diabetes detection and
control, is promoted as preventive measure
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Stroke is
emphasized
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Stroke
is not
emphasized
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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
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Incidence of Hemorrhagic Stroke in HK (2005-07)
Rate per 100,000 population
800
700
600
Women had lower
incidence rates than men
for all age groups
500
Male
400
Female
300
200
100
0
35-44
45-54
55-64
65-74
Age Group
75-84
85+
Remarks: Incidence rates were calculated based on hospital admission statistics
Hemorrhagic stroke was identified by ICD9: 431-432
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Incidence of Ischemic Stroke in HK (2005-07)
Rate per 100,000 population
2500
2000
Women had lower
incidence rates than men
for all age groups
1500
Male
Female
1000
500
0
35-44
45-54
55-64
65-74
Age Group
75-84
85+
Remarks: Incidence rates were calculated based on hospital admission statistics
Ischemic stroke was identified by ICD9: 433, 434, 436 and 437
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Prevalence of Daily Cigarette Smokers (2010)
30
Women had lower
prevalence rates
than men for all age
groups
Prevalence rate (%)
25
20
Male
Female
15
10
5
0
20-29
30-39
40-49
Age Group
50-59
60+
Source: Tobacco Control Office, Department of Health
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Prevalence of Hypertension (2003-04)
80
Prevalence rate (%)
70
Women had lower or
similar prevalence rates
as their male counterparts
60
50
Male
40
Female
30
20
10
0
25-34
35-44
45-54
55-64
Age Group
65-74
75+
Remarks: Hypertension was defined as a systolic blood pressure ≥140mmHg or a diastolic blood pressure ≥90mmHg
Source: Population Health Survey
2003/04
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Prevalence of Overweight (2004-05)
50
Women had lower prevalence rates
than men for most age groups
45
Prevalence rate (%)
40
35
Male
30
Female
25
20
15
10
5
0
25-44
45-49
50-54
55-59
60-64 65-69
Age 2Group
Remarks: Overweight was defined as a BMI ≥ 25kg/m
Source: Heart Health Survey
2004/05
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70-74
75-79
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80-84
15
Prevalence of Diabetes Mellitus (2004-05)
40
Prevalence rate (%)
35
30
Women had higher
prevalence rates than
men for the middle
aged and elderly
Male
25
Female
20
15
10
5
0
25-44
45-49
50-54
55-59
60-64
Age Group
65-69
70-74
75-79
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
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Prevalence of High Blood Cholesterol (2004-05)
90
Prevalence rate (%)
80
Women had higher prevalence
rates than men among the
middle aged and elderly
70
60
Male
50
Female
40
30
20
10
0
25-44
45-49
50-54
55-59
60-64 65-69
Age Group
70-74
75-79
80-84
Remarks: High blood cholesterol was defined as a plasma cholesterol ≥5.2mmol/L
Source: Heart Health Survey 2004/05
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Good
enough?
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How about
the
trends?
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Rate per 100,000 population
Trends in Stroke Incidence (Aged 35-44)
30
25
1999-2001
20
2002-2004
15
2005-2007
10
5
0
Hemorrhagic
stroke (Male)
Hemorrhagic
stroke
(Female)
Ischemic
stroke (Male)
Ischemic
stroke
(Female)
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)
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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
(a=5%)
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Trends in Male Daily Cigarette Smokers Prevalence
60
15-19
Prevalence rate (%)
50
20-29
40
30-39
40-49
30
50-59
60+
20
10
0
1980
1985
1990
1995
2000
2005
2010
Year
Source: Tobacco Control Office, Department of Health
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Trends in Female Daily Cigarette Smokers Prevalence
16
Prevalence rate (%)
14
15-19
12
20-29
10
30-39
40-49
8
50-59
6
60+
4
2
0
1980
1985
1990
1995
2000
2005
2010
Year
Source: Tobacco Control Office, Department of Health
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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
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Trends in Hypertension Prevalence
80
Prevalence rate (%)
70
60
Male 1995/6
50
Male 2003/4
Female 1995/6
40
Female 2003/4
30
20
10
0
25-34
35-44
45-54
55-64
65-74
Age Group
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
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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
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Trends in Overweight Prevalence
60
Prevalence rate (%)
50
Male
1995/6
40
Male
2004/5
30
Female
1995/6
20
Female
2004/5
10
0
25-44
45-49
50-54
55-59
60-64
65-69
70-74
Age Group
Remarks: Overweight was defined as a BMI ≥ 25kg/m 2
Sources: Cardiovascular Risk
Factor Prevalence Study 1995-1996; Heart Health
Survey 2004/05
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Trends in Diabetes Mellitus Prevalence
40
Prevalence rate (%)
35
Male
1995/6
Male
2004/5
Female
1995/6
Female
2004/5
30
25
20
15
10
5
0
25-44
45-49
50-54
55-59
60-64
Age Group
65-69
70-74
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 SurveyProject
2004/05
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Trends in Hypercholesterolemia Prevalence
80
Prevalence rate (%)
70
60
Male
1995/6
50
Male
2004/5
40
30
Female
1995/6
20
Female
2004/5
10
0
25-44
45-49
50-54
55-59
60-64
65-69
70-74
Age Group
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
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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
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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
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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
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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
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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
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Acknowledgments
Data provision
The Strategy and Planning Division of the Hospital
Authority
Prof Sarah M McGhee
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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
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