Cardiovascular risk factors and visiting nurse intervention--evaluation of a Croatian survey and intervention model: the CroHort study.

The aim of this study is to identify factors that influence the success of the implementation of the primary and secondary prevention programs in Croatia by the visiting/community services. Two main sources of information were used: reports about regular visiting nurse services in Croatia and research about visiting nurse participation in the Croatian Adult Health Cohort Study (CroHort) 2008. Out of the total number 9,070 respondents who participated in CAHS 2003 survey, during CroHort 2008 program 3,229 (35.6%) participants were re-interviewed. The qualitative analysis was done with a sample of 34 visiting nurses, which participated in the CroHort 2008. Results show that there are three key problems which limit preventive programs: inability of the health care system to recognize the importance of the primary prevention; visiting nurses' lack capacity to implement prevention and populations' lack of motivation and education.

Regional variations and trends in mortality from cardiovascular diseases in population aged 0-64 in Dalmatia and Slavonia, 1998-2009.

The aim of this paper was to analyse the regional variations and trends in mortality from cardiovascular diseases in the population aged 0-64 years in Dalmatia and Slavonia, over the period 1998 to 2009. Mortality data were derived from Central Bureau of Statistics. The results show that age-standardized mortality rates from total cardiovascular diseases, ischaemic heart diseases and cerebrovascular diseases were lower in Dalmatia than rates for Slavonia, for both genders. All mortality rates, except rates for ischaemic heart diseases mortality for men in both regions, showed the trend of decline. Dalmatia has a more protective factors in pattern of Mediterranean diet. The improvement of cardiovascular health and reduction of premature mortality from cardiovascular diseases requires a system and comprehensive intervention approach at all levels of health care and multisectorial coordination.

[Health status and health needs assessment--state of the art of the public health practice in Croatia]. / Procjena zdravlja i zdravstvenih potreba populacije javnozdravstvena praksa u hrvatskoj danas.

Public health practice performance is measured through its three core functions, i.e. assessment, policy development and assurance. We describe the existing health status and health care needs assessment practices in the Republic of Croatia. Health care needs assessment in Croatia includes mortality and morbidity information available through vital records but does not include community input (opinion and attitude) and participation. Health needs are not analyzed in order to determine the causes of health problems. Analysis of health needs of the population groups at highest risk also does not exist. Resources assessment is not part of the process, so we do not know how adequate the existing health resources are. In the Croatian health care system practice, the assessment function is limited through the almost exclusive use of the routine health and demographic statistics. Academic public health has introduced other kinds of more participative, subgroups oriented, qualitative methodologies but in daily routine, these methods are hardly used. Since health needs assessment is one of the core public health functions, in the future its practice has to be reoriented from pure monitoring towards identifying and solving community health problems. Partnership with community has to be a cornerstone for more efficient health needs assessment practice. In the light of previous statement, we present and discuss new trends in the assessment practice in Croatia, i.e. revision of routine health data collection, ways of performing intervention aimed health surveys, naturalistic approach in health needs assessment, and health needs research of population groups at highest risk.

[Decentralization and how to conduct it as a revolution or an evolution? County public health and management capacity building as a prerequisite for successful decentralization in the Republic of Croatia]. / Decentralizacija i kako je provesti--revolucijski ili evolucijski? Jacanje javnozdravstvenog i upravljackog kapaciteta regionalne samouprave kao preduvjet za uspjesno provodenje decentralizacije u Republici Hrvatskoj.

AIM: Based on the results of the first phase of the County Public Health Capacity Building Program named Health-Plan for It, implemented in the Republic of Croatia during the 2002-2008 period, this article analyzes the relationship between training of the county teams and their ability to develop health policy. Our hypothesis was that decentralized model of health planning and management would not occur just by changing legislation alone. Counties in Croatia needed educational support (learning-by-doing training) in order to improve public health practices at the county level. SAMPLE AND METHODS: During the 2002-2005 period, the first 15 county teams (so-called first cycle counties) completed their training. The teams consisted of 12 to 15 members, representatives of political and executive component, technical component (public health professionals, representatives of health and social welfare institutions) and community members (non-government sector and media). Teams were trained in cohorts. Three counties passed together through the six-month process of modular training (four education modules, with four days of intensive training and "homework" between modules) at the time. The remaining 5 counties (second-cycle counties) completed the same kind of training in 2007-2008. The Public Health Performance Matrix (the Local Public Health Practice Performance Measures instrument developed by the US CDC Public Health Practice Program Office) was used as an evaluation instrument. Each county team had to fill it out at the beginning of education. RESULTS: Comparison of the Public Health Performance Matrices of first cycle counties (training in 2002-2005) with those of the second cycle counties (trained several years later) yielded no differences. Although training materials were publicly available (accessible through the Croatian Healthy Cities web pages) for years, the second cycle counties did not spontaneously (without training) increase their county-level capacities for participative health needs assessment, health planning, and provision of health services tailored to the local needs. CONCLUSION: Results of this study showed that decentralized model of health planning and management in Croatia could not be developed without educational support given to the lower level of administration. Only through the training process (the Health-Plan for It County Public Health Capacity Building Program), county teams had managed to develop policy function and create County Health Profiles and Strategic Framework of the County Health Plan

[Health system research in the Republic of Croatia 1990-2010]. / Istrazivanja zdravstvenog sustava u Republici Hrvatskoj 1990-2010.

AIM: The aim of this study was to determine the scope and contents of peer-reviewed scientific publications that bring the results of the Health System Research (HSR) in the Republic of Croatia during the 1990-2010 period. The basic guidelines are in line with the research project, Health Services Research into European Policy and Practice (HSREPP). This project is being implemented with the aim of identifying, evaluating and improving the contribution of Health System Research to the development of Health Policy in Europe. This study included scientific publications indexed in the PubMed database and master theses and doctoral dissertations published at Schools of Medicine in Zagreb, Osijek, Rijeka and Split during the 1990-2010 period. In accordance with the project methodology, scientific publications indexed in PubMed (http://www.ncbi.nlm.nih.gov/pubmed) were searched for by the key words "Croatia AND (Health Care System OR Health System OR Healthcare System)". Then, the database of scientific publications indexed in PubMed was narrowed by key words divided into 4 groups according to HSREPP instructions. The search for master theses and doctoral dissertations was carried out by direct inspection of the completed works in the library of Andrija Stampar School of Public Health, School of Medicine, University of Zagreb. Access to master theses and doctoral dissertations at the other three medical schools was done by the Internet. We analyzed the collected summaries of all publications, master theses and doctoral dissertations and excluded all those that did not correspond to our research. RESULTS: Using this method, we found a total of 536 publications indexed in PubMed-in, 70 master theses and 22 doctoral dissertations meeting the study criteria. For further analysis, we separately considered master theses and doctoral dissertations on the one side, and scientific publications indexed in PubMed on the other side. All papers were listed by the year of publication, the author and the means of publication. Upon inclusion of the key words, 277 papers met the required criteria. After abstract analysis, 158 PubMed indexed papers were found to meet all the criteria and addressed the Health System Research in Croatia. There was a significant increase in the number of published papers during the 5-year study period. Upon analysis of the summary contents of master theses and doctoral dissertations, we separated 6 doctoral dissertations and 35 master theses that met the criteria of the research. They were divided into four groups: research of macro-, mezzo- and micro-level of Health System and assessment of Health Care System results. The group investigating the organization and delivery of health services (meso-level) and the group investigating health technology assessment (micro/meso-level) predominated. There were only a small number of high quality researches dealing with HSR in Croatia. Descriptive approach to the analysis predominated. Reform interventions require research, but are not part of the designed strategy. Funding of HSR is an important issue. The research in Croatia is financed by the Croatian Ministry of Science, Education and Sports. In the UK and the USA, HSR is funded by the National Health Services. In all publications, we could not find a systematic research of the Health System; however, we recognized a growing trend in the number of articles dealing with HSR in Croatia over the past 20 years. Comparison of the number of papers on the Health Care System in Croatia indicated a significant lag in comparison to Western Europe, and similarity with the countries of Eastern Europe.

[Quality improvement of health care services in Croatian emergency medicine]. / Unaprjedenje kvalitete zdravstvene usluge u hitnoj medicini u Hrvatskoj.

Emergency medical services (EMS) in the Republic of Croatia are currently organized as part of the existing health care system and delivered in the form of pre-hospital and hospital EMS. The pre-hospital EMS are delivered by standalone EMS Centers, EMS units set up in community health centers, and by general practitioners working in shifts and on call in remote and scarcely populated areas. In hospitals, each ward usually has its own emergency reception area, and only in a couple of cases there is an integrated emergency admission unit for the entire hospital. The current EMS structure does not meet the basic requirements that would make an EMS system optimal, i.e. equal quality, equal access, effectiveness and appropriate equipment. The EMS Restructuring Project is part of the Croatian health care system reform and is addressed by the National Health Development Strategy 2006-2011. As part of restructuring efforts, the Croatian National Institute of Emergency Medicine, 21 County Institutes of Emergency Medicine and county-level call centers are going to be set up. In addition, the project will introduce the following: integrated emergency admission areas at hospitals; telemedicine as part of emergency medicine; emergency medicine specialty for physicians and additional specialized training for nurses/technicians; separation of emergency and non-emergency transport; standards for vehicles and equipment and guidelines/protocols/algorithms for care. The Croatian National Institute of Emergency Medicine is an umbrella EMS organization. It shapes the EMS in Croatia and proposes, plans, monitors and analyzes EMS actions in Croatia. In addition, it submits a proposal of the Emergency Medicine Network to the minister, sets standards for EMS transport, and coordinates, guides and supervises the work of County Institutes of Emergency Medicine. County Institutes organize and deliver pre-hospital EMS in their counties. Integrated hospital emergency admission units represent a single point of entry for all emergencies at a particular hospital. Upon triage, depending on the level of emergency, patients are provided with appropriate care and treatment. The introduction of EMS specialty for physicians and additional specialized training for nurses/ technicians is going to increase competencies of all EMS team members. The main objectives of the EMS Restructuring Project to be achieved in the 5-year period are the following: to reduce the response time of pre-hospital EMS teams to 10 minutes in urban areas and 20 minutes in rural areas in 20% of team interventions; to bring patients to hospital within the "golden hour" in 80% of cases; to have 200 physicians specialized in emergency medicine; and to have 220 nurses/technicians that have successfully completed their specialized training in emergency medicine. The objectives are going to be monitored through indicators as part of the World Bank Project for which data have already been collected throughout Croatia: number of interventions; number of emergency interventions; time between call receipt and arrival to scene; time between call receipt and arrival to hospital emergency reception area; percentage of arrivals to hospital by EMS vehicles within 12 hours of symptom onset; polytrauma and cardiac arrest survival rate before admission to hospital; time spent in hospital emergency reception areas and integrated hospital emergency admission units; polytrauma and cardiac arrest survival rate within 24 hours of hospital admission; number of integrated hospital emergency admission units per county; and number of pre-hospital EMS teams per capita.

[National program of early detection of cancer in Croatia]. / Rano otkrivanje raka u hrvatskoj.

INTRODUCTION: A well organized and conducted program of cancer screening at the population level should be scientifically based, cost-effective at long term, and designed on the good practice examples. Appropriate diagnosis and treatment should be warranted by high rate of target population inclusion, while appropriate diagnosis and treatment should be warranted for those with positive findings. AIM: The aim is to present implementation of the national programs of early detection of breast and colon cancer in Croatia. RESULTS: In the first cycle screening for breast cancer (since the end of 2006), a total of 720,981 women were invited for mammography, of which 58.5% presented for screening, with more than 1500 cases of breast cancer detected. A total of 808,913 tests were distributed for colon cancer screening from the end of 2007 to the beginning of 2010, of which only 19.9% were returned, 7.7% of these positive. Colonoscopy yielded 77.5% of pathologic findings, including 388 (5.99%) carcinomas, 2492 (38.46%) polyps, 1641 hemorrhoids and 998 diverticula. CONCLUSION: In Croatia, the public health service has made maximal use of all its resources in the national programs of early cancer detection. Great efforts and time, along with continuous education of all those involved in the program, have been invested in preparatory activities, organization and coordination of the program, contacts and collaboration with family physicians, specialist units, mass media, regional and local authorities, partnership with non-governmental societies, monitoring, evaluation and quality control.

Cardiovascular diseases, risk factors and barriers in their prevention in Croatia.

Cardiovascular diseases are the leading cause of death in Croatia, with significant regional differences. Despite high mortality rates, high prevalence of various cardiovascular risk factors and well organized public health network, comprehensive system for cardiovascular disease monitoring and interventions does not exist. In this study we analyzed legislation framework and responsibilities of stakeholders relevant for cardiovascular disease surveillance and prevention. According to the international experiences we analyzed characteristics of cardiovascular disease prevention in Croatia and causes of the problems appeared in the preventive programs in Croatia. Analysis showed that primary problem is not inefficiency, but the existence of barriers in preventive activities definition, responsibilities distribution and task implementation. Main cause for such situation is incompatibility of the existing practices in clinical medicine and public health with recommendations from other countries. For the successful prevention of cardiovascular disease in Croatia at least three changes need to be made--define new terms and contents of prevention, define new responsibilities distribution and provide equity in health as basic criterion for successful preventive programs.

Psychological distress within cardiovascular risks behaviors, conditions and diseases conceptual framework.

Psychological distress (PD) is being increasingly recognized as a risk factor for cardiovascular diseases (CVD). Our aim was to recognize an association of PD and CVD in the Croatian adult population. We also explored association's strength obtainable as relative risk of PD on three levels; cardiovascular risk behaviors, conditions and diseases. This study used Croatian Adult Health Survey 2003 (CAHS 2003) data (N = 9,070). PD status was measured by the five-item Mental Health Scale of the Short Form questionnaire (SF-36) hence one distinguished subgroup consisted of population with PD and other without PD. Prevalence of cardiovascular risk behaviors, cardiovascular risk conditions and self-reported cardiovascular diseases within each subgroup were calculated using bootstrap method. Women had higher prevalence of PD in general population. Among distressed population women had higher prevalence of body mass index over 30, metabolic syndrome and angina pectoris. Men with PD had higher prevalence of high blood pressure and myocardial infarction with contradictory lower prevalence of angina pectoris then myocardial infarction. Physical inactivity was proven to be a risk behavior determinant with most impact on mental health. All CVD are consistently associated with higher prevalence and relative risks for PD both in men and women.

The geographic patterns of the exceptional longevity in Croatia.

The aim of this study was to provide an overview of the exceptional longevity patterns in Croatia. The prevalence of nonagenarians (aged 90 years or more) and centenarians (100 years or more) was calculated from the 1953-2001 census data. The data were analyzed with chi-square test and trend analysis. The results indicate steady and significant increasing trends in both age groups, more pronounced in women. Geographical distribution of the exceptional longevity had a clear coastline-to-mainland gradient, with higher prevalence of exceptionally old people in the coastal parts of the country. Additionally, exceptionally old respondents from the Croatian Adult Health Survey (CAHS) were compared to elderly ones (65-89 years old). The results suggested that exceptionally old respondents had lower prevalence of overweight and obesity and lower blood pressure, thus exhibiting strong survivor phenomenon. At the same time, exceptionally old respondents from the CAHS had higher prevalence of confirmed hypertension in medical history and reported taking blood pressure medication more often. The results of this study suggest that the pattern of exceptional longevity in Croatia has a clear coastline-to-mainland gradient, which is likely to be associated with the different lifestyle and dietary patterns between these two populations.

Socioeconomic inequalities estimation from public health surveys--data considerations, strengths and limitations.

The estimation of socioeconomic inequalities has lately become one of the major topics in public health research, as the numerous studies are showing strong association of inequalities with health status and outcomes. The aim of this study was to provide a general overview of the individual data available for the socioeconomic inequalities estimation from a public health survey and to compare different proxies used for socioeconomic inequalities estimation. The data from the Croatian Adult Health Survey were used, which is a large representative cross-sectional study of the general Croatian population that was performed in 2003. Four variables were compared--education and occupation class, and objective and subjective socioeconomic estimation. Strong regional differences were recorded within Croatia, generally showing better socioeconomic indices in the capital, city of Zagreb. Although all of these variables were significantly associated to one another, breakdown into the gender stratified education-by-occupation groups indicated that income was unevenly distributed in these groups and that it had non-linear association with education, especially in the white-collared occupations. Although socioeconomic inequalities do show striking association with many health related indices and outcomes and should therefore be included in all types of research on human subjects, due attention is needed in research planning, data encoding and entry, as well as interpreting the results based on this data.

Evaluation of Croatian model of polycentric health planning and decision making.

OBJECTIVE: To determine the progress in the development and implementation of health policies on a county level resulting from the learning-by-doing training provided through the County Public Health Capacity Building Program started in 2001 in Croatia. METHODS: Modular training using management tools, public health theory and practice, and SMDP's Healthy Plan-it tool, followed by the self-evaluation of the progress made by county teams in health needs assessment and health policy development, implementation, and assurance. Fifteen county teams consisting of politicians, executive officers, public health professionals, and community members. RESULTS: Twelve of 15 county teams completed the program. The teams made progress in the evaluated areas, although to a different extent, which did not depend on the amount of time they had or the governance experience. The differences in improvement depended on the differences in the strength of political, executive, and professional components of the teams. Teams with a strong political and/or executive component, but weak public health professional and community components made major improvements in policy development and/or assurance function, but performed less well in the health needs assessment and constituency building. The reversed was also true. CONCLUSION: Learning-by-doing training program improved public health practices on a county level in Croatia.

New directions in European public health research: report of a workshop.

Public health draws from a range of academic disciplines, social, medical and statistical, and answers questions relevant to improving the health of populations. We have initiated a Europe-wide study, Strengthening Public Health Research in Europe, to assess the development and use of public health research in both public policy and local decision making. The contemporary challenge for public health research is to integrate the capabilities of different academic disciplines to address policies for health. We have considered the development of public health research in five fields: political epidemiology, community health, health services, economics, and evaluation evidence and synthesis. The organisation and funding of research in Europe should be able to support new research fields and issues, to contribute to policy development and public health practice.

Counties selecting public health priorities--a "bottom-up" approach (Croatian experience).

The subject of this paper is how to incorporate a multi-disciplinary and inter-sectored approach into development of public health policy and plans at the local (county) level in Croatia by educational program. Method used was the public health capacity building program "Health--Plan for it", which was developed with the aim to assist the counties to overcome recognized weaknesses and introduce more effective and efficient local public health practices. Two main instruments were used: Local Public Health Practice Performance Measures Instrument, and Basic Priority Rating System. This program has helped counties to asses population health needs in a participatory manner, to plan for health and, ultimately, assure provision of the right kind and quality of services (better tailored to population health needs). This program's benefits are going beyond and above the county level. It provides support for the Healthy Cities project locally, and facilitates changes in national policymaking body's mindset that a "one-size-fits-all" approach is sufficient.

A naturalistic inquiry on the impact of interventions aiming to improve health and the quality of life in the community.

The goal of this study is to identify and describe variables contributing to the efficiency of health promotion interventions, and to assess whether these variables can serve as reliable and early indicators of the success of such interventions. The study sample includes 44 interventions selected through a network of key informants from five cities--Liverpool, Sandwell, Vienna, Pula, and Rijeka--by using a chain technique. Data on each intervention are collected through an in-depth interview with a program leader, the collection of project-related documents, and on-site observation. Qualitative analysis of data performed with content analysis and computer-assisted free-text analysis reveals different characteristics of interventions depending on whether they are initiated by the city government sector, health-care system, or citizens sector (independent of the city or country). The assessment of the efficiency of these three groups of interventions also differs because of varying features, scope (activity potentials) and impact they are able to accomplish. We have identified ways in which the efficiency of all three groups of interventions can be improved. The efficiency of the interventions within the city sector can be increased through an improved process of delegation to other sectors, higher involvement of user groups, and higher receptivity and organizational flexibility. The efficiency of the interventions within the citizens sector can be improved through professional, organizational, and financial support. Support from the professional community is important for citizens sector interventions in confirming the importance of the problem they address and legitimizing the actions they propose and undertake.

[125 years of infant mortality registration in Croatia (1874-1999)]. / 125 godina pracenja dojenacke smrtnosti u Hrvatskoj (1874-1999. godine).

Infant mortality data in Croatia have been registered in the last 125 years. A tremendous decline has happened during this period from 295.2/1000 live births in 1874 to 7.7/1000 live births in 1999. A tenfold decline was obtained during the second half of the 20th century. In the last years the decline has been slower. Significant differences are found between the counties and also in the counties between different years. Further analysis is needed to make conclusions because the small number of live births influences a lot the infant mortality. During the past period the causes of infant mortality have changed, too. There were classical reasons such as inadequate care about children, low hygienic conditions, poor nutrition, and infectious diseases. Today, causes of infant mortality in Croatia don't differ from those in developed countries. In the first place are perinatal causes and congenital malformations. The neonatal mortality accounts for 75% of infant mortality. Having in mind current reasons of infant deaths, it is not easy to separate the influences of socio-economical, biological or medical factors. It is particularly impossible to predict the influence of a risk factor on an individual case, because the outcome under the same conditions could be quite different.

What was the lifestyle of people who died by cardiovascular diseases?

AIM: The aim of this study was to find out the nutrition pattern and lifestyle for people who died by CVD. DATA: Population included cohort from continental and island regions of Croatia characterized by different nutrition, especially considering fat and/or oil consumption. Three groups of respondents were analyzed: whole population (WP), population of people died by CVD, and at the beginning of the study they were not taking drugs (CVD-N), and population of people died by CVD, and at the beginning of the study they were taking drugs (CVD-Y). RESULTS: Group CVD-N was characterized by higher proportion of people taking less than three meals per day (25.1%) comparing with WP (15%) and CVD-Y (10.9%); they prepare their food primarily with animal fat - even more than the whole population. Group CVD-Y was characterized by higher proportion of people preparing their food with oil, especially for preparing vegetables (63.5% comparing with 24.9% in whole population, and 16.4% in CVD-N group). Most important is the fact that CVD-N group was not different from general population, but it was very different comparing with CVD-Y. The CVD-N group smokes, consumes animal fat, alcohol, and coffee more than CVD-Y group. Blood pressure, cholesterol and post load glucose showed a little bit lower, but not significantly different values in CVD-N group comparing with CVD-Y. However the whole population show about 20 mm Hg lower blood pressure, and about 10 mg lower post load glucose comparing with both CVD-N and CVD-Y groups. CVD-Y was older in average than others, especially comparing with general population (64.9 vs. 50.1). They were also with higher BMI, 27% comparing with 25.5% in both general population and CVD-N. Age of death was also higher in average than in other groups (75 in CVD-Y group comparing with 73 in CVD-N and 72.2 in general population).