[Dr Teodor Gjurgjevic, lawyer, diplomat, polyglot, and the collaborator of Andrija Stampar]. / Dr. Teodor Gjurgjevic, pravnik, diplomat i poliglot, suradnik Andrije Stampara.

Dr Theodor Gjurgjevic was born in Stubicka Kaniza on 1 December 1909 and died in Zagreb on 20 March 1976. He finished high school in Zagreb in 1927 and obtained a doctoral degree from the Zagreb University Faculty of Law in 1933. In 1956, he obtained his second doctorate in modern history from the University of Oxford. He dedicated a large part of his career to international affairs: before and during World War II in the Yugoslav Ministry of Foreign Affairs in Belgrade and after the war at the Zagreb School of Public Health as a collaborator of Andrija Stampar. At the School he held different positions: senior officer, lecturer in postgraduate courses, assistant, counselor, and from the 1959 School secretary. After the Second World War, he was delegated by the Yugoslav government to participate in various expert groups. Thanks to his very broad education, especially his knowledge of many foreign languages, he was able to help in the international presentation and recognition of the School of Public Health in the extraordinary post-war conditions. He is credited for the establishment and operation of the European Association of Schools of Public Health (ASPHER). He was buried in the arcades of the Zagreb cemetery Mirogoj, reserved for prominent national figures.

Assessing primary care in Croatia: could it be moved forward?

It is well known that countries with strong primary care achieve better health outcomes at lower costs. Therefore, the effort of World Health Organization in promoting primary care as a basic principal of successful health care system is an ongoing process. Although Croatia was recognized as a country with primary care orientation due to the development of health centers and introduction of specialist training of general practitioners, it seems that many health care reforms aimed at better organization of health institutions and decreasing of health care costs did not result with higher primary care orientation. By application of the Primary Care Score instrument in 2014 (Croatia received 11.2 out of 20 possible points), and international comparison performed in 2002, it was concluded that among the eighteen OECD countries Croatia could be categorized as an "intermediate primary care country", obtaining the scores just a bit above the average.

Changes in the organizational structure of public health nurse service in the Republic of Croatia 1995 to 2012.

Since 1996, after the privatization of primary health care, public health nurse (PHN) in Croatia remained employed within the health center, mainly responsible for the preventive care of the inhabitants from defined catchment's area. Before that time they were part of general practice teams. The main aim of the study was to investigate what are the trends in the organizational structure of PHN service in Croatia, from 1995-2012. The main source was the Croatian Health Service Yearbooks. The obtained results shows that they are college educated and mostly in full-time jobs. The important findings are the lack of nurses and theirs regional differences. In highly demanding societies, with growing numbers of elderly, mental, social and economic problems, it will be worthy to consider the lower standard then 5 100 inhabitants per one PHN. Also, it should be taken into account to invest into the lowering of regional disparities.

Did the structure of work in the public health nurse service of the Republic of Croatia change in the period 1995-2012?

In Croatia, public health nurses (PHN) have been members of family doctor (FD) teams for decades, conducting a multifunctional and polyvalent scope of activities, including health promotion, prevention, as well as part of the treatment for the inhabitants of a defined catchment area. The main aim of the study was to investigate the trends in the number and structure of PHN visits in the period from 1996 to 2012. The main sources of data were Croatian Health Service Yearbooks. The results strongly indicate that PHN's are overloaded by a high number of visits, especially to chronic patients. While mothers and new-born children are in the PHN care, pregnant women and small children are rather neglected. Considering different working conditions and differences in population needs, a review of the standard is recommendable.

Getting some insight into the home care nursing service in Croatia.

Croatia, as the other Western societies are facing with the increasing share of the population over 65 years and consequently with more care-dependant people. Community living and care, including home care, is stimulating not just because of efficiency of care but also because of the peopleis preferences that home is a place of emotional and physical associations, memories and comfort. The aim of the study was to see if there is lack or surplus of Home care nursing services within the health care system. Data from the Croatian Health Insurance Fond Data base were analysed. The results of this research indicated that the number of inhabitants per one home nurse and physiotherapist contracted by the Croatian Health Insurance Fond was below the defined Standard. The average number of inhabitants per one home care nurse contracted by the CHIF for 2013 was 3373.9 compared to 3500 defined by the Standard. There was found also the huge regional differences in their distributions. The average number of contracted home physiotherapists for the same year was 9805.2 in comparison to the Standard, which was setup at the level of 15000 inhabitants per one physiotherapist.

[Anxiety and depression in elderly - prevalence and association with health care]. / Anksioznost i depresivnost u starijih osoba - pojavnost i povezanost s koristenjem zdravstvene zastite.

OBJECTIVE: To investigate the prevalence of anxiety and depression in the elderly inhabiting Koprivnica-Kri evci, Istria and Dubrovnik-Neretva Counties and their association with socio-demographic characteristics and healthcare utilisation. METHODS: A cross-sectional cluster survey carried out in 2006, encompassing a total of 1,469 examinees aged 70+. The Hospital Anxiety and Depression (HAD) Scale was used to screen for self-reported symptoms of anxiety and depression, which were further associated with socio-demographic characteristics and healthcare utilisation. RESULTS: The elderly have shown a high prevalence of borderline and probable anxiety (43%) and depression (53%), and regional differences (p<0.001). The level of anxiety was higher in women than men (p<0.001); as for depression, no statistically significant gender-based differences were found. The prevalence of probable depression increases (p=0.034) and that of probable anxiety decreases (p=0.028) with age. Anxiety and depression are associated with increased use of specialist health care and more frequent hospitalizations. CONCLUSION: High prevalence of anxiety and depression in elderly is associated with sociodemographic characteristics and frequent use of health care.

[Mortality rates of circulatory system diseases and malignant neoplasms in Zagreb population younger than sixty-five--call for alarm]. / Mortalitet od cirkulacijskih bolesti i zlocudnih novotvorina u gradu zagrebu u osoba mladih od 65 godina--stanje za uzbunu?

AIMS: The aim of this work was to analyze the public health indicators for circulatory heart diseases and malignant neoplasms in the population younger than 65 in the City of Zagreb, Croatia, and compare them with the European Union (EU) countries. The purpose was to evaluate the situation and propose the public health preventive measures. METHODS: The study population were Zagreb citizens aged 0-64 according to the 2001 census. Total Zagreb population was 779145, making 17.6% of total Croatian population. Data from the Croatian Bureau of Statistics and Dr Andrija Stampar Institute of Public Health were used. The standardized 0-64 mortality rates of the selected diseases 2006-2010 were used in the analysis. RESULTS: In 2010, the standardized mortality rates of all analyzed diseases were significantly higher in Zagreb population aged 0-64 than the EU averages except for cervical cancer. In 2010, the mortality rates in Zagreb population aged 0-64 were as follows: circulatory system diseases 61.22, ischemic heart disease 28.99, cerebrovascular diseases 12.51, malignant neoplasms 94.69, tracheal and lung cancer 24.92, breast cancer 21.08 and cervical cancer 2.05. Standardized mortality rates in Zagreb population aged 0-64 for circulatory system were lower than for Croatia (61.22 vs. 63.25), but higher for malignant neoplasms (94.69 vs. 91.2), except for cervical cancer (2.05 vs. 3.14). CONCLUSION: High standardized mortality rates for the selected diseases in the City of Zagreb, Croatia, were observed. The rates were higher in Zagreb population compared to EU averages except for cervical cancer. This situation urges revision of the public health strategy and implementation of more intensive preventive and screening measures to reduce the risk factors.

Differences in healthcare service utilisation in elderly, registered in eight districts of five European countries.

AIMS: The aim of the study was to compare and analyse the differences in self-reported frequencies of visits paid to physicians and hospitalisation rates, as well as their association with socio-demographic factors and health status self-rated by elderly. METHODS: A cross-sectional study was performed in eight districts of five European countries (Finland, Sweden, Ireland, Croatia, and Greece). A total of 3540 persons aged 70 or more were interviewed by trained interviewers. Healthcare service utilisation and its association with demographic characteristics and self-rated health were analysed using descriptive statistical methods, chi-square test, and logistic regression. RESULTS: Almost 90% of elderly visited a physician in the past year; 50% visited a specialist, while 24% were hospitalised. A visit to a specialist was paid by 70% of the Greek, 50% to 60% of the Croatian, and around 40% of the Irish, the Finnish, and the Swedish elderly. The highest proportion of hospitalisations (32%) was encountered in Greece and the lowest one (20%) in Sweden. Self-rated poor health appears to be the only common denominator associated with increased healthcare utilisation. Younger age stood out as a statistically significant predictor of the likelihood of specialist consults, while older age, male gender, and the synergy of male gender and current single life were disclosed as the predictors of hospitalisation frequency. CONCLUSIONS: Healthcare service utilisation exercised by the elderly across European districts was found to be highly variable and showed a clear distinction between north-western and south-eastern Europe; this is in line with differences in self-rated health.

[Cardiovascular health, diet and salt in the elderly]. / Kardiovaskularno zdravlje, prehrana i prehrambeni unos soli kod starijih osoba.

INTRODUCTION: The measures of primary prevention of cardiovascular disease are focused on lifestyle modifications in order to reduce the incidence of hypertension. Hypertension is a preventable risk factor for the development of cardiovascular disease, which is the leading cause of mortality in the elderly in Croatia. AIM: The aim of this paper is to present the share of circulatory system diseases in total hospitalization rate of the elderly. The aim is also to propose preventive public health interventions for elderly population to modify their dietary habits considering salt intake. METHODS: Gerontology analysis of the hospitalization rate includes data on geriatric patients from the City of Zagreb and Croatia as a whole for 2007, according to disease groups and prevalence. Databases of the National Institute of Public Health and Department of Gerontology, Dr. Andrija Stampar Institute of Public Health served as the source of data. DISCUSSION: Salt reduction is considered as an efficient and widely applicable measure of lifestyle modification as a non-pharmacological intervention for hypertension in the elderly. The introduction of legal provisions on dietary standards for the elderly is proposed for implementation of appropriate and preventive diet for this population group. CONCLUSION: Comparison of the rate of hospitalization of geriatric patients according to groups of diseases in the Zagreb area and Croatia in 2007 revealed the group of circulatory system diseases to be the leading cause of geriatric hospitalizations at the national level. Steering the health care planning and large-scale implementation of the program of preventive measures for the elderly with emphasis on salt intake reduction to up to 5 grams per day could reduce the prevalence of hypertension in elderly population and consecutively lower the incidence of their consequences.

Translation of evidence-based tobacco use prevention programming in Croatia.

Croatia faces a major threat of smoking-related health burdens given the monumental changes this newly formed country has undergone in the past 15 years because of its postcommunist democratic and economic transitions and the destructive 1991-1995 war with Serbia. This article provides information on Croatia's general background, current smoking prevalence and attitudes, and current evidence-based smoking prevention efforts. Furthermore, various cultural and contextual conditions within Croatia that facilitate or impede smoking prevention research utilization are discussed. Finally, it is concluded that new research is needed that continues to build on comprehensive research-tested multicomponent prevention initiatives utilizing school-, family-, community-, and mass media-based delivery modalities, which specifically focus on the social influences of smoking.

Chronic patients--persons with diabetes frequent attenders in Croatian family practice.

Chronic diseases cause high frequency visits and generate the long-term frequent attenders (FAs). The connection between frequent attendance and specific morbidities in the health care systems in transitional Europe has been underestimated. We investigated whether frequent visits of chronic patients in primary care are related to characteristic of chronic disease (diabetes mellitus) and whether this is influenced by the family practice in the transitional health care. We analyzed the number of visits a day time work for 490 persons with diabetes in the period 1997 to 2000. As the cut-off points between frequent attenders and non frequent attenders (NFAs) we used the value of the third quartile (Q3) of visits determined for the sex and age groups in the parallel study in the whole population. The analysis was performed for 23 variables: demographic characteristics of patients, disease characteristic and variables of physician. Logistic regressions were employed to identify the predictors of FAs/NFAs. 56.9% (in 1997) to 62.4% (in 2000) persons with diabetes were FAs, compared to 22.4% to 24.3% FAs patients in the whole population. Logistic regression analysis significantly differentiated the two group of visits with 68% accuracy. 4 variables are significant predictors for FAs/NFAs: diabetes as the main disease (p = 0.0005), diet-only-treatment (p = 0.0062), treatment by secondary care (p = 0.0116), and if glycated hemoglobin test (HbA1c) is determined (p = 0.0272). Understanding the similarities and differences of FAs/NFAs persons with diabetes may be important in improving the care and management of chronic diseases in family medicine in transitional health care systems.

[Croatian health survey: cigarette smoking]. / Hrvatska zdravstvena anketa: pusenje.

AIM: The aim of the study was to calculate the prevalence of smoking habit among Croatian population according to sex, age groups and country regions. The aim was also to analyze the use of health services by smokers and nonsmokers. METHODS: Data collected during the 2003 Croatian Health Survey were used in the study. The sample was representative of particular regions. A total of 12,254 individuals aged 18 were interviewed. RESULTS: According to data obtained in the survey, there were 27.4% of daily smokers in the population aged 18. There were great differences between the regions. The prevalence of smoking habit was found to be higher in the east regions of inland Croatia and north Adriatic region than in other regions (29% vs. 32%). The lowest prevalence was recorded in the City of Zagreb (23%). The prevalence of cigarette smoking was higher in men (33.8%) than in women (21.7%). The highest prevalence of cigarette smoking in men was recorded in the Slavonia (east) region and lowest in north region (40.1% vs. 28.5%). In women, the highest prevalence was recorded in north Adriatic region (Istria) and lowest in Zagreb (29.2% vs. 13.9%). The prevalence of daily smokers also differed between counties within the same region. The prevalence of cigarette smoking was higher in the young than in older individuals. In some counties (mostly in the east of Croatia), more than 40% of daily smokers were aged 18-20. The lowest prevalence was in central Croatia. The prevalence of cigarette smoking in young individuals was higher in south Adriatic than in north Adriatic region. According to the level of education, the highest prevalence of smokers was recorded among individuals with with secondary school. Considering the use o health services, smokers were found to have less primary health care visits but more frequent and longer hospitalizations. Nonsmoker more frequently used preventive check-ups for high blood pressure, prostate carcinoma screening and colorectal carcinoma, whereas female smokers more frequently used screening for cervical and breast cancer than female nonsmokers. DISCUSSION: Croatia is an average European country. Now the situation is better than it was in the past. A survey conducted in 1972 showed the prevalence of daily cigarette smoking to be 56.9% in male and 10.1% in female population. Since then, smoking habit has decreased in men and increased in women. CONCLUSION: The differences recorded according to regions, sex and age groups are high. War situation and socioeconomic conditions (war, unemployment, low income) could influence the differences among regions and counties. The data collected can be used as a guidance on planning intervention measures.

[Physical inactivity as public health problem]. / Javnozdravstveni problemi sporta i rekreacije.

The aim of the paper is to present the public health aspects of physical inactivity, and the importance of sport, recreation and other types of physical activity to health of population. Reduction of physical inactivity in today's every day life became great public health concern. The causes of such situation are linked to the pattern of modern life, sedentary type of work, autoimmunization in production, passive role of citizens in sports, and others. Adequate physical activity is very important means in prevention of many health problems, like obesity, arterial hypertension, diabetes, hearth diseases, atherosclerosis, osteoporosis and others. Physical activity and regular exercises in elderly increase independency from others in every day living, increase physical condition and reduce accidents, improve mental health, satisfaction with life; reduce hypertension and quantity of drugs. Physical inactivity increases economic burden of the country. The results of the Croatian Health Survey from 2003, done on representative sample of Croatian adult population shows that 44% of men and 30% of women are physically inactive. Situation in cities is even worse. In Zagreb 85% of men and 45% of women are inactive. The criteria for physical active person were walking three times a week for 30 minutes at least. The solution of the problem for the future is to pay more and more intensive attention to develop comprehensive community programs. More support should be given in construction of facilities for sport and recreation, during wintertime and for persons with special needs. The key role and responsibility for the promotion of physical activity of citizens will have primary health services (family practitioners, public health services), nongovernmental organization and media.

Present state and possibilities for improvement of cancer prevention and early detection in the Osijek-Baranya county.

Cancer morbidity and mortality are on a steady increase in Croatia. Technologic possibilities for appropriate management are available for four cancer sites, i.e. cancer of the breast, cervix uteri, colorectum and prostate, and include cancer prevention and early detection in individuals yet free from manifest signs of the disease. The magnitude of the problem, the experience acquired to date, health care personnel available, and additional resources required to launch a systematic program of early detection of the disease are presented. The program should be initially launched in a county with greatest experience in early detection of cancer, where health care service is ready to immediately start its implementation. The role of family physician, gynecologic service at primary health care level, and polyclinic-consultation hospital service in program implementation is described. The following three possible options for early detection of cancer are analyzed and proposed: minimal program (early detection every 3 years), medium program (the same individuals examined every 2 years), and optimal program proposed by the American Cancer Society and other national and international organizations.

Health of returnees in Osijek Region and required special measures of health care and community organization.

Many citizens from the Osijek-Baranja County, in order to survive, left their homes during the 1991/92 war in Croatia and spent between 5 and 7 years in exile. The aim of this pilot research was to assess the health status (physical, mental and social) of refugee /returnee population and their use of health services, to identify the factors influencing their adaptation, and to propose the health programs, psychological and social support, which could help foster integration into the social and community life, education and employment. The study was done on a randomized sample of 589 respondents using the 2003 Croatian Health Survey with an additional questionnaire related to the problems of returnees. The results of the study show good organization of health service in returnees' communities, with exception of gynecological and dental services. There was also a presence of health transportation problem and the problem in the supply of medicines. Finally, the results show that the returnees' communities were dominated by social problems such as lack of employment, lack of support for elderly, poverty, and concerns for children's prospects. This implies the necessity for intervention in both mental and social aspects. Measures to be undertaken in the next stage of the Project will be aimed at the work in the refugee communities and based on public health working methods such as organization of the community by stimulating intergenerational solidarity, education and raising awareness of self-help.

[Smoking habits among health staff in the county of Koprivnica-Krizevci--comparative study 1998 and 2002]. / Navika pusenja djelatnika u zdravstvu Koprivnicko krizevacke zupanije--usporedna studija 1998. i 2002.

The study examined smoking habits among health care workers of all health institutions in the County of Koprivnica-Krizevci with the aim of establishing the prevalence. The first research of smoking habits was done in 1998 in order to get basic data about smoking habits, and the second research was carried out in 2002 with the aim of establishing a trend of smoking habits. An anonymous qestionnaire was given to all employees of all health institutions in the County. It was answered by 508 persons (44%) in 1998 and by 622 persons (50%) in 2002. As far as profession is concerned, 49 (53)% of those who answered the questionnaire were doctors, 24 (42)% dentists, 7 (9)% pharmacists, 53 (58)% were professional nurses and 28 (37)% administrative-technical non-health professionals. The data in parentheses are for 2002. The survey showed that of all employees who answered the questionnaire 34% in 1998 were smokers and 31% in 2002, while 17% were ex-smokers (1998 and 2002) and 48% in 1998 and 52% in 2002 have never been smokers. Although the damage of smoking and consequences is a matter of every day talk about, and the employees of health institutions are the first expected to set an example to become aware and informed, the data of this research showed that the decrease of prevalence of smokers among health care workers is very slow.

Frequent attenders in family practice in Croatia: retrospective study.

AIM: To determine the number of "frequent attenders" in family practice offices in Croatia according to the number and proportion of frequent attender visits in the total number of visits, and to follow up the frequent attenders and the number of visits they made over a period of three years. METHODS: The retrospective study involved 8 family practice offices in Northern Croatia. The number of visits to family practice was determined for 4,312 patients aged over 18 years. There were 1,826 men (42.3%) and 2,486 (57.7%) women. The follow up period lasted from January 1, 1997 to December 31, 1999. The borderline value that divided the frequent from non-frequent attenders was the value at the third quartile of the number of visits in a single age-sex group of patients. RESULTS: We recorded a total of 58,088 visits of patients older than 18 years to 8 family practice offices in the three-year period. In 1997, out of 4,312 patients who made a total of 17,938 visits, 944 (22%) frequent attenders made 11,257 (63%) visits. In 1998, there were a total of 20,350 visits made, with 966 (22%) frequent attenders making 12,145 (60%) visits. In 1999, a total of 20,725 visits were made, with 988 (23%) frequent attenders making 12,259 (59%) visits. The differences in the distribution of frequent vs non-frequent attenders according to age and sex were not statistically significant in any of the three study years (chi-square, p=0.727). Older men and older women were not more often frequent attenders than younger men and younger women, respectively. Out of 4,312 patients, 1,714 (40%) were frequent attenders in one of the three study years. Of these, 884 (21%) were frequent attenders in one year, 476 (11%) in two years, and 354 (8%) in all three subsequent study years. Out of 4,312 patients, 1,762 (41%) patients in 1997, 1,139 (26%) in 1998, and 1,116 (26%) patients in 1999 did not make a single visit to a family physician. CONCLUSION: Frequent attender visits make a great proportion of the total number of visits to family practice offices in Croatia, a country with a health care system in transition. Eight percent of patients remained being frequent attenders during all three study years.

[Medical specialists in Croatia: general overview, possibilities in planning and education in the future]. / Lijecnici specijalisti u Hrvatskoj: opci pregled, mogucnost planiranja i izobrazbe u buducnosti.

The paper describes the dynamics of trends in the number of specialists and the differences that have arisen over a 14-year period among individual specialties. Shown and analysed separately is the basic demographic information (obtained from the National Health Workers Registry) about the specialists working in Croatia in 2000. The data were used to illustrate the two options for planning them: by statistical method for analysing a time sequence and by prediction of specialist needs by anticipated old age retirement. At the end of 2000 there were 7,383 specialists, or 65.8% of the physician total employed in Croatian health service. Of these, 3,664 (49.6%) were females, with the median for females and males being 47 and 50 years, respectively. In relation to 1986, there was a twofold increase or greater in the number of maxillofacial surgeons (basic index 260; average rate of annual increase 7.1%), followed by psychiatrists, epidemiolgists, child surgeons and medical cytologists. The paper uses the Holt two-parameter method of exponential smoothing of the time sequence made up of the number of medical specialists per 100,000 population in 1980-99. Assuming maintained average annual growth of three specialists, this prognostic procedure predicted specialist density of 185/100,000 population for 2009. The feasibility of a more direct planning is illustrated with individual specialist sex and age data at certain age of life. It permits estimating the number of specialists to leave the health system for the most common reason, i.e. old-age retirement. On the set criterion of lady doctors reaching the age of 60 and their male colleagues 65 years, we predicted for each medical speciality the annual number of specialists due to retire for old age by the year 2020. In some specialties, the difference in the number of specialists anticipated to go into old-age retirement in two successive years will reach close to 50% or even slightly higher. In this way, the necessary number of replacement specialists for the retired can be estimated for each medical specialty by taking note of the critical years when, because of great variation in age composition, a larger number of specialists could simultaneously leave their posts. For these critical years, a sufficient number of specialists should be ensured by harmonizing our length of education and training curricula with those in force in the EU countries. The number of specialists and their composition will also be changing, depending on the health system's strategic solution to the need for specialist work in the Family Medicine Service.