Preventing Heart Preventing Heart Disease and Cancer Disease and Cancer

in Zagrebin ZagrebWorksite, Community, and Worksite, Community, and

MediaMedia

The PartnershipThe Partnership

Andrija Štampar School of Public Andrija Štampar School of Public Health (ASSPH)Health (ASSPH)

London School of Hygiene and London School of Hygiene and Tropical Medicine (LSHTM)Tropical Medicine (LSHTM)

University of California, San University of California, San Francisco (UCSF, Institute for Francisco (UCSF, Institute for Global Health)Global Health)

EuropaPress Holding (EPH)EuropaPress Holding (EPH)

InvestigatorsInvestigators Luka Voncina, LSE, ASSPHLuka Voncina, LSE, ASSPH Stipe Oreskovic, ASSPH, Europress Stipe Oreskovic, ASSPH, Europress

HoldingHolding Luka Kovacic, ASSPHLuka Kovacic, ASSPH Martin McKee, LSHTMMartin McKee, LSHTM Susannah Tompkins, LSHTMSusannah Tompkins, LSHTM Thomas Novotny, UCSF Institute for Thomas Novotny, UCSF Institute for

Global HealthGlobal Health Usma Khan, IGHUsma Khan, IGH Larry W. Green, UCSF Larry W. Green, UCSF

Croatia at a GlanceCroatia at a Glance Population:Population:

4,422,2484,422,248 Literacy: Literacy: 98.5%98.5% Infant mortality Infant mortality

rate:rate:6.92 deaths/1,000 live 6.92 deaths/1,000 live birthsbirths

Life expectancy: Life expectancy: menmen 69.1, women 76.669.1, women 76.6

Population growth Population growth rate:rate: 0.31 0.31 %%

Chronic Disease Mortality, Chronic Disease Mortality, Croatia vs. Eastern and Croatia vs. Eastern and

Western EuropeWestern Europe

0

50

100

150

200

250

Age Standardized Mortality per

100 000

Croatia EasternEurope

WesternEurope

CVD Mortality men

CVD Mortality women

Lung Ca MortalityMen

Lung Ca MortalityWomen

Risk Factors Risk Factors Prevalence of physical inactivity by age

group and sex, Croatia, 2003.

Age Group Male Female

Prevalence Prevalence

18 – 29 37.6 47.5

30 – 39 39.4 42.6

40 – 49 40.8 43.6

50 – 59 45.2 43.6

60 – 69 46.9 51.2

70 - 100 61.4 68.7

Risk Factors Risk Factors Prevalence of elevated blood pressure (>160 systolic and/or

>95 diastolic) by age group and sex, 2003.

Age Group Male Female

Prevalence Prevalence

18 - 29 5,40 1,30

30 - 39 10,70 5,10

40 - 49 22,80 13,30

50 - 59 26,40 23,40

60 - 69 32,20 34,30

70 - 100 34,50 38,10

Risk FactorsRisk Factors

Prevalence of obesity (BMI >30) by age group and sex, Croatia, 2003.

Age Group

Male Female

Prevalence Prevalence

18 - 29 6,6 4,6

30 - 39 19,3 10,5

40 - 49 23,4 18,9

50 - 59 27,7 28,7

60 - 69 27,3 34

70 - 100 15,8 26,9

Risk FactorsCurrent smoking prevalence by age group and sex, Croatia,

2003.

Age Group

Male Female

Prevalence Prevalence

18 - 29 39,3 31,2

30 - 39 46,8 29,3

40 - 49 36,1 31,4

50 - 59 35,3 21,9

60 - 69 23,9 9,4

70 - 100 16,8 5,9

Study QuestionStudy Question

Can Can a a worksiteworksite--based health based health promotion and disease prevention promotion and disease prevention program reduce program reduce CVD and cancer CVD and cancer risk factors, morbidity, and risk factors, morbidity, and unnecessary health care unnecessary health care utilization among employees of utilization among employees of a a large media company, large media company, their their familiesfamilies, , and their communitiesand their communities??

Subjects and variables – Subjects and variables – Phase 1Phase 1

Subjects: adult employees of EPH in Subjects: adult employees of EPH in Zagreb, N=1200Zagreb, N=1200

Comparison group: adult employees of Comparison group: adult employees of EPH not in Zagreb, N=500 (estimated)EPH not in Zagreb, N=500 (estimated)

Variables:Variables: Knowledge about risks;Knowledge about risks; Risk behaviors;Risk behaviors; Health care utilization;Health care utilization; Screening practices;Screening practices; Physiological measurementsPhysiological measurements (depending on funding). (depending on funding).

Background SettingBackground Setting

World Bank Project on CVD and Public World Bank Project on CVD and Public Health InfrastructureHealth Infrastructure

Croatian National Health Survey Croatian National Health Survey (ASSPH)(ASSPH)

The Big BreakfastThe Big Breakfast Say YES to No Smoking! (NGO/ASSPH)Say YES to No Smoking! (NGO/ASSPH) Healthy Cities Croatia ProjectHealthy Cities Croatia Project Tradition of worksite-based health and Tradition of worksite-based health and

social welfare support in Former social welfare support in Former YugoslaviaYugoslavia

The Big Breakfast – World The Big Breakfast – World Food Day 2003Food Day 2003

BBC, CNN, Lancet BBC, CNN, Lancet etc.etc.

Croatians sit Croatians sit down to big down to big breakfast breakfast

Tens of thousands Tens of thousands of Croatians sat of Croatians sat down on Sunday down on Sunday for what is being for what is being described as the described as the biggest breakfast biggest breakfast in the world. in the world.

Study Concept:Study Concept:The Precede-Proceed The Precede-Proceed

ModelModel Flexible and ScaleableFlexible and Scaleable Evidence-based and Evidence-based and “Evaluable”“Evaluable” Participatory Process Participatory Process Platform for Best Platform for Best PracticePracticess

Proceed-Proceed Model of Proceed-Proceed Model of Health Program Planning Health Program Planning

and Evaluation and Evaluation

Hallmark:Hallmark: ParticipationParticipation

StakeholdersStakeholders: EPH, Union (TUCJ): EPH, Union (TUCJ) Community (Center of Gravity)Community (Center of Gravity): Families, : Families,

communities in which employees livecommunities in which employees live Health as a Social IssueHealth as a Social Issue: tradition in : tradition in

CroatiaCroatia Social CapitalSocial Capital: reinforcement for EP: reinforcement for EPH as H as

employer and it substrate for employees employer and it substrate for employees Transdisciplinary CollaborationTransdisciplinary Collaboration: :

epidemiologyepidemiology, policy, worksite health, , policy, worksite health, health education, sociology, clinical health education, sociology, clinical medicinemedicine

MethodologyMethodology Employee-management-investigator Employee-management-investigator

steering committee—identify main steering committee—identify main issuesissues

Community assessment using Croatian Community assessment using Croatian National Health Survey (possibly National Health Survey (possibly physiologic measurements)—baseline physiologic measurements)—baseline and yearlyand yearly

Interventions:Interventions: EducationEducation PolicyPolicy Health systemHealth system CommunityCommunity WorksiteWorksite

Comparison GroupComparison Group

Collect baseline and yearly Collect baseline and yearly informationinformation

Implement interventions after Implement interventions after three years of initial intervention three years of initial intervention groupgroup (delayed application) (delayed application)

Optional: use another comparable Optional: use another comparable employee groupemployee group

Measure change in knowledge, risk Measure change in knowledge, risk behavior, screening practices, and behavior, screening practices, and basic health indicators over time.basic health indicators over time.

Dissemination and Dissemination and Sustainability—Phase 2Sustainability—Phase 2

Translate successes to families, Translate successes to families, communities, other settingscommunities, other settings

Local investments by EPH and other Local investments by EPH and other employers in risk factor reduction employers in risk factor reduction and health promotion based on and health promotion based on evidenceevidence

Ministry of Health, World Bank, Ministry of Health, World Bank, Stability Pact, and others will Stability Pact, and others will support national and possibly support national and possibly regional dissemination.regional dissemination.

StrengthsStrengths

Strengths: Strengths: Strong public health tradition in Strong public health tradition in

CroatiaCroatia EPH can provide media strength in EPH can provide media strength in

interventions and disseminationinterventions and dissemination We got the guy who wrote the book We got the guy who wrote the book

on community health planningon community health planning International collaboration can build International collaboration can build

on diverse evidence baseon diverse evidence base Some strategic successes and Some strategic successes and

investments alreadyinvestments already

WeaknessesWeaknesses

Comparison group may experience Comparison group may experience similar secular changessimilar secular changes

Fiscal uncertaintyFiscal uncertainty Target group may be resistant Target group may be resistant

(journalists!!)(journalists!!) Significant loss to follow-up up with Significant loss to follow-up up with

leaving EPHleaving EPH Resistance of local communities to Resistance of local communities to

policy changes for Chronic Disease policy changes for Chronic Disease approaches.approaches.

Hvala!Hvala!