HEALTH MONITOR SURVEY - AN INTEGRATED PART OF DEVELOPMENT CINDI CONCEPTUL MODEL

IN THE REPUBLIC MACEDONIA

National programme for prevention of noncommunicable disease and health

promotionin the Republic of Macedonia, 2002 -

2007WHO CINDI Programme

Countrywide Integrated Noncommunicable Disease Intervention Programme

National coordinator of the WHO CINDI, Univ. Prof. Vera Simovska

Community and primary care-baseddemonstration project for health promotion andnoncommunicable diseases (NCD) prevention hasbeen prepared as an integrated part of conceptualmodel for CINDI National Programme.

Republic of Macedonia is in the process ofjoining CINDI and implementing the CINDI conceptthrough the process of health care reform.

In focus of the reform in primary health care isthe implementation of health promotion and NCDprevention measures in preventive practice of“family” doctors.

The purpose of the study:

1. To analyse professional reasons that justify realizationof the CINDI Programme based on information of healthstatus in the Republic of Macedonia.

2. Assessment of national capacity in primary health careto realize CINDI project on promoting healthy nutritionand physical activity in different age groups.

3. The role of National Health Authority in CINDI teamto confirm the Macedonian CINDI-Plan of action inhealth promotion heart disease and other chronic diseaseprevention related to physical activity and nutritionover the next 5 year (2002-2007).

M e t h o d s :1. Secondary data obtained from

mortality/morbiditystatistics in the Republic of Macedonia (1990-2001).The results for family aggregation of common risk factors

for chronic diseases obtained from medical research such asBMI Systolic/diastolic BP T. Chol. TG HDL LDL Glyc.smoking decreased VO2max dietary habit and stress in

randomized simples (Demonstation Projects 1990 and 1998).2. National capacity in primary health care obtained

fromWHO questionnaire connected with “Assessment of nationalcapacity for noncomunicable disease prevention & control”in 2001 year.3. Protocol and guidelines about CINDI principles and

strategies for health promotion and disease prevention (WHOCINDI publications).

R e s u l t s:

1. NCD are the main cause of morbidity and mortalityduring the last 10 years in the Republic of Macedonia.

( Figures-1 and Figure-2).In the last three decades the cardiovascular disease,especially coronary heart disease, malignant neoplasm's,and diabetes mellitus remains the most common cause ofdeath for the Macedonian population.

In 1972 mortality from them accounting for 37% fromtotal mortality, and year by year this percentage hasincreasing significantly up to 55.6% in 2001 withcontinuous trend to this days.

Figure 1. Mortality rate from noncommunicable diseasesin the Republic of Macedonia for the period 1991- 2001 up to 100.000 population

500450

400350

300

250200

15010050

0

385.9359.5

108.3 111.4

1991 1993

464.9

129.5

1995

464.9 458.7

140.5 142.6

1997 1999

468.6

150.3

KVBCancer

2001

Figure 2. Morbidity rate from circulatory diseases in the Republicof Macedonia up to 100.000 population

Hypertensia25000

20000

15000

10000

5000

01972 1978 1984 1990 1991 1992

Ischemic hard diseaseCerebro vascular

Circ u la to ry d is e a s e s

1993 1994 1995 1997 1998

The results for common risk factors forNCD include:1. BMI distribution varies significantly

according to the stage of transition of a country.Figure-3 illustrates the tendency for rapidly

increase in the proportion of the populationwith high BMI than the proportion of thepopulation with low BMI in the early stage oftransition.

The distribution of BMI tends to changeagain in the later phases of transition with anincrease in the prevalence of high BMI among

the poor.

Figure 3. BMI Distribution in adult population in Skopjein the last 10 years (1990-2000 year)

%80

70

75.8 199065.5 1995

58.8 1998200060

50

40

30

20

41.6

18.215.9

14.9

41.5

2318.616.8

9.3

10

0BMI < 25 BMI > 25-29.9 BMI > 30

Figure 4. Prevalence of systolic and diastolic blood pressurein adult population in Skopje

%100

80

88.780.9

68.3

199073.8 1998

60

4016.6

20 10

0<140 >140

1.2 2.4

>160 <90

23.7

11.9 14.37.9

>90 >95

systolic BP diastolic BP

Figure 5. Prevalence of risk factors for NCD in adultpopulation from central region in Skopje

80%

60

40

23.820 14.2 18.2

12.5

0

28.823.4

2.5 3.7

18.215.8

75

35.9 35.228.2

19901998

2. There are great potential within primary health care to realize CINDI project for health promotion and the primary prevention of major chronic diseases through changes of lifestyle of the population such as increased physical activity and balanced diet (average 1488 population per one MD).The territory of the Republic of Macedonia is divided into five regions with district centres for the implementation of all NCD related preventive activities (Figure 6).

Figure 6. Organizational structure - CINDI HEALTHMONITOR SURVEY CENTRES in the Republic of Macedonia

167

1877

149

150

222389

3. The role of the Macedonian Health Authorityin CINDI team is to accept an alternativeclassification system for prevention strategies aimedat chronic multi-factorial conditions.This is based on three levels of preventiondirected at everyone in the population (public healthpromotion) an above/average risk groups (selectiveprevention) and at high-risk individuals (targeted

prevention).In this new scheme promotion and prevention

are used to describe those action that occur beforethe full development of the condition.

This project form a link between precedemedical research and the application of new indexas mathematical model for predicting the effects

of non-pharmacologicalinterventions inthepopulation at above/average and high risk forNCD such as abdominal obese individuals withatherogenic risk factors.

Logistic model in form of equation is:In “RR” =108.2588-1.7689 DKN-B in +1.7087 -

BMIin+0.3993- Hb 2.9423-VO2max OPV -10.5402 WHO in + 0.0770-50% kcal/h

Exponent B can be interpreted in terms of relative risk(“RR”) in cohort studies. The proposed non-pharmacologicalintervention is hypocaloric hiperprotein diets of1200kcal/d and1400kcal/d(second phase) since the

relative risk is less than 1 (ln“RR”<1).Increased physical activity by the recommendations of

ACSM (1993) and CDC(2001)statistically significantpromotes development of VO2max.Change in level of VO2max at 17.16% from baseline

promotes significant greater reduction in level of WHR WCsm %fat (%F) body weight (BWkg) LBM kg BMR kcal/day

and LDL/HDL in PAD(physical activity and diet) thanthose in D (diet) group obese subjects(Figure 7).

Figure 7. Change in level of VO2max and “major” risk factors for NCD in FAD

(physical activity and diet) and D (diet) group of abdominal obese subjects 25 %

VO2max

TT %M LBM WHR OS LDL/HDL

17,1HDL10,4

14,815

5%FAI BMR

-5.3 -6.3-7,9

-10,3

-1.8-3,3 -3.3 -5.6-4,5-9,5 -7.7 -9.3

-28,6

VO2-OPV-3.1

-5,2

-10,2

FADD

-5

-15

-25

-35

CINDI PROGRAMME IN THE REPUBLIC OF MACEDONIA - CONCEPTUAL MODEL

Ministry of Health

Coordination CINDI Centre

Administrative Sector

INTERVENTION PROCESSES

Used fromhealthservices

Demonstartion arearandomized groups

Groups (gender and age)Location (schools, work)

Used fromCINDI

programme

First-knowledge variables

-behaviour-family

-cultural level

Community levelpopulation

Secondvariables

Inicial indicators:1. Morpho-phisiological

risk-factors :BMI; WHRHTA mmHg;

Fc in rest/maxTot. cholest; TGHDL2-holest

VO2 max./ METs.

2. Behavioural riskfactors:Nutrition, Smoking and

-social support

Final indicators:1. risk factors

2. morbidity of“major” NCD3. mortality

-community-organizedgroups andindividuals

-screening ofrisk factors:education/promotion

1. individual healthstatus,

2. socio-demographiccharacteristics

3. social enviroment

CINDI Conceptual modelin Macedonia, 2002 – 2007.National coordinator of the WHO CINDI Programme:Physical inactivity MONITORING AND EVALUACIONSimovska Vera, MD,PhD.

Monitoring of health behaviours and related factors on a national level is

an important vehicle for health promotion and disease prevention.

The overall purpose of the CINDI Health Monitor is:- to evaluate and to promote favourable health behaviours in population- to evaluate the effectiveness of national health policy.

The proposal-project to establish a CINDI national health behaviour

monitoring system in the Republic of Macedonia was created in 2002 year

as part of CINDI conceptual model for development and implementation of

National programme for chronic diseases prevention and health promotion

(WHO CINDI Programme).

Conclusions: