EUR/01/5015946 ORIGINAL: ENGLISH UNEDITED E74080
17th Annual Meeting of CINDI Programme Directors
Report on a WHO Meeting
Qawra, Malta 9–10 June 2000
2001
EUR/01/5015946 ORIGINAL: ENGLISH UNEDITED
REGIONAL OFFICE FOR EUROPE ______17TH ANNUAL MEETING OF CINDI PROGRAMME DIRECTORS
Report on a WHO meeting
Qawra, Malta 9–10 June 2000
SCHERFIGSVEJ 8 DK-2100 COPENHAGEN Ø DENMARK TEL.: +45 39 17 17 17 TELEFAX: +45 39 17 18 18 TELEX: 12000 E-MAIL: [email protected] WEB SITE: HTTP://WWW.WHO.DK 2001
ABSTRACT
The 17th Annual Meeting was held to discuss the implementation of the countrywide integrated noncommunicable disease intervention (CINDI) programme in the previous year and the plan of work for the coming year. Reports were presented on the implementation of CINDI in participating countries, and on the activities of the CINDI working groups on monitoring, evaluation and research; smoking; hypertension; the workplace; children and young people; nutrition and elevated blood cholesterol; nursing; diabetes; physical activity; guidelines and training for preventive practice; and policy development. The discussion on monitoring and evaluation focused on the methodology for surveys and data analysis. The first draft of an analysis of the second CINDI survey on policy development and implementation processes in CINDI country programmes was presented. In addition, the participants discussed networking at the regional and global levels, and a plan was presented to establish a WHO global network on an integrated approach to the prevention and control of noncommunicable diseases.
Keywords CHRONIC DISEASE – prevention and control HEALTH PLANNING PUBLIC HEALTH ADMINISTRATION HEALTH SERVICES – organization and administration PROGRAM EVALUATION HEALTH CARE SURVEYS EUROPE EUROPE, EASTERN MALTA
© World Health Organization – 2001 All rights in this document are reserved by the WHO Regional Office for Europe. The document may nevertheless be freely reviewed, abstracted, reproduced or translated into any other language (but not for sale or for use in conjunction with commercial purposes) provided that full acknowledgement is given to the source. For the use of the WHO emblem, permission must be sought from the WHO Regional Office. Any translation should include the words: The translator of this document is responsible for the accuracy of the translation. The Regional Office would appreciate receiving three copies of any translation. Any views expressed by named authors are solely the responsibility of those authors.
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CONTENTS
Page
1. Introduction...... 1 1.1 Opening session ...... 1 1.2 Election of Officers...... 2 2. CINDI network...... 2 2.1 CINDI Joint Annual Progress Report for 1999...... 2 2.2 Annual Progress reports from new CINDI countries...... 2 2.3 Second period of cooperation between the WHO Regional Office for Europe and countries in respect of the WHO CINDI Programme...... 4 3. Collaboration with headquarters ...... 4 3.1 WHO global strategy for NCD prevention and control ...... 4 3.2 Global Forum on NCD prevention and control (GF)...... 5 4. Collaboration with other WHO Regions...... 6 4.1 Regional Office for Africa (AFRO)...... 6 4.2 Regional Office for the Eastern Mediterranean (EMRO)...... 7 4.3 Pan American Health Organization (PAHO)...... 7 4.4 Collaboration with CDC ...... 7 5. Working Groups...... 8 5.1 Joint report of the CINDI Working Groups...... 8 5.2 Monitoring, evaluation and research...... 9 5.3 Smoking...... 10 5.4 Hypertension...... 11 5.5 Workplace...... 12 5.6 Children and Youth...... 13 5.7 Nutrition and Elevated Blood Cholesterol...... 13 5.8 CARMEN/CINDI Working Group on Physical Activity ...... 14 5.9 Nursing ...... 14 5.10 Diabetes ...... 14 5.11 Guidelines and Training for Preventive Practice...... 14 6. CINDI monitoring and evaluation ...... 15 6.1 Methodology...... 15 6.2 CINDI data analysis...... 18 7. Policy development...... 20 7.1 Second comparative analysis...... 20 7.2 The art and science of implementation in CINDI: lessons for health promotion and disease prevention...... 21 8. CINDI Winter School ...... 21 9. CINDI Highlights...... 21 10. CINDI millennium project...... 21 11. CINDI Internet presentations ...... 22 12. Future meetings...... 22 13. Conclusions and recommendations...... 23 13.1 CINDI network...... 23 13.2 Collaboration with headquarters...... 23 13.3 Collaboration with other regions ...... 23 13.4 Working Groups...... 24
13.5 CINDI monitoring and evaluation ...... 27 13.6 Data analysis...... 28 13.7 CINDI Winter School ...... 29 13.8 CINDI Visibility ...... 29 13.9 CINDI millennium project: Children’s Internet Forum...... 30 13.10 Future meetings...... 30 Annex 1 FINAL PROGRAMME ...... 31 Annex 2 FINAL LIST OF PARTICIPANTS ...... 34 Annex 3 PROGRESS OF CINDI IN 1999: SUMMARY OF THE COUNTRY REPORTS ...... 41 Preface ...... 42 Programme objectives and documentation ...... 43 Administration and management ...... 43 Monitoring, surveys and data collection...... 45 Intervention...... 46 Resources and financing ...... 53 Other topics...... 55 Report received from ...... 55 Report missing from ...... 55 Annex 4 GLOBAL FORUM ON NCD PREVENTION AND CONTROL ...... 56 Current needs in networking...... 56 Objectives of the GF...... 56 Governance...... 57 Potential tools of the GF ...... 57 Annex 5 CINDI HEALTH MONITOR QUESTIONNAIRE ...... 58 Annex 6 SUMMARY ON RF AND PE DATA AVAILABLE IN THE CDMC (31 MAY 2000) ...... 65 Annex 7 DRAFT PROTOCOL: ACCESS TO AND USE OF THE WHO CINDI DATABASE ...... 66 Annex 8 TERMS OF REFERENCE: CINDI WORKING GROUP ON MONITORING, EVALUATION AND RESEARCH...... 67 Annex 9 SUMMARY OF INFORMATION ABOUT ALCOHOL CONSUMPTION (BASED ON DATA IN CD ROM)...... 69 Annex 10 LETTER TO THE REGIONAL DIRECTOR, WHO REGIONAL OFFICE FOR EUROPE ...... 72 Annex 11 CINDI MILLENNIUM INITIATIVE: SMOKING PREVENTION AND REDUCTION IN HEALTH PROFESSIONALS...... 73
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1. Introduction
1.1 Opening session
The aim of the meeting was to discuss progress achieved in programme implementation in countries since the 16th annual meeting in Dornbirn, Austria, June 1999, as well as the design and implementation of major collaborative CINDI projects and the related plan of work (Annex 1 – Programme of the meeting).
Dr L. Deguara, the Minister of Health of Malta, and Dr R. Busuttil, the Director-General of Health of Malta, welcomed the participants (Annex 2 – Final list of participants) to Malta. Dr Deguara emphasized that the participation of CINDI-Malta – an active member of the CINDI network for sixteen years – had been strengthened over the past 6–8 years following a reform in the Department of Health Promotion.
As noncommunicable diseases (NCD) account for the vast majority of causes of death in Malta, it was the policy of the present Government to prioritize programmes aimed at their prevention. The reform had resulted in an infiltration of the CINDI concept into the formulation of the health policy of Malta. NCD prevention and health promotion form the main elements of the Maltese National Health Policy – Health Vision 2000. The priority intervention objectives are: reduction in smoking; reduction in the prevalence of obesity; lowering of blood cholesterol and blood pressure; encouraging a more active lifestyle.
Dr Deguara highlighted the following action taken by the Health Promotion Department, which demonstrates the commitment of the Maltese health authorities to reduce the risk factors for NCD and enhance the provision of health services for their management: S Expansion of smoking cessation clinics run by health centres to cover worksites. S Active participation in the Quit and Win smoking cessation competition. S Introduction of weight reduction programmes in health centres and in the community. S Ongoing promotion of the healthy Mediterranean diet; active contribution to the formulation of the CINDI food-based dietary guide and to the preparation of the WHO European Food and Nutrition Action Plan. S Drawing up of a national breastfeeding policy, which was launched in May 2000, and which will be backed by appropriate legislation. S Participation in the European Network of Health Promoting Schools. S Improvement in the management of diabetes through the involvement of Maltese diabetologists in the WHO diabetes management programme.
Dr Deguara felt that capacity-building in the area of health promotion and disease prevention, supported by a steadily increasing budgetary allocation for the Health Promotion Department and reinforced human resources, have brought the health promotion and disease prevention strategy adopted by the Ministry of Health in line with the current approach. This approach declared during the 5th Global Conference on Health Promotion held in Mexico City just prior to the present meeting, urged countries to invest in health through improvement in social and economic structures.
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Dr A. Shatchkute, Regional Adviser, Chronic Disease Prevention, conveyed to the participants the greetings of Dr M. Danzon, Regional Director of the WHO European Office. She thanked Dr Deguara and his team for hosting the meeting and supporting its organization and acknowledged the very active contribution to the programme made by Dr R. Busuttil during his term as CINDI Programme Director and by Ms M. Ellul since she had taken over this function in 1999.
Dr Shatchkute informed the participants that a reform process had been started in WHO/EURO that provided an opportunity to update and further develop CINDI implementation. She mentioned that since the last meeting a number of CINDI products had been elaborated (the CINDI food-based dietary guide, the second CINDI survey on policy development, the CINDI database on risk factors). Important items for discussion during the meeting were the WHO global strategy of NCD prevention and control to which CINDI had been contributing and the new WHA Resolution on the prevention and control of NCD adopted by the WHA53 this year.
1.2 Election of Officers
Ms M. Ellul was elected as Chairperson of the meeting; Dr D. Muacevic-Katanec was elected as Co-Chairperson; WHO/EURO would be responsible for the report.
The provisional programme was adopted.
2. CINDI network
2.1 CINDI Joint Annual Progress Report for 1999
Dr T. Laatikainen introduced the main points of the 1999 CINDI joint progress report, which had been compiled from the annual country progress reports (Annex 3). She emphasized that the CINDI network has been further strengthened by the establishment of new demonstration areas and the improved implementation of CINDI experiences at national level in many countries.
Professor P. Puska, Chairman of the CINDI Programme Management Committee, mentioned that the standard of the material presented in the country progress reports still varies somewhat although there is steady improvement. The participants were requested to review the report during the meeting and to let Dr Laatikainen know, in writing, of any changes that should be made, if possible by the end of the meeting but at the latest by 23 June 2000.
In acknowledging the very clear presentation of the report, Professor Glasunov said that reference to international coordination was lacking in the report. In this connection, Dr Shatchkute encouraged the CINDI Programme Directors to make their publications better known. In the future, a list of publications should be included in the CINDI joint progress report.
2.2 Annual Progress reports from new CINDI countries
Latvia Dr V. Dzerve presented the CINDI-Latvia programme which has the following sub-components: 1) health promotion and primary prevention; 2) education and training of health professionals; 3) research and monitoring. Priority areas are cardiovascular diseases, cancer, mental disorders and diabetes mellitus with the focus of intervention on tobacco, poor diet and obesity, elevated cholesterol and elevated blood pressure. EUR/01/5015946 page 3
In the demonstration area (Kuldiga), the main activities during the first year of Latvia’s membership in CINDI were related to the primary prevention of NCD (Quit and Win smoking cessation competition, Healthy Weeks, adaptation and distribution of national guidelines, training of trainers), research and monitoring (support to the FINBALT survey, population-based risk factor survey, population-based survey to assess health care in the region) and improvement of the quality of health care (improvement of CVD primary and secondary prevention and of the hypertension management skills of primary health care staff through development and distribution of national guidelines, the development of referral chain guidelines, training of trainers).
A CINDI conference was held and a pharmacy-based hypertension management project launched.
It was noted that good progress had been made in the CINDI-Latvia Programme.
Italy Professor M.T. Tenconi reminded the meeting that in Italy CINDI is organized in three regional programmes and three local projects.
In 1999 surveys on risk factors for atherosclerosis were carried out in Lombardy, Latina Province, Sardinia and Valle dell’Irno.
In the Region of Lombardia, special units of preventive medicine dedicated to chronic diseases have been organized as part of the Prevention Department of each of the 14 Local Health Agencies. Activities include the promotion of healthy lifestyles (nutrition, smoking, alcohol and drug abuse, and physical activity), screening for and management of risk factors for cardiovascular diseases and screening campaigns in the at-risk population. The table below gives an overview of the screening activities carried out.
Table 1. Screening activities – CINDI Lombardia
% Units Children visual defects 28 (6 out of 8) Breast cancer 18 (4 out of 8) Cancer of cervix uteri 18 (4 out of 8) TBC 14 (3 out of 8) Odontopathies 10 (2 out of 8) Auxology 4 (1 out of 8) Postural defects 4 (1 out of 8) Speech defects 4 (1 out of 8) 100 22
Professor Tenconi reported on the G7/G8 Cardio-ANMCO software developed by the Centre for Cardiovascular Disease Prevention (WHO Collaborating Centre), Udine, for the assessment and monitoring of CVD risk factors.
It was noted that the work being carried out in Italy within CINDI is substantial and it was hoped that Italy could become a full member of the programme within the coming year.
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Romania Dr M.I. Popa reported that the local CINDI protocol had been finalized and intervention guidelines prepared. An Operational Committee had been formed in October 1999 to coordinate and implement the programme. The Committee set up a Coordinating Council in February 2000 comprising representatives of ministries and groups involved in CINDI activities. The Council acts as an advisory body.
In Romania, the programme is being implemented in the demonstration area of Pucioasa. Much progress was made during their first year; activities included local health information campaigns, work to involve the local authorities and the training of baseline survey interviewers.
Despite financial and other restraints at national and local levels, it was planned that intervention would start in the demonstration area in the near future. It was envisaged that at least two more demonstration areas would be set up in 2000.
The enthusiasm and effort that has resulted in the good progress made in all three countries in their first year of CINDI membership was appreciated. The intervention projects mentioned by the new CINDI countries could be usefully shared with other countries.
2.3 Second period of cooperation between the WHO Regional Office for Europe and countries in respect of the WHO CINDI Programme
Dr Deguara signed the agreement for the second period of cooperation between the Ministry of Health of Malta and WHO/EURO in respect of the CINDI Programme.
A similar agreement was signed in May 2000 between Lithuania and WHO/EURO at the Ministry of Health of Lithuania.
3. Collaboration with headquarters
3.1 WHO global strategy for NCD prevention and control
Professor V. Grabauskas briefed the participants on the latest development related to the WHO global strategy for NCD prevention and control. He recalled that during the meeting of the Fifty- first World Health Assembly (WHA) in 1998, the very serious attitude of the countries to NCD prevention and control was clearly demonstrated through the adoption of the Resolution WHA 51.18 “Noncommunicable Disease Prevention and Control”.
At the meeting of the WHO Executive Board in January 2000, it was considered timely to formulate a concrete proposal on how to deal with NCD prevention and control. The report of the Director-General of WHO (DG) on NCD prevention and control was prepared. In May 2000, the Fifty-third WHA was unanimous in its agreement to promote global action against NCD. Resolution WHA 53.17 “Prevention and control of noncommunicable diseases” was adopted setting up very clear guidelines on how to plan the action to be taken. Many points were along the lines of the CINDI approach. (A copy of the Resolution was distributed at the meeting to all CINDI Programme Directors.)
For the first time in many years, the vast majority of countries recognize the burden of NCD. NCD prevention and control has been declared a priority even by the developing and low and EUR/01/5015946 page 5
middle income countries. The measures proposed in Resolution WHA 53.17 to deal with these diseases – to take the commonality of the risk factors for major NCD as a major approach in attacking the problem globally – were the same as those used in the CINDI approach.
Professor Puska noted that CINDI had played an active role in the preparation of the Director- General’s report on NCD prevention and control.
In the light of these developments, the CINDI Programme Directors agreed that the time was optimal for them to address the Regional Director of WHO/EURO on the implementation of the WHA Resolution 53.17. A drafting group comprising Ms Ellul, Dr Gaffney, Professor Grabauskas and Professor Puska was set up to prepare a letter for the signature of the Programme Directors at the meeting (Annex 10).
3.2 Global Forum on NCD prevention and control (GF)
Dr G. Goldstein transmitted the greetings of Dr A. Alwan, Director, NCD/HQ Cluster. He said that the global strategy for NCD prevention and control highlights the role of the WHO in stimulating regional and global networking for the integrated prevention of the major NCD and in strengthening community-based activities, particularly in the developing countries. The strategy recommends the establishment of a global network of national and regional programmes for the prevention and control of NCD in order to facilitate the dissemination of information and exchange of experiences, and to support regional and national initiatives. It provides the vision, principles and framework for the GF.
In connection with the need for practical NCD prevention programmes and better international collaboration, Professor Puska felt that the other WHO Regions might wish to consider adopting the approach being taken by CINDI and CARMEN.1 The approval of this approach by the WHA gives a formal backing to the work being carried out by these programmes.
Dr Goldstein reported that a meeting on the GF, organized by the WHO headquarters NCD Cluster, was held in Joensuu, Finland, on 2–4 May 2000. With the exception of the Western Pacific Region (WPRO), all the Regions were represented. Discussion centred on the practical steps that would be connected to setting up CINDI and CARMEN-type networks in other Regions, as well as on the establishment and role of the proposed GF (Annex 4) short summary of the meeting).
The current plan of action related to setting up the GF was presented by Dr Goldstein as follows: 1. Endorsement of the report of the Joensuu consultation by the Directors of the WHO Regional Offices and the Executive Director of the WHO headquarters MNH Cluster (June 2000). 2. Submission of a GF progress report to the CINDI and CARMEN Programme Management Committees (June 2000). 3. Establishment of a GF Steering Committee and organization of the first telephone conference (July 2000).
1 The CARMEN Programme is the WHO Region for the Americas’ programme equivalent to CINDI.
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4. Identification of seed funding for immediate activities, including the preparation of the first meeting in 2001 (July 2000). 5. Preparation of proposals for fund raising (July 2000). 6. Development of regional plans for the establishment of networks (? August 2000). 7. Development of regular interaction between the Regional Offices and the relevant departments of national Ministries of Health in order to strengthen synergism, prevent overlap¸ and maximize joint effort. 8. Preparation of papers on the GF for international fora such as the Fifth Preventive Cardiology Conference, May 2001.
During the ensuing discussion, Dr Busuttil, Professor Grabauskas and Professor Puska supported the idea of a GF. They proposed that, should it be established, representation of the regional programmes be at the level of the international network and not at the level of individual participating countries. It was also proposed that CINDI be represented by the WHO Regional Adviser for NCD Prevention, the Chairman of the CINDI Programme Management Committee and by a CINDI Programme Director elected on a rotational basis.
Dr Goldstein reported that it is yet to be determined whether the GF will absorb INTERHEALTH. Questions on the future of this programme would be resolved in the coming months.
In Professor Glasunov’s opinion, a GF would help to develop and strengthen CINDI and its position in the Regional Office. It could also be useful for the Regional Office and headquarters together to build opportunities for training; the annual CINDI Winter School, for example, could be used for global purposes. Professor Glasunov pointed out that the development of the demonstration area was the backbone of the CINDI Programme. He suggested setting up a consultation process to develop a strategy on how to position CINDI in the GF and to determine how CINDI can contribute.
In conclusion, the meeting supported the plans for the establishment of a GF. A consultation process should be launched on how CINDI could participate in the GF.
4. Collaboration with other WHO Regions
4.1 Regional Office for Africa (AFRO)
Dr A. Filipe Junior outlined the structure of the Division of NCD at WHO/AFRO which is relatively new having been created in September 1998.
In Africa there is a heavy burden of communicable diseases, now aggravated by HIV/AIDS, and an increase in NCD such as hypertension, rheumatic heart disease, diabetes and cancer.
Dr Filipe Junior said that there was an increasing awareness of the burden of NCD in Africa and of the way NCD is viewed by health decision-makers.
Dr Filipe Junior explained that they have started gathering data (community-based and hospital- based) on the real situation regarding NCD prevention and control. An Expert Committee has been set up and has prepared a regional strategy for NCD. Another group has made EUR/01/5015946 page 7
recommendations on the management of hypertension. There are guidelines on the management of diabetes. Several training courses have been held. NCD/AFRO is planning to set up a network of 5–10 countries as a demonstration. CINDI will be used as a model.
Professor F. de Padua kindly offered the assistance of CINDI-Portugal in launching CINDI-type programmes in Portuguese speaking communities.
4.2 Regional Office for the Eastern Mediterranean (EMRO)
Owing to other commitments Dr O. Khatib, Acting Regional Adviser, Noncommunicable Diseases, was unable to participate in the meeting.
4.3 Pan American Health Organization (PAHO)
It was noted that CINDI-CARMEN collaboration was very productive. CARMEN participated in the Quit and Win smoking cessation campaign, the second CINDI policy survey and the CINDI/CARMEN survey on tobacco prevention and control policies. CARMEN chairs the Working Group on Physical Activity.
4.4 Collaboration with CDC
Mr G. Hogelin reported on some of the new activities being carried out at CDC that he felt might be of interest to the CINDI Programme Directors.
In the area of surveillance, comparative behavioural risk factor data on the 50 largest US cities are available. Work has also been carried out on policy development. As part of the CVD prevention programme, data on such process indicators as smoke-free worksites, availability of sidewalks and walking trails, and reduced-fat school lunches will be worked on. Mr Hogelin hoped that these data would be useful to the CINDI Programme Directors.
A second area that CDC has expanded is training. In 1999 they initiated a CVD Institute (a training course) in Black Mountain, Virginia, with international participation (students and faculty). The Institute will be repeated in 2001 and Mr Hogelin hoped that some of the CINDI programmes could be represented.
Another institute initiated is the Evidence-based, Chronic Disease Epidemiology Institute in San Diego, California. Here too international participation has been budgeted for and it was hoped that CINDI could take advantage of this course in the future.
CDC has recently developed a new community-based programme REACH, designed to address health disparities in the US: 32 communities were being funded in 2000 and it was hoped that 15 more could be funded in the near future. From these model projects it was hoped that new ways to approach community health could be found and that these fundings would help researchers such as CINDI programme teams.
Finally Mr Hogelin mentioned the “Prevention Effect” project that is a knowledge management system. This system will compile community-based research findings and look into the effectiveness of community-based interventions. In the context of populations, it will identify actions taken and the effectiveness of those actions. It will enable practitioners to rapidly identify successful interventions, their settings and populations.
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In summary, CDC has new initiatives in surveillance, model projects, training and knowledge management. Mr Hogelin expressed the hope that these would be of use to CINDI in the future and he invited the participants to take advantage of them.
Dr Hogelin said that CDC was presently supporting the CINDI network with some modest resources and will be offering the same support to the CARMEN network. Should WHO networks develop, CDC would be happy to extend this support. It was the aim of CDC to further the existing networks so that they may serve their constituents.
Dr Shatchkute expressed her appreciation of CDC’s support to CINDI and reported that the funds already received would be used for CINDI monitoring and evaluation in the countries. CDC was also invited to participate in CINDI technical projects (e.g. hypertension management, assessing health inequalities).
Dr Shatchkute also mentioned that CINDI might be able to contribute to the CDC knowledge management system by providing programme experience.
Collaboration between CINDI and CDC can be used as an example to demonstrate to the GF how an institution can assist two regional networks and how networks can collaborate.
5. Working Groups
5.1 Joint report of the CINDI Working Groups
The joint report for 1999, containing annual reports from the Working Groups on Policy Development, Smoking, Children and Youth, Hypertension, Guidelines and Training for Preventive Practice, was distributed to all Programme Directors.
Professor Puska reminded the participants that the CINDI Working Groups2 had been established so that important priority subject matters could be dealt with by interest groups.
The CINDI Programme Management Committee supervises and evaluates the work of the Groups. The Chair of each Working Group submits an annual report to the Chair of the CINDI Programme Management Committee.
Each Working Group has its own terms of reference and every year presents a plan of work for the approval of the CINDI Programme Directors.
The Working Groups are established for a certain period of time. When its work is completed a Working Group might be terminated or re-established.
The Working Group on Diabetes has completed its work. It is however possible that some issues still need to be addressed.
Concerning physical activity, CINDI will continue to participate in the CARMEN/CINDI Working Group on this topic.
2 Policy development, Monitoring, Evaluation and Research, Nutrition and Elevated Blood Cholesterol, Smoking, Children and Youth, Hypertension, Worksite Programmes, Guidelines and Training for Preventive Practice, Nursing, Diabetes. EUR/01/5015946 page 9
It was concluded that the working group system is useful but that it could be strengthened. Since there are a number of newcomers to CINDI, the time was right to ascertain which countries are interested in which groups. Programme Directors should review the list and let WHO/EURO know in which group(s) they wish to be involved.
5.2 Monitoring, evaluation and research
Future data collection and analysis strategy The discussion was aimed at further elaborating the policy on access to and use of the CINDI database
At present a dataset resulting from the surveys on risk factors and process evaluation is available at the CINDI Data Management Centre (CDMC) (Annex 6). The Working Group on Monitoring, Evaluation and Research had recommended that the dataset become WHO property when the validity of the country data had been checked and the data incorporated in the database of the CDMC. Therefore it was recommended that a copy of the dataset also be kept in WHO/EURO.
Professor MacLean introduced a draft document regarding the policy on access to and use of the core dataset (risk factors and process evaluation surveys) (Annex 7). Professor Morava commented that Principle 1 and Principle 3 outlined in the draft should be reworded since they contradicted each other. It was also noted that from the text it was not clear which data – raw or aggregated – were referred to. This should be rectified.
It was concluded that the draft document presented at the meeting is valid as policy document until the final version is elaborated.
It was agreed that any comments on the content of the policy guidelines on access to and use of data should be made to CINDI/EURO within two weeks after the meeting. If no response was received within this time limit, it would be understood that no comments were forthcoming.
At present several databases exist that contain the results of various surveys and to which CINDI Programme Directors have a certain degree of access. Therefore the discussion covered the issue of policy with respect to data collection, the establishment of databases and their storage, access to and use of databases.
It was concluded that the issue of the policy on access to and use of the CINDI data would be included in the agenda for the next meeting of the Working Group on Monitoring, Evaluation and Research.
The terms of reference of the Working Group on Monitoring, Evaluation and Research At its meeting on 17–18 March 2000, the CINDI Programme Management Committee approved the terms of reference of the Working Group on Monitoring, Evaluation and Research. The participants of the meeting discussed these terms of reference and approved them (Annex 8).
The terms of reference of the CINDI Data Management Centre (CDMC) Professor Nüssel introduced his proposal to update the terms of reference of the CDMC to reflect the new opportunities provided by the development of information technology. Almost all CINDI centres were able to establish their own databases, perform basic data analysis and send
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their data to the CDMC electronically. Therefore Professor Nüssel suggested that the CDMC should concentrate its efforts on better communication with CINDI centres through a system of error-checking raw data to establish certified data sets. Certified data would be placed on the Internet in such a way that the users could access it. The CDMC would then carry out data analyses as requested by the Working Group on Monitoring, Evaluation and Research or certified users.
Professor Nüssel’s proposal was supported. It was agreed that the terms of reference of the CDMC were to be amended to include reference to the high potential of the CDMC to improve communication among CINDI Centres.
5.3 Smoking
Quit and Win tobacco cessation campaign Before presenting the experience of the International Quit and Win 2000, Professor Puska introduced the project. Countries participating in the Quit and Win campaign follow jointly agreed rules. Contestants are daily smokers of 18 years of age or older. They are required to abstain from smoking for at least four weeks. This is verified through a cotinine test of the winners. Based on earlier experience, an estimated 20% of the participants are still smoke-free at the one-year follow-up.
The Quit and Win campaign has rapidly grown in popularity as a practical, international smoking cessation intervention. It began in 1994 with the participation of 13 CINDI countries. In 1996, 25 countries took part and in 1998 there were over 200 000 participants involving over 48 countries world wide.
International Quit and Win 2000 – the fourth campaign – arranged in May 2000, set a new world record. About 420 000 smokers world wide were joined across 81 countries in the pursuit of the common goal to give up smoking. The National Public Health Institute (KTL), Finland, coordinated International Quit and Win 2000, supported by the WHO and two commercial partners: Pharmacia Corporation and Glaxo Wellcome.
According to Professor Puska, the popularity of the campaign is largely due to its unique and positive approach to a problem that is receiving increasing attention world wide as a major health threat. “Contestants may win one of the prizes, but by quitting smoking they win over tobacco and all the harm it causes. Everyone who quits smoking is a winner.”
Dr Deguara, the Minister of Health of Malta, drew the winning lot for the Super prize of the International Quit and Win 2000 as follows:
International super prize: Chile Regional Prizes: S European Region Russia S American Region Cuba S Eastern Mediterranean Region The United Arab Emirates S South East Asian Region The Maldives S Western Pacific Region Kiribati S African Region Kenya
The results of the International Quit and Win 2000 will be presented and discussed at the meeting of the Working Group on Smoking, Copenhagen, 24–25 November 2001. EUR/01/5015946 page 11
Professor Puska proposed that the next Quit and Win campaign be organized in 2002. The CINDI Programme Directors supported the proposal. They felt that this project is a very practical preventive activity and acknowledged the role of Professor Puska in its success.
It was noted that all promotional material produced in relation to the Quit and Win campaign at international level should include the CINDI logo among the logos of other supporting bodies.
Tobacco policies in CINDI-CARMEN countries The Working Group on Smoking and the Working Group on Guidelines and Training for Preventive Practice are participating in the work related to the survey on tobacco policies initiated and supported by headquarters (the Tobacco Free Initiative and the CVD programme). Professor Pardell presented the preliminary results of the survey on tobacco policies in CINDI- CARMEN countries. Almost all CINDI countries and a number of CARMEN countries participated in the survey.
The final report will be presented to WHO headquarters in July 2000. The CINDI Programme Management Committee will decide on the further analysis of the data.
CINDI millennium initiative on smoking prevention and reduction in health professionals Professor Pardell presented the preliminary design of the CINDI millennium initiative on smoking prevention and reduction in health professionals (Annex 11 – minutes of the Informal planning consultation, EURO, 6 April 2000). The project, which will focus on physicians (including students), will be the responsibility of the Working Group on Smoking and the Working Group on Guidelines and Training Preventive Practice and will be implemented in partnership with the WHO/EURO Tobacco or Health programme. Collaboration will also be established with EUROPREV (the European Review Group on Prevention and Health Promotion in General Practice/Family Medicine, Web site at www.europrev.org). Dr M.R. Sammut, EUROPREV, explained its activities. A survey on the attitudes and knowledge of GPs in relation to disease prevention and health promotion was the current major activity of the Group.
It was agreed that the CINDI-Catalonia team would work in close collaboration with the CINDI- Finland team and the EUROPREV secretariat to collect available information about tobacco use by health professionals, particularly physicians. The CINDI Working Group on Smoking will organize a meeting in Copenhagen on 24–25 November 2000 where the development of this project will be decided.
Those interested in taking part in the project should inform WHO/EURO.
5.4 Hypertension
Pharmacy-based hypertension management project CINDI and the EuroPharm Forum will run a pilot project on the feasibility of the protocol and guidelines for the project, “Pharmacy-based hypertension management model”. Estonia, Latvia, Lithuania, Portugal, Slovenia and Spain (Catalonia) are involved in the project.
Developments in self-measurement of blood pressure The document on self-measurement of blood pressure, “Guidelines for the use of self blood pressure monitoring: a summary report of the first international consensus conference” (Journal
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of Hypertension 18: 493–508 (2000)) and the document prepared by the CINDI Working Group on Hypertension on self-measurement of blood pressure (final draft) have been distributed. How these should be recommend for practice in the CINDI countries needs to be discussed.
The CINDI statement on the clinical and epidemiological uses of automatic devices for blood pressure measurement, submitted to and endorsed by the CINDI Programme Directors at the 16th annual meeting in Dornbirn in 1999, has been distributed to CINDI countries.
Survey on policies regarding hypertension prevention and management Professor Pardell introduced a proposal to assess the current situation regarding policies on hypertension prevention and management in CINDI countries. It was agreed that the questionnaire to be used to update the hypertension management survey would be similar to the one used in 1994, with the addition of a few new topics. Some data could be obtained from the CDMC.
The above three topics will be on the agenda of the next meeting of the Working Group on Hypertension which is planned for end 2000.
5.5 Workplace
Professor W. Drygas referred to previous meetings where problems with the Working Group had been discussed. He commented that although there are numerous preventive activities directed to workplace in the countries, little interest in participating had been shown by the countries and no finances were available to support activities of the Working Group. As an example, he referred to the document “Guidelines on improving the physical fitness of employees” produced jointly by the WHO/EURO Occupational Health and CINDI programmes and edited by Mr F. Kelly several years previously. It had not been possible to publish the document owing to lack of funds.
Professor Drygas reported that he had carried out a survey (17 countries responded to the questionnaire) on workplace programmes in CINDI countries. CINDI programmes in Austria, Belarus, Bulgaria, Canada, Croatia, the Czech Republic, Finland, Malta, Poland, Russia, Slovakia had experience in interventions at the workplace. The number of enterprises where health promotion and diseases prevention activities were implemented varied from 1–3 (Bulgaria, Belarus, Russia) to 100 (Canada). In most countries CINDI activities were financed by the enterprises involved. In Belarus, Canada, Croatia, Russia special documents on interventions at the workplace were produced. Intervention programmes in most countries were focused on smoking, hypertension and obesity.
Professor Drygas proposed combining this Working Group with the Working Group on Physical Activity. He also requested that another Programme Director be nominated as Chair.
The participants thanked Professor Drygas for his report and for the work done. It was concluded that if this Working Group were to continue, resources would need to be found to support it (e.g. by approaching companies in countries).
It was recommended that the CINDI Programme Management Committee determine whether the Working Group should continue and if so identify a Chair. EUR/01/5015946 page 13
5.6 Children and Youth
Professor Grabauskas outlined the two main activities covered by the Working Group: (1) drafting of joint publications on: a) the assessment CINDI Children’s component activities in national centres; b) the results of breast-feeding support programmes in CINDI countries; c) changes in the health behaviour of school-aged children in the CINDI countries (results of 1994 and 1998 cross-national surveys); (2) updating international data files.
It is planned to continue the elaboration of the CINDI document: “Policy guidelines for smoking prevention among children and youth”. At the meeting of the CINDI Working Group on Children and Youth in Kaunas on 8–9 March 1999, an initiative group comprising representatives from Estonia, Finland, Lithuania, Russia and Slovakia was identified to elaborate the above-mentioned document. The group was asked to prepare the first proposals for the document by the end of June 2000. It was envisaged that the Working Group on Smoking would collaborate in this work.
The Working Group also plans to be involved in the development of a “Nonsmoking Class Competition” for CINDI countries. An initiative group comprising representatives from Estonia, Finland, Lithuania and Russia was encouraged to elaborate proposals for this project.
5.7 Nutrition and Elevated Blood Cholesterol
Professor MacLean reported that the CINDI dietary guide was finalized. It will be available in English and Russian. Countries were encouraged to translate the document or use it as a background document when preparing national nutrition guides. Professor Glasunov informed the participants that the document had already been successfully used by the CINDI-Russia team in the elaboration of the national healthy nutrition policy in Russia.
Professor MacLean informed the participants that he, as Chair of the CINDI Working Group on Nutrition and Elevated Blood Cholesterol, had participated in the consultation on the development of the First Food and Nutrition Action Plan for the WHO European Region held in Malta on 8–10 November 1999, organized by the WHO/EURO Programme for Nutrition, Infant Feeding and Food Security. CINDI is one of four WHO/EURO programmes contributing to the elaboration of the Action Plan for Food and Nutrition Policy in the WHO European Region. The CINDI dietary guide is one of the products to be used in the implementation of the Action Plan.
It was agreed that practical use of the CINDI dietary guide in countries, training of health professionals on healthy nutrition and improvement in monitoring nutrition and dietary habits would be CINDI priorities in the Action Plan.
Dr J. Maucec Zakotnik presented a summary of the outcome of the WHO/EURO multidisciplinary training seminar for policy makers on food and nutrition action plans in Southeast Europe that took place on 1–3 June 2000 in Krajn, Slovenia. CINDI-Slovenia participated actively in the seminar. Its aim was to explore current policies related to food and nutrition, to develop an intersectoral food safety, nutrition and supply chain action plan, and to elaborate a strategy to develop and implement a national food and nutrition action plan. Eight countries participated. The seminar was very useful for strengthening intervention in the field of nutrition.
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5.8 CARMEN/CINDI Working Group on Physical Activity
Interest in participating in the above Working Group was shown by Austria, Canada, Poland, Portugal and Slovenia. It was agreed that Professor MacLean would represent CINDI at the next meeting of the Working Group to be held in Sao Paolo, Brazil, in October 2000.
5.9 Nursing
The Chair of the Working Group on Nursing had resigned. It was noted that over the last two years the Working Group had not been functioning.
It was the general consensus that the area of nursing is important in CINDI. Therefore those CINDI Programme Directors that were interested in forming a new group should send the name of their programme representative to EURO. It was agreed that if the group were to be set up, Professor A. Nissinen would be asked to act as Chair.
5.10 Diabetes
On behalf of Professor Z. Metelko, Dr D. Muacevic-Katanec demonstrated the Croatian Diabetes register and proposed that links with the diabetes databases of other CINDI countries be established to enhance prevention of CVD in persons with diabetes. It was agreed that the CINDI Programme Management Committee would revise the terms of reference of this Working Group.
5.11 Guidelines and Training for Preventive Practice
Continuing Medical Education (CME) Dr Sammut, representative of EUROPREV, explained the main objectives of that Organization. These were mainly centred on antismoking initiatives and other preventive practices. The collaboration of EUROPREV with CINDI was acknowledged and strongly supported.
A short report of the WORKING GROUP meeting (Barcelona, November 1999) was presented. The meeting was held at the WHO European Centre for Integrated Health Care Services in Barcelona (Dr M. Garcia-Barbero) with the participation of Dr J.R. Eskerud, Dr M. Garcia- Barbero, Professor V. Grabauskas, Dr A. Oriol-Bosch, Professor Pardell, Dr Shatchkute, Dr Tresserras as well as local observers and experts.
In accordance with the main conclusions and recommendations of the Barcelona meeting, a survey on the current situation regarding CME and needs assessment in CINDI countries was carried out in the months prior to the present meeting. The response rate was very low.
Following the suggestions made at the UEMS (Union Européenne de Médecins Spécialistes) meeting “Consensus on CME of the European Accreditation Council for CME”, Brussels, 12 May 2000, in which Professor Pardell represented CINDI, the Programme Directors encouraged the Working Group to further explore possibilities of implementing a pilot project related to a CME accreditation system in the CINDI context.
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CINDI masters in population health Professor Grabauskas gave a very brief résumé of the history of this initiative: S The faculty of the CINDI Winter School identified a need for extended training in public health, based on the CINDI concepts. S Two small-scale consultations were held to discuss the process of establishing such training. S A master collaborative project design was presented to EURO; CINDI Programmes in Canada, Finland, Lithuania, Russia and Spain (Catalonia) agreed to participate.
Since it had been not possible to further develop the project owing to shortage of funds in EURO, it was proposed that possibilities of collaboration among the above-mentioned CINDI programmes be explored so that those interested in a CINDI-MPH degree could start collecting credits. Two CINDI centres offered courses from January 2001: Finland (a one-credit course through the North Karelia Visitors Programme) and Lithuania (a two-credit course on “Epidemiological foundations for the integrated prevention of noncommunicable diseases”).
It was agreed that one credit could be awarded for participation in the CINDI Winter School (40 hours’ student time per week).
Dr Shatchkute commented that an application for USD 400 000 from WHO headquarters efficiency funds had been made for this initiative. A response was awaited.
6. CINDI monitoring and evaluation
6.1 Methodology
Manual of operation – Monitoring and evaluation: CINDI Programme Professor MacLean summarized the content of the second draft of the document “Manual of operation – Monitoring and evaluation: CINDI Programme” which had been sent to all Programme Directors. It was compiled from the CINDI Protocol and Guidelines issued in 1987 and updated in 1996 and various CINDI survey questionnaires. The document also contains instructions regarding transfer of risk factor data to the CDMC using a data transfer format.
It was proposed that the process evaluation questionnaire contained in the second draft be replaced by a questionnaire on health behaviour and lifestyle-related risk factors. The smoking questionnaire recommended for use in the risk factor surveys differs from the smoking questionnaire currently recommended by WHO headquarters. The Working Group on Monitoring, Evaluation and Research and the CINDI Management Committee should determine which smoking-related questionnaire is to be used in CINDI surveys.
The participants were asked to review the document, paying special attention to the part on the methodology and system of CINDI core data collection and analysis (mainly risk factor surveys). This area could be more clearly described and proposals to this end were requested. Comments on the manual of operation are to be sent to WHO/EURO within one month after the meeting.
It was noted that, from the data collected during risk factor surveys, it is difficult to calculate the proportion of hypertensives in CINDI countries since the relevant questionnaire does not seek
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information on people undergoing treatment. Therefore, when preparing the new questionnaire, the question “Are you taking drugs for high blood pressure?” will be included. The same applies to the issue of high cholesterol.
Dr V. Moltchanov will modify the data transfer format to include questions regarding treatment for hypertension and hypercholesterolemia.
CINDI process evaluation The principles of common process evaluation in CINDI were agreed already some 10 years previously when a common questionnaire for this evaluation was prepared.
Professor MacLean reported that the process evaluation surveys carried out in countries indicated that the process evaluation questionnaire was not very useful for monitoring health behaviour and that some questions were ambiguous. Therefore a recommendation had been made by the CINDI Working Group on Monitoring, Evaluation and Research to replace this questionnaire with a new questionnaire.
Professor Puska explained that the FINBALT study group and the Working Group on Monitoring, Evaluation and Research, together with WHO/EURO, had elaborated the new questionnaire (Annex 5). It is aimed at monitoring risk factors and lifestyle-related health behaviour at the community level and is based on the questionnaire used in the FINBALT Health Monitor survey. It includes most of the questions contained in the old process evaluation survey. It was noted that Estonia, Finland, Latvia, and Lithuania were participating in the FINBALT project. These countries have very good experience in carrying out these surveys and it has been shown that the results and data are very useful for various purposes.
The new questionnaire was briefly discussed. The Programme Directors agreed on the proposed replacement. Since the survey will reflect mainly health behaviour and lifestyle-related risk factors, it was agreed to refer to it as the “CINDI health monitor survey” rather than the “process evaluation survey”.
It was noted that CINDI process evaluation should be intensified. The methodology described in the CINDI Handbook for Process Evaluation in Noncommunicable Disease Prevention should be used for this purpose.
Dr Laatikainen introduced the methodology of the CINDI health monitor survey. It was recommended that the survey be carried out either in the demonstration area(s) or nationwide. Since the ultimate goal of CINDI is to implement the programme at national level, it was agreed that the survey could be conducted at national level as a random sample survey. It was also recommended that an independent additional sample survey be conducted in the same demonstration area(s) as the risk factor surveys. If it is not feasible to conduct the survey at national level, it could be carried out in the demonstration area(s) only.
The sample should be of at least 1500 persons and the core age group between 25 and 64 years. Each country will be free to have additional samples from younger or older age groups.
The survey questionnaire includes two categories of questions: (1) an obligatory survey question; (2) a highly recommended survey question. It was noted that when countries run the survey, additional questions could be added to serve local needs. EUR/01/5015946 page 17
Countries can choose their own methods of data collection according to their possibilities and situation. Data can be collected by mail, by telephone interview or by personal interview. The survey should be carried out twice in a five-year period.
It was emphasized that, in order to be able to assess the trends, countries shall use the same survey methodology every time. It was noted that to have comparable data and establish a data archive of good quality, every survey should contain details on the survey area and method of data collection, as well as contacting information in respect of those charge of the study.
It was agreed that in 2000–2001, a pilot round of CINDI health monitor surveys would be carried out in as many countries as possible (Table 2). Raw data from these surveys will not be gathered centrally. Each country will process its own data. Data could be then analysed for specific purposes in one centre (e.g. data could be sent in table format to CINDI-Finland for elaboration of a report).
It was recommended that a training seminar on the methodology and procedures of the CINDI health monitor be organized. Professor Puska kindly agreed to support a training seminar in Helsinki in autumn 2000.
The support received from CDC for the CINDI monitoring and evaluation component was appreciated very much.
Table 2 Interest in carrying out the Country Process evaluation surveys already carried out proposed CINDI Health Monitor Survey Bulgaria No earlier studies Interested in carrying out survey in demonstration area Canada Health and lifestyle survey carried out annually Croatia Survey carried out in 1995 Interested in carrying out the survey Comment: New questionnaire needs to be discussed Estonia FINBALT Health Monitor Survey carried out every Will continue the FINBALT second year surveys Finland Health behaviour survey carried out annually Hungary Health behaviour survey carried out in 1996. Interested in carrying out the survey Italy No process evaluation surveys carried out Survey could be done in demonstration areas NB: Mail questionnaire not possible Latvia Participation in FINBALT Lithuania FINBALT Health Monitor Survey carried out every Will continue the FINBALT second year surveys Questionnaire includes additional questions to back up national policy Romania No earlier process evaluation surveys Interested in carrying out the survey in 2000–2001 Turkmenistan No earlier process evaluation surveys
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6.2 CINDI data analysis
Mortality trends in CINDI countries Professor Grabauskas introduced the results of the further mortality trends analysis at national level. He said that the question of types of mortality data analyses had been discussed on several occasions. For the present meeting, the data on mortality trends had been analysed as proposed by the CINDI Working Group on Monitoring, Evaluation and Research and approved by the CINDI Programme Management Committee in 1999.
The data analysed are from the WHO HFA database and include data on mortality from all causes, cancer, CVD and coronary heart disease. Data are presented by five-year age groups within the 25–64 years age group, for males and females.
Professor Grabauskas commented that the Working Group on Monitoring, Evaluation and Research had recommended that the starting point for analysis be 1985. The current analysis was carried out by analysing trends and then grouping countries according to trends (increasing, decreasing, and stable). The results of the analysis were presented in graphics. Professor Grabauskas noted that it is also possible to demonstrate the results using a map. This technique makes country grouping clearer. However, since 1991, a number of countries in central and eastern Europe have experienced a sharp increase followed by a decreasing trend in all causes and CVD mortality and it is not possible to reflect this aspect on a map. Therefore, Professor Grabauskas proposed that other types of data analysis be considered, e.g. taking 1991–92 as a second starting point for data analysis.
It was concluded that the data analysis will be finalized and the trends presented in tables and graphics. Further consideration will need to be given to how country groupings can be presented. The results of the analysis will be sent to WHO/EURO for entry into the CINDI website.
Countries were encouraged to collect mortality data at demonstration area level also.
Introduction of the databook on risk factors Professor Nüssel presented the structure and content of the databook (in accordance with the recommendations of the meeting of the Working Group on Monitoring, Evaluation and Research, Heidelberg, 1–2 October 1999). It is now available on the Internet (CDMC website). The CINDI/EURO homepage and the CDMC homepage were demonstrated.
It was recommended that countries check the data presented. It was concluded that for the purpose of data analysis, it was necessary to know whether risk factor surveys had been carried out according to the CINDI Protocol and Guidelines.
It was very much appreciated that the databook on risk factors is now on the Internet and accessible. Those Programme Directors who do not have a password should contact Professor Nüssel (either before the end of the meeting or by mail after the meeting).
Analysis of risk factors surveys data Professor Puska reported that the data was in the process of being analysed; no draft was yet available.
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Alcohol data analysis In 1999, the Working Group on Monitoring, Evaluation and Research proposed that an analysis of data on alcohol and physical activity be initiated. At the 16th annual meeting of the CINDI Programme Directors in Dornbirn in June 1999, Professor Grabauskas presented a possible method of analysing the alcohol data using the alcohol questionnaire contained in Annex 9 of the CINDI Protocol and Guidelines. CINDI-Lithuania was charged with assisting the CDMC in checking the availability of data on alcohol use for comparative analysis and was granted access to the data available at the CDMC. It was found that eight countries had submitted data on alcohol. However, for technical reasons, several of the data files were inaccessible. Recently several countries had sent new data, which would seem to indicate that more data were available. The analysis of the data to hand (Annex 9) indicated that each country had used its own set of survey questions thus making a common analysis impossible.
Professor Grabauskas concluded that the results of this analysis showed that it was not clear how many countries have data on alcohol. A decision was needed on which questionnaire should be used in order to allow a standardized presentation of the data.
In the ensuing discussion, Dr Gaffney, Dr Moltchanov and Professor Puska stressed the importance of adhering to the methodology defined in the CINDI Protocol and Guidelines.
Professor Morava commented that even if only one of the questions were common to all questionnaires used in an alcohol survey, the answer would depend on the culture of the country. He felt that, since alcohol was such an important lifestyle component, whatever data were available should be used for comparison. Ms M. Ellul commented that the surveys on alcohol use should reflect the various age groups of the population.
It was agreed that attempts to analyse alcohol use should be continued. In order to assess the comparability of the data already collected, the Programme Directors – by the end of the meeting if possible – would reply to the following questions: Which data on alcohol did your country programme submit to the CDMC? Which questions were used in your country?
It was concluded that if it were not possible to pool the data, countries would be encouraged to prepare case studies.
It was reconfirmed that the questions on alcohol consumption as defined in Annex 6 of the CINDI Protocol and Guidelines are obligatory in risk factor surveys. Countries were encouraged to use additional questions that would allow them to determine the trends in their countries.
CVD in women Professor MacLean reported that all the CINDI countries had been contacted with the proposal to participate in a study on CVD in women. A data template (for data on CVD mortality and the level of risk factors) was made available in case of interest. There were two requirements for participation: 1) that countries were able to analyse their own data; 2) that the data were at least from 1995. Six countries had completed the data template and another six had agreed to participate. Other countries with data they can analyse themselves can be included.
The results of the analysis were presented at the First International Conference on Women, Heart Disease and Stroke, Victoria, British Columbia, Canada, 7–10 May 2000, and will also be
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presented at the IEA European Regional Meeting “From Molecules to Public Health”, Kaunas, Lithuania, 24–26 August 2000.
7. Policy development
7.1 Second comparative analysis
In the absence of Dr A. Petrasovits, progress achieved in the second comparative analysis of policy development and implementation processes in CINDI programmes was reported by Professor I. Glasunov, Co-chair of the Working Group on Policy Development.
Professor Glasunov reminded the participants that the CINDI Working Group on Policy Development initiated the study in November 1998. A questionnaire had been elaborated and distributed to CINDI and CARMEN participating countries. All CINDI countries and three CARMEN countries participated in the survey. One country, in addition to information on policy issues at national level, also sent information on policy development and implementation processes in eight CINDI participating regions of the country.
An Ad Hoc Working Group3 met in L’Esterel, Canada, in January 2000 to review the completed questionnaires and advise on possible ways of analysing the data. A preliminary database was set up with the support of the Memorial University, Newfoundland, Canada, under the leadership of Dr A. Petrasovits. Data from the first CINDI policy survey will be added to the database in the future.
The Co-Chairs met in Montreal in April 2000 to specify the content of the database, determine priorities for analysis and attempt to prepare some basic tables. A preliminary report on the survey was elaborated. The report was presented and discussed at a meeting of the Ad Hoc Working Group on 8 June in Malta. Professor Glasunov summarized the outcome of the Montreal meeting, the report of which was distributed to all participants in the present meeting.
It was noted that interest in prevention by the health care systems, the role of primary health care in CINDI implementation, and the possibility of linking primary health care and public health were rated as the highest strategic issues facing CINDI in the future.
The work done by the Working Group on Policy Development and the Ad Hoc Group on the survey analysis was appreciated.
It was concluded that the analysis of the data resulting from the second CINDI policy survey should be continued and a report prepared. It was proposed that the results be submitted to a journal for publication. Although some countries submitted both national and demonstration area information, it was agreed that only national data would be used in the analysis. Data from demonstration areas can be analysed separately but in this case it will be necessary to have data from all demonstration areas.
It was agreed that in the meantime the countries should verify the country data included in the database. Countries wishing to use the data shall seek permission to do so from the country that owns the data.
3 Dr B. Gaffney, Professor I. Glasunov (Co-Chair), Dr G. Hogelin, Professor I. Miseviciene, Dr V. Molchanov, Professor H. Pardell, Dr A. Petrasovits (Chair), Dr A. Peruga, Dr A. Shatchkute, Dr S. Stachenko, Dr R. Tresseras. EUR/01/5015946 page 21
Time will be allotted at the 18th annual of CINDI Programme Directors meeting in 2001 to reflect on the results of the data analysis.
7.2 The art and science of implementation in CINDI: lessons for health promotion and disease prevention
Progress made in preparing the above publication was also presented. A series of meetings and telephone conferences had taken place between 1998 and 2000, which had resulted in structuring the content of the publication and compiling a set of material on specific sections. There will be sections on policy development, marketing, capacity building, monitoring and evaluation, good practices and lessons learned, enhancing preventive practices (health systems), and partnerships and coalitions. It is planned that the publication will contain a number of case studies to illustrate preventive practice in CINDI.
The participants of the meeting encouraged the Drafting Group to continue the preparation of the publication.
8. CINDI Winter School
Professor Puska encouraged the participants to send their team members to the CINDI Winter School that will take place in Helsinki on 22–26 January 2001.
9. CINDI Highlights
Since it had not been possible to finalize the document owing to pressure of work and incomplete contributions, the Health Promotion Agency for Northern Ireland had prepared a draft which was presented to the Programme Directors who were requested to verify the correctness of the content. They were reminded that the document should reflect highlights and that it would not be possible to include every activity carried out by CINDI programmes.
10. CINDI millennium project
The project was established to improve CINDI visibility and to intensify preventive efforts in young age groups through collaborative Internet communication among CINDI centres. CINDI- Austria, CINDI-Northern Ireland (United Kingdom) and CINDI-Portugal demonstrated the development in their countries of Internet presentations by schoolchildren on health issues.
The demonstration projects were very much appreciated by the participants of the meeting. It was recommended that this project be further developed. Croatia and Finland expressed an interest in taking part.
It was agreed that CINDI-Austria and CINDI-Northern Ireland (United Kingdom) will attempt to assure the further progress of the project within the CINDI network. Professor E. Nüssel agreed to enquire whether Villa Bosch would be interested in supporting this project.
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11. CINDI Internet presentations
Dr Shatchkute informed the participants that a description of the WHO CINDI Programme is available at the following Web address: http://www.who.dk/zoro/inv/cindi01.htm. It was recommended that a list of CINDI Programme Directors be added to the description. It was agreed that, within two months after the meeting, all CINDI country website addresses are to be received in EURO for inclusion in the Internet.
12. Future meetings
IEA European Regional Meeting: from Molecules to Public Health, Kaunas, Lithuania, 24–26 August 2000 Professor Grabauskas reported that eleven CINDI participating countries had shown an interest in taking part. There will be a CINDI session.
3rd European Conference on Tobacco Professor Puska reported that it is planned to organize the conference in June 2001 in Warsaw. If the conference takes place, Professor Puska would like to include in the programme the launching of the CINDI Millennium initiative on smoking prevention and reduction in health professionals.
5th International Conference on Preventive Cardiology “Practising prevention for the 21st century”, Osaka, Japan, 27–31 May 2001 Professor MacLean reported that it is planned to organize a CINDI session at this conference. It was agreed that the agenda for this session would be discussed at the meeting of the CINDI Programme Management Committee in January 2001 in Helsinki.
World Conference on Tobacco, Chicago, Illinois, USA, August 2000 A Quit and Win session will be organized at this conference.
Meetings of the CINDI Programme Management Committee The next meeting will take place in Helsinki on 26–27 January 2001 (immediately after the CINDI Winter School).
Annual meetings of the CINDI Programme Directors The 18th meeting will be hosted by CINDI-Croatia in Brioni. It was proposed that the meeting take place on 8–9 June 2001. The dates will be agreed with Professor Metelko. Professor Puska conveyed an invitation from Dr C. Komodiki to host an annual meeting in Cyprus. Associate Professor L. Komarek informed the participants that he would explore with the Ministry of Health the possibility of hosting the annual meeting in 2002 in Prague. EUR/01/5015946 page 23
13. Conclusions and recommendations
13.1 CINDI network
13.1.1 CINDI Joint Progress Report Countries prepared detailed annual progress reports indicating active programme development.
The CINDI network had been further strengthened by the establishment of new demonstration areas and improved implementation of CINDI experiences at national level in many countries. Programme Directors were requested to review the joint progress report during the meeting and inform Dr Laatikainen of any changes that should be made by 23 June 2000 at the latest.
13.1.2 Progress reports from new countries: Italy (Associate Member), Latvia, Romania Good progress had been made in all three new member countries.
It was hoped that it would be possible for Italy to become a full member of CINDI within the coming year.
13.1.3 Second term of cooperation between the WHO Regional Office for Europe and countries in respect of the CINDI Programme Dr L. Deguara, Minister of Health, Malta, signed the agreement between the Ministry of Health of Malta and the WHO Regional Office for Europe for a second term cooperation in respect of the CINDI Programme. In this connection the very active contribution to the programme made by Dr R. Busuttil and Ms M. Ellul was appreciated very much.
A similar agreement between Lithuania and WHO/EURO was signed in May 2000.
13.2 Collaboration with headquarters
13.2.1 WHO Global Strategy of NCD prevention and control A letter to the Regional Director of the WHO Regional Office for Europe was prepared and signed by all the CINDI Programme Directors, expressing appreciation of Resolution WHA53.17 on the prevention and control of NCD and their willingness to take every measure possible to implement the Resolution.
13.2.2 Global Forum on NCD prevention and control (GF) The meeting supported the WHO headquarters plans to establish a GF.
It was suggested that a consultation process be started in CINDI to determine how best to support the Forum.
13.3 Collaboration with other regions
Good collaboration with the CARMEN programme was acknowledged.
AFRO and EMRO were welcome to collaborate more intensively with the CINDI programme.
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The support received from CDC was very much appreciated. It was agreed to further the collaboration on the following subjects: the CDC training seminar on CVD prevention, the CINDI Health Monitor survey, the knowledge management system “the Prevention Effect”, and community-based intervention projects such as those addressing inequalities in health.
13.4 Working Groups
13.4.1 Joint report of the CINDI Working Groups Annual Working Group reports were received from the Working Group on Policy Development, Smoking, Children and Youth, Hypertension, and Guidelines and Training for Preventive Practice.
The working group system was considered useful and should be strengthened.
Since there are a number of new CINDI Directors, the Chairpersons of the Working Groups were requested to update their lists of members by sending letters enquiring the interest of the CINDI countries. The letters should include the terms of reference of the Working Groups.
Various data sets have been collected through Working Group projects. Thought should be given to how these can be made easily accessible to CINDI countries.
13.4.2 Working Group on Monitoring, evaluation and research Terms of reference of the Working Group The updated terms of reference of the Working Group on Monitoring, Evaluation and Research were approved.
CINDI Data Management Centre (CDMC) The terms of reference of the CDMC are to be amended to include reference to the high potential of the CDMC to improve communication among CINDI Centres.
It was agreed that when the individual country data is checked for the quality by CDMC and placed at the CDMC it becomes the WHO property to which the WHO CINDI policy to access and use of data rules should be applied.
Policy regarding access and use of CINDI databases The draft policy regarding access to and use of data available at the CDMC was discussed and approved. The draft is valid as the current policy on access to and use of data at the CDMC.
Any comments on the content of the policy guidelines on access to database available at the CDMC should be made to CINDI/EURO within two weeks after the meeting. The next version of the policy document will be presented at the CINDI Programme Directors’ annual meeting in 2001.
The issue of access to and use of data collected through Working Group surveys should be discussed at the next meeting of the Working Group on Monitoring, Evaluation and Research.
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13.4.3 Working Group on Smoking Quit and Win tobacco cessation campaign Of the four tobacco cessation campaigns held since 1996, the International Quit and Win 2000 was the most successful in terms of number of participating countries.
The Quit and Win 2000 Draw took place during the meeting. The global winner was Chile. Six regional prizes were also drawn.
A meeting of the Working Group on Smoking will be held on 24–25 November 2000 at WHO/EURO to discuss the results of the International Quit and Win 2000 and the CINDI Millennium Initiative on smoking reduction in health professionals.
The next Quit and Win campaign will be organized in 2002.
The CINDI logo should be included in all Quit and Win international promotional material.
CINDI millennium initiative on smoking prevention and reduction in health professionals The proposal on the CINDI Millennium Initiative on smoking prevention and reduction in health professionals was supported and the outline of the project approved.
The participation of the EUROPREV was very much appreciated.
The project will be further developed at the meeting of the CINDI Working Group on Smoking that will take place in WHO/EURO on 24–25 November 2000.
Those interested in taking part in the project should inform WHO/EURO.
CINDI-CARMEN survey on tobacco policies The participation rate in the survey on tobacco prevention policies supported by headquarters was very high. The final results of the survey will be analysed by CINDI-Catalonia and submitted to WHO headquarters in July 2000.
The CINDI Programme Management Committee will decide on further analysis of the data.
13.4.4 Working Group on Hypertension The proposal to carry out a survey on hypertension management policies was approved. A survey questionnaire will be elaborated by the Working Group and circulated to all CINDI countries in September 2000.
A Working Group seminar is planned for October–November 2000 to discuss the results of the survey on hypertension management policies and the implementation strategy of the 1999 WHO- ISH Guidelines for the Management of Hypertension
Currently six countries are testing the feasibility of the protocol and guidelines of the joint CINDI/EuroPharm Forum pharmacy-based hypertension project. The results of this pilot project and first experience of running the project will be discussed at the above seminar.
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Regarding self-measurement of blood pressure, it was recommended that the “Guidelines for the use of self-blood pressure monitoring: a summary report of the first international consensus conference” (Journal of Hypertension 18: 493–508 (2000)) and the document prepared by the CINDI Working Group on Hypertension (final draft) be used.
13.4.5 Working Group on Workplace The CINDI Programme Management Committee should consider whether the Working Group should continue and, if so, find a Chair. Resources would need to be found to support it.
13.4.6 Working Group on Children and Youth An initiative group has been formed to elaborate the CINDI policy document: “Policy guidelines for smoking prevention among children and youth”. The first proposals for the document would be ready by end June 2000. The Working Group on Smoking will collaborate in this work.
13.4.7 Working Group on Nutrition and Elevated Cholesterol The CINDI dietary guide has been produced and is available in English and Russian. The very popular nutrition pyramid poster has been widely distributed. Countries are encouraged to translate the guide or use it in connection with the preparation of local guidelines on healthy nutrition.
The participation of CINDI in the WHO/EURO Nutrition Action Plan 2000–2005 was supported. The following areas for collaboration with the Plan were identified: development of nutrition policy, monitoring of nutrition, public education and training of health personnel.
13.4.8 Joint CARMEN/CINDI Working Group on Physical activity Professor MacLean will take part in the Working Group meeting to be held in Sao Paulo, Brazil, October 2000.
13.4.9 Working Group on Nursing If the group were re-established, Professor A. Nissinen would be asked to act as Chair.
13.4.10 Working Group on Diabetes Countries are encouraged to establish links between their diabetes databases to improve the prevention of CVD in persons with diabetes.
At its next meeting, the CINDI Programme Management Committee will discuss the future terms of reference of the Working Group.
13.4.11 Working Group on Policy development Second comparative analysis of policy development survey All CINDI countries participated in the survey and this was appreciated.
A one-day meeting to continue the preparation of the report on the analysis of the survey results took place in Malta on 8 June 2000.
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A preliminary database was established with the support of the Memorial University, Newfoundland, Canada, under the leadership of Dr A. Petrasovits, Chair, CINDI Working Group on Policy Development. Data from the first CINDI policy survey will be added to the database in the future.
Programme Directors should verify the correctness of the data presented in the database in respect of their countries.
A session (2–3 hours) will be allotted at the annual meeting of CINDI Programme Directors in Croatia in 2001 to present and discuss the results of the survey.
Only national data will be included in the analysis. Data from demonstration areas could be analysed separately but then it would be necessary to have data from all demonstration areas.
It was agreed that all CINDI Programme Directors should have access to the database. To this end, a policy on access to and use of the data will be prepared by the Working Group on Policy Development for the approval of CINDI Programme Directors.
The progress achieved in preparing the publication on “The art and science of CINDI implementation” was acknowledged.
13.4.12 Working Group on Guidelines and Training for Preventive Practice Continuing Medical Education The report of the meeting of the Working Group that took place in Barcelona on 19– 20 November 2000 was approved.
The document “Conceptual bases for a CME Accreditation System. How to improve NCD practices through accreditation of CME activities in the CINDI network” will be further elaborated. It is planned to run a pilot project on the implementation of a CME accreditation system in 5 countries.
A survey on continuing medical education will be carried out in CINDI countries.
CINDI Masters in population health Owing to shortage of resources, the further development of the initiative will at present be limited by attempting to establish a pilot collaborative project among CINDI-Canada, CINDI- Catalonia, CINDI-Lithuania and CINDI-Russia.
13.5 CINDI monitoring and evaluation
13.5.1 Introduction of the databook on risk factors It was very much appreciated that the databook on risk factors is now on the Internet and accessible.
The presentation format of risk factors data on the Internet demonstrated by CDMC was approved.
Those Programme Directors who do not have a password should contact Professor Nüssel.
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Any comments on the policy regarding access to CINDI data presented on the Internet are to be sent to WHO/EURO within two weeks after the meeting.
Countries were encouraged to continue send the risk factor survey data to the CDMC. To this end the data transfer format elaborated by the CDMC should be used. The transfer format is to be updated in the near future to include questions regarding treatment of hypertension and hypercholesterolemia.
13.5.2 CINDI monitoring and evaluation: manual of operation The second draft of the document, “CINDI monitoring and evaluation: Manual of operation”, prepared by WHO/EURO, was discussed and approved. In this regard the following was agreed: S The national mortality data for trends analysis should be taken from the WHO headquarters database; countries were encouraged to collect and report mortality data at the level of demonstration areas. S The recently issued CINDI Handbook for Process Evaluation in NCD Prevention should be used for process evaluation. S The questionnaire for process evaluation as presented in the WHO/EURO document. “Protocol and Guidelines. CINDI Programme”, is no longer recommended as an obligatory component of the international CINDI monitoring and evaluation procedure. S In order to monitor health behaviour, the questionnaire “CINDI Health Monitor” was approved at the meeting. It is to be included in the document, “CINDI monitoring and evaluation. Manual of operation”, as an obligatory component of CINDI monitoring. S Regarding smoking, the questionnaire used in the “CINDI Health Monitor” is in line with the WHO headquarters smoking questionnaire. Therefore it was recommended that it also be used in the risk factor surveys. However, changes in questionnaires used might prevent comparability of data for trend analysis. Therefore the issue regarding which questionnaires are to be used should be further discussed by the Working Group on Monitoring, Evaluation and Research. S Participants were requested to send comments regarding the Manual of operation to WHO/EURO by 15 July 2000.
13.5.3 CINDI Health Monitor It was agreed that instead of the CINDI process evaluation survey a CINDI Health Monitor survey would be organized. CINDI countries were encouraged to run such a survey as a pilot round at national or demonstration area level in 2000–2001.
A training seminar on the methodology and procedures of the CINDI Health Monitor survey is planned to take place in Helsinki in autumn 2000.
13.6 Data analysis
13.6.1 CINDI mortality data analysis The type of mortality data analysis prepared by CINDI-Lithuania was approved. The analysis will be finalized and submitted to WHO/EURO by the end of the year. It will be entered on the WHO/EURO CINDI Internet page.
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The proposed maps of trends need to be further discussed by the Working Group on Monitoring, Evaluation and Research in order to reflect more accurately dynamics in mortality in Central and Eastern Europe. It was recommended that trends starting in 1991 should also be analysed for this purpose.
13.6.2 Alcohol data analysis The results of the analysis of the alcohol database indicated that there is no clear picture of how many centres have data on alcohol and whether this data is comparable. Programme Directors were requested to supply information to CDMC and WHO/EURO on: a) which alcohol data they have submitted to the CDMC; and b) which questions were included in their alcohol survey questionnaires. It was agreed that if it were not possible to analyse pooled data, case studies would be proposed.
Concerning the questions to be included in risk factor surveys regarding alcohol, it was agreed that the question on alcohol consumption presented in the WHO/EURO document, “Protocol and Guidelines. CINDI Programme”, is obligatory (for comparison of data between CINDI countries). However the inclusion of additional questions suitable for determining the trends in the countries was encouraged.
13.6.3 Analysis of CVD in women A template for data on CVD in women was sent to all CINDI countries. Six countries sent data which were analysed. The results of analysis were presented at the First International Conference on Women, Heart Disease and Stroke, 7–10 May 200, Victoria, British Columbia, Canada. They will also be presented at the IEA European Regional Meeting “From Molecules to Public Health” 24–26 August 2000, Kaunas. Lithuania.
13.6.4 Analysis of data on risk factors The draft for the preparation of an article was not yet available.
13.7 CINDI Winter School
The next CINDI Winter School will take place on 22–26 January 2001, in Helsinki, Finland. The participants of the meeting were encouraged to send their team members to this training seminar.
13.8 CINDI Visibility
It was noted that CINDI now is presented on the WHO/EURO Internet page. The address is the following: http://www.who.dk – select Health topics – Noncommunicable diseases and their control.
Countries were requested to send their CINDI-country Web addresses (if available) to EURO by 1 September 2000 for inclusion in the list of CINDI Directors to be entered on the WHO CINDI Internet page.
A draft of the CINDI Highlights was prepared and edited by the Health Promotion Agency of Northern Ireland on the basis of contributions of the CINDI countries. Programme Directors were requested to verify the edited text before the end of the meeting.
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13.9 CINDI millennium project: Children’s Internet Forum
The presentations of the CINDI-Austria, CINDI-Northern Ireland and CINDI-Portugal were appreciated very much. It was agreed that CINDI-Austria and CINDI-Northern Ireland would attempt to assure further progress of the project within the CINDI network.
Professor Nüssel agreed to enquire whether Villa Bosch would be interested in supporting this project.
13.10 Future meetings
The next CINDI Programme Management Committee meeting will take place in Helsinki, 26–27 January 2001. The next annual CINDI Programme Directors meeting will take place in Croatia, 8–9 June 2001. The venue will be indicated later.
The invitations (preliminary) to host annual Directors meetings in Cyprus and the Czech Republic were appreciated.
A CINDI session will be organized at the IEA European Regional Meeting “From Molecules to Public Health” 24–26 August 2000, Kaunas, Lithuania.
Professor MacLean agreed to explore the possibility of a CINDI presentation or session at the 5th International Conference on Preventive Cardiology “Practising Prevention for the 21st Century” in Osaka, Japan, on 27–31 May 2001.
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Annex 1
FINAL PROGRAMME
Friday 9 June 2000 08.30 – 09.00 hours Registration
09.00 – 09.30 hours Opening session (Dr L. Deguara, M.D., M.P., Minister of Health; Dr A. Shatchkute, Regional Adviser, Chronic Disease Prevention, WHO Regional Office for Europe)
Election of Officers
09.30 – 10.00 hours CINDI Joint Progress Report (Professor P. Puska)
Discussion
10.00 – 10.40 hours Country reports: S Latvia (Dr V. Dzervé) S Italy (Professor M.T. Tenconi) S Romania (Dr M.I. Popa)
Discussion
10.40 – 11.00 hours Coffee break
11.00 – 12.30 hours Global strategy of NCD prevention and control (Dr A. Shatchkute) S WHA.53 Resolution on Prevention and Control of Noncommunicable Diseases (Professor V. Grabauskas) S Global Forum (Professor P. Puska, Dr G. Goldstein) S Discussion on the role and needs of CINDI in the Forum S Collaboration with other Regions o AFRO (Dr Antonio Pedro Filipe Junior) o CARMEN (Dr A. Shatchkute ) o CDC (Mr G. Hogelin)
12.30 – 12.45 hours Joint report of the Working Groups (Professor P. Puska)
12.45 – 13.00 hours Quit and Win tobacco cessation campaign (Professor P. Puska)
13.00 – 14.00 hours Lunch (including the Quit and Win Draw)
14.00 – 15.30 hours Parallel working sessions: 1. CINDI monitoring and evaluation (including demonstration of the databook on the Internet, operational manual, future data collection and analysis strategy) (Professor E. Nüssel, Professor D. MacLean) 2. CINDI Millennium Initiative on smoking reduction in health professionals and other activities regarding smoking (Professor H. Pardell, Professor P. Puska) 15.30 – 16.00 hours Break
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16.00 – 17.30 hours CINDI data analysis: S CINDI mortality data analysis (Professor V. Grabauskas) S Alcohol data analysis (Professor V. Grabauskas) S CVD in women (Professor D. MacLean) S Analysis of risk factor (presentation of draft article) (Professor P. Puska)
Saturday 10 June 2000
08.30 – 10.30 hours Parallel working sessions: 3. Hypertension (Professor H. Pardell) (including: – hypertension management policy survey; – seminar to discuss the further policy development in the light of the WHO/ISH guidelines for the management of hypertension; – involvement of pharmacists in hypertension control) 4. Training seminar on process evaluation survey (Professor P. Puska)
10.30 – 11.00 hours Break
11.00 – 12.30 hours CINDI Working Groups – planned activities
Introduction (Professor P. Puska) S Monitoring, Evaluation and Research (including reports from parallel sessions no. 1 (with respect to policy issues related to access and use of databases) and no. 4) (Professor D. MacLean, Professor E. Nüssel) S Hypertension (including report from parallel session no. 3) (Professor H. Pardell) S Smoking (including report from Parallel session no. 2) (Professor H. Pardell, Professor P. Puska) S Nutrition and elevated blood cholesterol (Professor D. MacLean) S Workplace (Professor W. Drygas) S Children and Youth (Professor V. Grabauskas) S Physical activity (Dr A. Shatchkute) S Diabetes (Dr D. Muacevic-Katanec) S Nursing (Dr A. Shatchkute)
Other issues related to CINDI Working Groups (Dr A. Shatchkute)
12.30 – 13.00 hours Policy Development:
Progress reports (Professor I. Glasunov): S Second comparative analysis of policy development and implementation in CINDI participating countries S Draft of the publication “The science and art of CINDI implementation”
13.00 – 14.15 hours Lunch
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14.15 – 15.00 hours Capacity building:
S Continuing medical education (Professor H. Pardell, Dr R. Tresserras) S CINDI Masters in Population Health (Professor V. Grabauskas) S Discussion
15.00 – 15.15 hours Break
15.15 – 16.00 hours CINDI visibility:
S Highlights (Dr B. Gaffney) S CINDI Millennium project – Internet demonstration from schools in CINDI-Austria, CINDI-Finland, CINDI-Portugal and CINDI- Northern Ireland (Dr G. Diem, Professor P. Puska, Professor F. de Padua, Dr B. Gaffney)
16.00 – 16.30 hours Future meetings, other issues (Dr A. Shatchkute)
16.30 – 16.45 hours Conclusions and recommendations
16.45 – 17.00 hours Closure of the meeting
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Annex 2
FINAL LIST OF PARTICIPANTS
Temporary Advisers
Professor Aikan Akanov Tel: +7 3272 336461 Director General Fax: +7 3272 336461 National Healthy Lifestyle Centre E-mail: [email protected] 63, Ablaishan E-mail: [email protected] 480002 Almaty Kazakhstan
Dr Maria Avdicova Tel: +421 88 4153261 State Institute of Public Health Fax: +421 88 4123637 Cesta K. Nemocnici 1 E-mail: [email protected] 975 56 Banska Bystrica Slovakia
Ms Yvette Azzopardi Tel: +356 242 862 Scientific Officer (Nutrition) Fax: +356 235 207 Health Promotion Department and International Health 1, Crucifix Hill Floriana CMR 02 Malta
Dr Ray Busuttil Tel: +356 243 066 Director General (Health) Fax: +356 242 884 Ministry of Health E-mail: [email protected] Palazzo Castellania 15, Merchants Street Valletta Malta
Dr Günter Diem Tel: +43 5574 64570 1039 Director Fax: +43 5574 64570 6 1037 Arbeitskreis für Vorsorge-und Fax: +43 5574 64570 44 Sozialmedizin gemeinn. Betriebs GesmbH E-mail: [email protected] Rheinstrasse 61 6901 Bregenz Austria
Professor Wojciech K. Drygas Director Tel: +48 42 632 6029/6721 Dept. of Social and Preventive Medicine Fax: +48 42 632 6029 Medical University E-mail: [email protected] Zachodnia 81/83, Skr. Pocz. 4A 90-932 Lodz Poland
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Dr Vilnis Dzerve Tel: +371 761 5094 Latvian Institute of Cardiology Fax: +371 761 4641 13 Pilsonu str. E-mail: [email protected] 1002 Riga Latvia
Ms Maria Ellul Tel: +356 221 890 Director Health Promotion Fax: +356 235 107 Department for Health Promotion and E-mail: [email protected] International Health 1, Crucifix Hill Floriana CMR 02 Malta
Dr Brian Gaffney Tel: +44 1232 311 611 Chief Executive Fax: +44 1232 311 711 The Health Promotion Agency for E-mail: [email protected] Northern Ireland 18 Ormeau Avenue Belfast BT2 8HS United Kingdom
Professor Igor S. Glasunov Tel: +7 095 924 8988 Head Fax: +7 095 924 2137 Department of Policy Development in E-mail: [email protected] Disease Prevention and Health Promotion National Centre of Preventive Medicine Petroverigskij per 10 101953 Moscow Russia
Professor Vilius Grabauskas Tel: +370 7 22 61 10 Rector Fax: +370 7 22 07 33 Kaunas University of Medicine E-mail: [email protected] Mickevitchiaus str. 9 3000 Kaunas Lithuania
Dr Alexander A. Grakovich Tel: +375 17 264 17 13 Deputy Director Fax: +375 17 264 16 95 Research Institute for Evaluation of Working Capacity of the Disabled Staroborisovski Tract 24 220114 Minsk Belarus
Mr Gary Hogelin Tel: +1 770 488 5269 Director of Research Fax: +1 770 488 5964 Center for Disease Control E-mail: [email protected] Center for Health Promotion and Education Atlanta, Georgia 30333 USA
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Dr Rustam Kazimov Tel: +993 12 35 02 48 Chief Fax: +993 12 35 02 48 Educational and Informational Centre E-mail: [email protected] “Health Promotion and Prevention” Turkmenian Research Institute of Preventive and Clinical Medicine Ul. 1 Maya 31 Ashgabat 744006 Turkmenistan
Assoc. Professor Lumir Komarek Tel/fax: +420 2 673 10291 Head E-mail: [email protected] Centre of Health and Environment National Institute of Public Health Srobarova 48 100 42 Prague 10 The Czech Republic
Mr Vesa Tapio Korpelainen Tel: +358 13 226 422 Executive Manager Fax: +358 13 123 414 North Karelia Project E-mail: [email protected] Siltakatu 10A 80100 Joensuu Finland
Dr Pekka Kuosmanen Tel: +358 20 516 8050 Provincial Medical Officer Fax: +358 20 516 8056 Provincial State Office of Eastern Finland E-mail: [email protected] P.O. Box 94 80101 Joensuu Finland
Dr Tiina Laatikainen Tel: +358 9 4744 8936 Department of Epidemiology and Fax: +358 9 4744 8338 Health Promotion E-mail: [email protected] National Public Health Institute Mannerheimintie 166 00300 Helsinki Finland
Professor David MacLean Tel: +1 902 4943860 Head Fax: +1 902 4941597 Clinical Research Centre E-mail: [email protected] Dalhousie University Faculty of Medicine 5849 University Avenue Halifax, Nova Scotia B3H 4H7 Canada
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Dr Jozica Maucec Zakotnik Tel: +386 61 1383 485 Director CINDI-Slovenia Fax: +386 61 1383 484 Zdravstveni Dom Ljubljana E-mail: [email protected] (Community Health Centre Ljubljana) Ulica Stare pravde 2 1000 Ljubljana Slovenia
Professor Irena Miseviciene Tel: +370 7731073 CINDI Coordinator Fax: +370 7796498 Director E-mail: [email protected] Biomedical Research Institute Kaunas Medical University Eiveniu Str. 4 3007 Kaunas Lithuania
Dr Vladislav A. Moltchanov Tel: +358 9 4744 8644 Division of Health and Chronic Diseases Fax: +358 9 4744 8338 National Public Health Institute E-mail: [email protected] Mannerheimintie 166 00300 Helsinki Finland
Professor Endre Morava Tel/fax: +36 1 210 2954 Director E-mail: [email protected] Institute of Public Health Semmelweis Medical University P.O. Box 370 1445 Budapest Hungary
Dr Diana Muacevic-Katanec Tel: +385 1 233 2222 “Vuk Vrhovac” Institute Fax: +385 1 233 1515 Clinic for Diabetes Endocrinology and Metabolic Diseases University of Zagreb Dugi dol 4a 100 00 Zagreb Croatia
Dr Ivi Normet Tel: +372 6269 732 Chief Specialist Fax: +372 6269 714 Bureau of Health Care Organization E-mail: [email protected] Department of Health Care Ministry of Social Affairs Gonsiori 29 Tallinn 10147 Estonia
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Professor Egbert Nüssel Tel: +49 6221 533 118/9 Director Fax: +49 6221 533 177/299 Wissenschaftliches Institut der Praxisärzte E-mail: [email protected] Schlosswolfsbrünnenweg 33 69118 Heidelberg Germany
Professor Fernando de Padua Tel: +351 21 791 0160 Director Fax: +351 21 791 0169 National Institute of Preventive Cardiology E-mail: [email protected] Av. Antonio Serpa 26, 2nd floor 1050/027 Lisbon Portugal
Professor Helios Pardell Tel: +34 93 227 29 00 Executive Director Fax: +34 93 227 29 90 CINDI Catalonia Programme E-mail: [email protected] Dept. of Health and Social Security General Direction of Public Health Pavello Ave Maria Travessera de les Corts, 131–159 08028 Barcelona Spain
Dr Gordana Pavlekovic Tel: +385 1 4684 440 School of Public Health “Andrija Staphar” Fax: +385 1 4684 441 Rockefellerova 4 10000 Zagreb Croatia
Dr Ivan Stelianov Peshev Tel: +359 2 958 1515 National Centre of Public Health 15 Dimitar Nestorov St. 1431 Sofia Bulgaria
Dr Mircea Ioan Popa Tel: +40 1 313 80 14 General Director Fax: +40 1 313 66 60 Public Health General Direction E-mail: [email protected] Ministry of Health E-mail: [email protected] Ministerului Str. 1–3 70109 Bucharest Romania
Professor Pekka Puska Tel: +358 9 4744 8336 Director Fax: +358 9 4744 8338 Division of Health and Chronic Diseases E-mail: [email protected] National Public Health Institute Mannerheimintie 166 00300 Helsinki Finland EUR/01/5015946 page 39
Ms Marjo Pyykönen Tel: +358 9 4744 8907 Secretary Fax: +358 9 4744 8338 National Public Health Institute, KTL E-mail: [email protected] Mannerheimintie 166 00300 Helsinki Finland
Dr Mario R. Sammut Tel: +356 41 33 09 Honorary Secretary Fax: +356 44 60 30 Malta College of Family Doctors E-mail: [email protected] St Philips Hospital St Venera HMR 16 Malta
Mr Patrick Sandström Tel: +358 9 4744 8630 Researcher Fax: +358 9 47 448338 Epidemiology and Health Promotion E-mail: [email protected] National Public Health Institute Mannerheimintie 166 00300 Helsinki Finland
Professor Iryna P. Smyrnova Tel: +380 044 271 72 83 Executive Director Fax: +380 044 277 42 09 Research Institute of Cardiology E-mail: [email protected] Narodnogo Opolcheniya Str. 5 252151 Kiev Ukraine
Professor Maria Teresa Tenconi Tel: +39 0382 507278 Hygiene Section Fax: +39 0382 507558 Department of Preventive Medicine E-mail: [email protected] University of Pavia Via Forlanini 2 27100 Pavia Italy
Dr Ricard Tresserras Tel: +34 93 227 2990 Head of Health Education and Chronic Fax: +34 93 227 2949 Disease Prevention Service E-mail: [email protected] Department of Health and Social Security Generalitat de Catalunya Travessera de les Corts 131–159 Pavello Ave Maria 08028 Barcelona Spain
Ms Eeva Riitta Vartiainen Tel: +358 9 4744 8634 National Public Health Institute, KTL Fax: +358 9 4744 8338 Mannerheimintie 166 E-mail: [email protected] 00300 Helsinki Finland
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Associate Professor Margus Viigimaa Tel/fax: +372 7 448 467 Estonian CINDI Programme Director E-mail: [email protected] Department of Cardiology Tartu University Hospital Puusepa St. 8 51014 Tartu Estonia
Observers
Dr Anna Maria Gianti Tel: +39 0172 421921 Hygiene Section Fax: +39 0382 507558 Department of Preventive Medicine E-mail: [email protected] University of Pavia 27100 Pavia Italy
World Health Organization
Headquarters
Dr Gregory Goldstein Tel: +41 22 791 3559 Health Promotion Fax: +41 22 791 3111 Noncommunicable Disease Prevention E-mail: [email protected]
Regional Office for Europe
Ms Betty Kayser el Tawil Tel: +45 39 17 14 29 Secretary Fax: +45 39 17 18 18 Chronic Disease Prevention E-mail: [email protected]
Ms Anna Müller Tel: +45 39 17 12 09 Administrative Assistant Fax: +45 39 17 18 18 Chronic Disease Prevention E-mail: [email protected]
Dr Aushra Shatchkute Tel: +45 39 17 13 86 Regional Adviser Fax: +45 39 17 18 18 Chronic Disease Prevention E-mail: [email protected]
Dr Sylvie Stachenko Tel: +45 39 171717 Director Fax: +45 39 171818 Health Policy and Services E-mail: [email protected]
Regional Office for Africa
Dr Antonio Pedro Filipe Junior Tel: +263 4 706951 Fax: +263 4 700742
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Annex 3
PROGRESS OF CINDI IN 1999: SUMMARY OF THE COUNTRY REPORTS
Progress of CINDI in 1999 Summary of the Country Reports
National Public Health Institute Department of Epidemiology and Health Promotion Mannerheimintie 166 FIN–00300 Helsinki Finland
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Preface
CINDI (Countrywide Integrated Noncommunicable Disease Intervention) Programme is a WHO/EURO coordinated programme for prevention of major noncommunicable diseases and for promotion of health by coordinated and comprehensive action to reduce common, established risk factors and to favourably influence related lifestyles in the population. The programme is coordinated by the European Regional Office of WHO in Copenhagen. Between annual Programme Directors’ Meetings the programme is managed by CINDI Management Committee (present chair of the National Public Health Institute, Finland). The international data centre of CINDI programme is in Heidelberg, Germany.
The Annual Meeting of CINDI Programme Directors in Dornbirn, Austria on June 4–5 1999 reviewed the CINDI progress in 1998. The CINDI 1999 progress will be reviewed in the Annual Meeting of CINDI Programme Directors in Malta on June 9–10 2000. Prior to the meeting, the member countries have reported the progress in their national CINDI reports (emphasising changes, new initiatives and results of the existing activities). This paper presents selected important notes of the country reports following the topics of the report, as specified in the CINDI protocol. A progress report was received from 25 countries. It should be emphasized that this report by no means presents a comprehensive picture of the CINDI programmes in the participating countries. However, it mainly highlights some important developments, changes and activities in the CINDI programmes in the respective countries during 1999. Thus, many successful and innovative activities are not necessarily mentioned in this report.
The CINDI Management Committee met in Copenhagen in March 17–18 2000. The Committee reviewed the progress and discussed a number of important issues, for example strengthening of the common monitoring. The Committee also discussed the plan of WHO for global NCD strategy that had been presented to the forthcoming World Health Assembly. The experience of the 3rd CINDI Winter School was reviewed and the plans for the 4th CINDI Winter School in January 2001 was approved.
The collaboration with the CARMEN programme of PAHO (CINDI’s sister programme in Latin America) developed through several activities. These included common working groups in physical activity, participation in Quit and Win etc. The plan for global NCD strategy includes the idea, supported by CINDI, that similar networks will be established in all other regions of WHO and that a global forum will be developed for communication between the networks and other major global partners.
A total number of 27 countries participated in the CINDI programme in 1999. Four new countries joined the CINDI network in 1999: Cyprus, Italy, Latvia and Romania. Italy acted as an associate member. In addition to totally new CINDI countries the CINDI network was also strengthened by the establishment of new demonstration areas and by the improvement of national implementation of CINDI experiences in many countries.
Tiina Laatikainen Pekka Puska Senior researcher Chairman National Public Health Institute, Finland CINDI Management Committee EUR/01/5015946 page 43
Programme objectives and documentation
Austria: Special focus was on the theme “women and health”.
Belarus: Several directives of the Ministry of Health Care concerning the CINDI administration and activities in the Republic of Belarus were issued. The document “Progress in CINDI Programme Development in the Republic of Belarus during 1996–1998” was prepared.
Canada: Focus was on dissemination, deployment, information technology and qualitative monitoring and evaluation of implementation.
Czech Republic: A specific objective was the further extension of health promotion and disease prevention into practice of GPs. Methods of prevention and health promotion focused on cancer prevention. Marked extension was achieved in the collaboration with the National WHO Office.
Germany: The main objective during 1999 was to introduce a new software to physicians for the monitoring of risk factors in private practitioners’ offices.
Italy: Focus was mainly in the prevention of cardiovascular diseases.
Kazakhstan: Special focus was on hypertension control.
Malta: Particular emphasis in activities was on adolescent health.
Romania: Special focus of programme was put on CVD and uterine cancer prevention. Main objectives are to reduce major NCD risk factors in demonstration area.
Slovenia: One of the main objectives was to implement Local Health Information System into general practices.
Ukraine: The main focus was on hypertension control and anti-smoking activities.
Administration and management
Belarus: The Coordination Council on development and control of the execution of CINDI Programme since 1997 has been under the guidance of Vice-Minister of Health Care of the Republic of Belarus V.P. Philonov. The CINDI Programme in the Republic of Belarus is headed by the Deputy Director of Belarussian Research Institute for Evaluation of Working Capacity of the Disabled, A.A. Grakovich.
Bulgaria: The National Centre of Public Health became responsible for the programme in the demonstration areas. A special team was created for this coordination in 1999.
Croatia: Activities of education and data collection was transferred to regional centres.
Cyprus: Cyprus became an official member in CINDI in 1999. CINDI programmes fall under the direct responsibility of the Ministry of Health.
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Estonia: The responsibility of the programme was shared among the Department of Public Health in the Estonian Ministry of Social Affairs, the Estonian Centre for Health Education and Promotion, the Estonian Institute of Cardiology and the University of Tartu.
Finland: From the beginning of year 2000, Dr Tiina Laatikainen became the CINDI coordinator of KTL.
Germany: A network information model for patient-related information exchange among private practitioners’ offices was created.
Hungary: The name of the Institute hosting the national CINDI Centre has changed due to the reorganization of Hungarian universities. The new name is Department of Public Health, Semmelweis University.
Italy: The Ministry of Health was actively contacted in order to promote the full CINDI membership.
Kyrgyzstan: Plans for the creation of the National Centre to coordinate the activities in health promotion and prevention of diseases were made. This National Centre would also be in charge of CINDI Programme implementation in Kyrgyzstan.
Latvia: Latvia became an official member in CINDI in 1999. All activities are coordinated through the CINDI office. Activities carried out in 1999 were managed by the Pharmacists Society of Latvia, the Latvian Institute of Cardiology and the Mental Health Care Centre.
Malta: A quality service charter was created to establish criteria of operation within administration and management. Three new posts were created for health promotion officers.
Romania: Romania became an official member of CINDI in 1999. A new Operational Committee was established by Ministry of Health. Discussions regarding the leadership of the Romanian CINDI program are ongoing.
Russia: A new region, Ufa (Bashkortostan), was accepted as the new Russian CINDI centre. Currently there are 15 CINDI regions in Russia.
Slovakia: Trebisov became a new demonstration area.
Slovenia: An executive committee was established in order to monitor and evaluate the CINDI progress in Slovenia.
Spain (Catalonia): Collaboration was strengthened with the personnel working at the health administration in the demonstration area of Girona.
Turkmenistan: The management was carried out by CINDI “Health Prevention and Promotion” Public Educational Information Centre in Central Policlinic of the pilot district.
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Monitoring, surveys and data collection
Austria: A third cross-sectional population health survey was carried out in Vorarlberg with a sample of 2400 people. On the basis of cancer registration and the results of the mammogram screening program a cohort of women with breast cancer was examined in order to evaluate the effect of the screening program.
Belarus: Work within the demonstration project “Prevention of Noncommunicable Diseases in City” carried out earlier in Novopolotsk, Vitebsk region, was also started in Polotsk.
Bulgaria: The risk factor survey data from Stara Zagora, Dobrich and Yambol was analysed. The building up of the CINDI database is under work.
Canada: The province of BC is in the process of completing the last provincial nutrition survey. The Quebec Heart Health Children Survey was completed.
Croatia: A national pilot survey of cardiovascular disease risk factors was carried out. The registry of AMI was maintained.
Czech Republic: Follow-up survey of the Quit and Win campaign was conducted. Results from the Health Behaviour of School-aged Children survey were elaborated and published. A survey concerning GPs’ attitudes towards prevention activities in primary care was carried out.
Cyprus: The second risk factor survey was initiated in 1999 and is expected to be completed by the end of February 2000.
Estonia: The second risk factor survey was carried out in Tallinn. Additionally the survey included 24-hours nutrition study and the process evaluation questionnaire. The Tartu-Stockholm cardiovascular risk factor study was continued. In connection with the SELECT Project, 256 inhabitants of the island Hiiumaa were studied.
Finland: A annual health behaviour survey was carried out in the spring of 1999 using a national sample.
Germany: Risk factor data was collected from 16 private practitioners’ offices. The data will be used to show physicians the high importance of outcome data in evaluating their own intervention work.
Hungary: The follow-up survey was carried out for Quit and Win 1998. More detailed analyses of the risk factor survey carried out in Pecs in 1995–1996 were performed and the results were published.
Italy: Atherosclerosis risk factor surveys were carried out in Lombardy, Sardinia and Valle dell’Irno.
Kazakhstan: A risk factor survey was carried out in 4 regions.
Latvia: Risk factor survey was carried out in the demonstration area.
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Lithuania: The fourth cross-sectional survey on NCD risk factors was carried out in five rural regions. The survey to evaluate the efficiency of the breastfeeding support programme was continued. A survey on NCD risk factors and some psychosocial factors was carried out among preschool children in Kaunas and in Siauliai. The follow-up survey of Quit and Win contest was carried out.
Malta: Preparatory work was made for the health appraisal exercise with WHO and health behaviour survey among schoolchildren, which are both planned to be carried out in 2000.
Poland: Several new regions have expressed their interest in joining the CINDI program.
Romania: Risk factor survey was started in the demonstration area in October 1999. The survey is planned to be completed in April 2000.
Russia: The one-year follow-up survey of the Quit and Win campaign was carried out. Summary of the needs assessment for development of regional policy for healthy nutrition was made in Electrostal, Chelyabinsk, Krasnodar, Perm and Arkhangelsk. In St Petersburg a study of physical health status among children was carried out. Population surveys were carried out in Chelyabinsk, Tver and Tomsk. A survey among 6–17 year old children was carried out in Orenburg. Quality control work for the MONICA data was finalized in Novosibirsk.
Slovakia: The pilot study of the project “healthy children in healthy families” was carried out in Banska Bystrica. The data from the second risk factor survey from 1998 in Banska Bystrica and in Trebisov was analysed. The first survey on psychological and social risk factors of cardiovascular diseases was carried out. Mortality data was analysed and standardized until the year 1998. A Quit and Win follow-up survey was carried out.
Slovenia: A pilot study on NCD risk factors was carried out in 10 general practices. Monitoring of risk factors’ influence on NCD is in progress in Ljubljana.
Spain (Catalonia): A cross-sectional survey with physical examinations is carried out in 1999– 2000 in the demonstration area.
Turkmenistan: A risk factor survey was carried out in demonstration area. Situation analyses on NCD and smoking were conducted based on the Health For All database and the data received from State Committee for Statistics.
Ukraine: A risk factor survey will be conducted during the years 1999–2000. The follow-up survey of Quit and Win was carried out.
Intervention
Health related services Belarus: A collective meeting of the sanitary-epidemiological and medico-controlling councils of the Ministry of Healthcare on the noncommunicable disease prevention in the Republic of Belarus was held in April 1999. On national level the “Disability Prevention” Project was created.
Bulgaria: A national strategy “Better Health for Better Future” is under preparation. EUR/01/5015946 page 47
Canada: Some of the eight provincial Heart Health Demonstration Programs have completed the Dissemination phase and are preparing the protocols for the Deployment phase. Health Canada has launched an initiative on Diabetes with components in surveillance, First Nations, public health and community strategies for diabetes control.
Croatia: A new software for the follow-up of diabetes patients, which enables communication between all diabetes centres in the country was developed further.
Estonia: Preparations for implementation of the CINDI/EuroPharm Forum project were made.
Hungary: The nesting of CINDI management at the university has offered an opportunity to introduce CINDI initiatives in university education.
Italy: Special Health Services dedicated to chronic disease prevention at the community level were organized in 15 local health agencies in Lombardy.
Kazakhstan: Regional centres for health promotion were established. The draft programme “Schools on solidifying health” was approved in April 1999. The program is first started in schools in Almaty, Shimkent, Semipalatinsk and Karaganda.
Kyrgyzstan: The Faculty of Public Health was established at the Medical National Academy.
Latvia: The pharmacy based hypertension management model was implemented. Suicide prevention health services were improved.
Lithuania: Two meetings were organized within the National network of Health Promoting Hospital. The 4th National HPH conference was organized in November in Taurage. The CINDI Meeting of the Working Group on Children and Youth was held in Kaunas in March.
Malta: Internet links were established for applications to services.
Romania: The Operational Committee has proposed remunerative “points” for community prevention in the Frame-Contract between providers of primary health care and National House of Health Insurance.
Russia: A project concerning healthy nutrition regional policy development in Russia was started. Preparations for the project on health promotion and disease prevention of youth at the regional level were made. CINDI Russia participated in the development of the National concept on Health Promotion.
Slovakia: The activities of the counselling centres in the Public Health Institutes were strengthened.
Slovenia: The health promotion implementation was started on a national level.
Spain (Catalonia): A consensus on the preventive activities among the elderly was achieved in 1998 and published in 1999.
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General educational activities Belarus: Several national seminars on health topics were carried out. An anti-tobacco campaign was carried out by the Republican Health Centre.
Bulgaria: Several TV and radio programmes. Also health education material and patient education guidelines were produced.
Canada: About 5000 copies of “The Healthy Heart Kit” were distributed to physicians. The impact of the Kit is being evaluated. An international Conference on Diabetes and Cardiovascular Disease took place on June 1999 in Winnipeg. A Summer School on Primary Prevention of Stroke and Heart Disease took place in Saskatchewan.
Croatia: Plenty of education for primary health care physicians was organized. TV broadcasting and written education material was also produced.
Czech Republic: The National Health Promotion Conference focusing on cancer prevention was organized in cooperation with WHO. A campaign at the occasion of the World No Tobacco Day was organized. There were several training courses for health professionals and lay persons. Printed health education material was also produced.
Cyprus: National guidelines on blood pressure and cholesterol control were developed and will be distributed to GPs and cardiologists in connection with a training course.
Estonia: National hypertension guidelines were prepared. Estonian Heart Week was carried out in April. National Conference on Hypertension was organized in Tallinn in December. Several teaching seminars were organized and health education material produced.
Finland: A regional Public Health Conference of Western Finland was organized. National Quit and Win was organized by a coalition of NGOs.
Hungary: A nation-wide peer education network to prevent smoking, alcohol abuse and HIV infections among secondary school students was developed.
Italy: Several health education activities were carried out and health education material was produced.
Kazakhstan: Guidelines for prevention of hypertension were prepared. Education was provided for health personnel. Several mass media activities, conferences and other educational events were organized.
Kyrgyzstan: “Quit and Win 1999” campaign was organized. Special health days and campaigns were organized. Several mass media activities were carried out and health education material was produced.
Latvia: A public Health Research Workshop was carried out in Riga in November. Training of health personnel in fields of hypertension control and mental health problems was carried out. Three national guidelines on CVD were prepared.
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Lithuania: Several training courses on CVD prevention and health promotion were organized for GPs and other health personnel. The guidelines on NCD prevention were prepared. Many health education materials were produced.
Malta: Various interventions were made in schools and communities to highlight health promotion and disease prevention.
Poland: The National CINDI-Poland Seminar was carried out in Spala in October 1999.
Romania: The National Day of the Heart was organized. Active recruitment of possible new demonstration areas and CINDI centres was accomplished.
Russia: Six issues of the National Journal “Health Promotion and Disease Prevention” were published. Guidelines for Prevention in Primary Care were published.
Slovakia: Several educational activities were carried out in connection with World Health Day, Earth Day, World day without smoking, Nutritional Health Day, etc. Many workshops for the public health personnel were organized along with several mass media activities.
Slovenia: Many educational activities among health personnel took place.
Spain (Catalonia): An antismoking campaign targeted to youngsters was launched. A health education pamphlet for the elderly was prepared and distributed to Catalonia. Campaigns and other activities in connection of “Hypertension Day”, “World nonsmoking day”, etc., were organized.
Turkmenistan: The national “Quit and Win” campaign was conducted among students. A small project on improvement of mass media use in distributing the information on NCD and risk factors was implemented in collaboration with Centre for Medical Prevention.
Ukraine: Guidelines for hypertension control were published. Several educational activities, campaigns, workshops, conferences and meetings were organized. There were lots of media contacts and lots of printed health education material was produced.
Community organization Belarus: Intersectoral cooperation was built up between the Ministry of Education and the Ministry of Healthcare. In order to integrate the nonmedical sectors of the society, creation of the interdepartmental council on noncommunicable disease prevention at the level of the Ministry of Health care was started.
Croatia: Several associations such as Croatian Association of Diabetic Patients, Croatian Anti- Cancer League, etc., were involved in the programme.
Czech Republic: Organization of interdisciplinary district intervention teams for cancer prevention.
Finland: Collaborations took place, i.e. with food industry and pharmaceutical industry (smoking cessation).
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Romania: The national seminar and workshop on “Public Health and Environment Protection – Responsibilities for Central and Local Administrations” focused on community organization in health promotion work.
Turkmenistan: CINDI participated in a number of training seminars on strengthening links with NGOs. A special conference was organized by CINDI in December 1999 with the participation of international organizations and NGOs.
Regulatory, structural activities Bulgaria: Several acts and more than 100 secondary legislation tools related to disease prevention and healthy environments were enacted over the last 2–3 years. For example, in 1999, the Narcotic Substance Control Act and the Curative Establishment in Bulgaria Act were enacted. Structural changes of the health care system are ongoing.
Croatia: As a result of an intensified antismoking campaign, a new law prohibiting smoking in all public places was enacted.
Czech Republic: Members of the CINDI coordinating centre have repeatedly presented the CINDI programme in the parliament to promote health promotion and disease prevention issues in the legislation.
Finland: Tobacco legislation was amended to ensure smoke-free areas in restaurants and bars.
Kazakhstan: The CINDI program was approved at national level. The state programme “Health of the People” is accepted.
Kyrgyzstan: A draft of a tobacco control and prevention law was agreed upon by 10 agencies and was submitted to the Government and Parliament of the Republic in November 1999.
Lithuania: Several representative from municipalities, Ministries and NGOs participated in the National Forum for Health which was organized under the auspices of the WHO Regional Office. Further development of national policy to reduce inequities in health and health care was discussed and agreed upon. Partnership with the national coordinating committees of the WHO Cross-National Studies on Health Behaviour in School-aged children and the WHO, CE and CEC Project on European Network of Health Promoting Schools was developed.
Russia: National CINDI Working Group on Nutrition was established.
Spain (Catalonia): Development in the new tobacco regulations.
Turkmenistan: A draft of CINDI Strategic Development in Turkmenistan was prepared.
Demonstration areas Belarus: Minsk, 1 700 200 inhabitants. “Cardiology” Project, “Diabetes Mellitus” Project, “Stomatology” Project, “Prevention of Noncommunicable Diseases and Organized Work Community” Project, “Schoolchild’s Health” Project, “Preventive Department” Project. Relating to all these projects, several seminars concerning health and disease prevention were carried out and many media contacts were established. Also, health personnel training was organized. The Republican Research Centre of Preventive Medicine was established. EUR/01/5015946 page 51
Grodno region, 67 700 inhabitants. “Family Doctor” Project: Several health campaigns were carried out. Fines for selling tobacco products and for smoking in public places were introduced. Brest region, 1 504 400 inhabitants. “Healthy Life Style” Project: Several mass media programmes and articles concerning disease prevention and healthy life style were introduced. “Trauma Prevention” Project: monitors trauma incidence. Novopolotsk, 97 400 inhabitants. “NCD Prevention in Cities” Project: Health monitoring is carried out, with emphasis on health issues of children. Several seminars were carried out and mass media contacts were established. Gomel, 513 000 inhabitants. “Teenagers’ Health” project: Basic examinations were carried out. Several educational activities. Bobrujsk, 226 600 inhabitants. “Industrial Workers’ Health” Project: Several educational and mass media activities.
Bulgaria: Stara Zagora, Dobrich, Yambol, Veliko Turnovi. In all CINDI areas active training of health personnel was carried out. A new edition of the Good Practice Guideline was prepared. A “Quit and Win” campaign and several other health education activities were organized with active involvement of NGOs and other community organizations.
Canada: Nova Scotia. The Dissemination Research Phase is being conducted over a five year period (1996–2001) in the Western Health Region of Nova Scotia. The Heart Health Partnership was formed to include several organizations, community groups, and government agencies. The Heart Health Partnership focuses on building organizational capacity. The first two and a half years of the project were focused on measuring baseline capacity and the development of the capacity building strategies.
Croatia: Demonstration area not defined
Czech Republic: 25 districts as CINDI areas, totally 3 839 200 inhabitants. Education of GPs and nurses in health promotion and disease prevention methods. General educational activities conducted in local press, radio and TV, publication of district health bulletins, organization of Health Days, and distribution of health education leaflets. Collaboration with many community organizations.
Estonia: Hiiumaa, Rakvere, Valga, Elva. District “Heart Days” were carried out in all these districts. The County Government of Hiiumaa actively supports the activities carried out in Hiiumaa.
Finland: North Karelia, 175 000 inhabitants. Plans developed for establishing new type of centre for sustained disease prevention and health promotion activities in North Karelia. Pilot project on use of information technology for local health promotion of Joensuu health centre. General educational activities in demonstration area: “Smoke-free North Karelia” and many media contacts. Contacts continued with various community organizations.
Germany: Karlsruhe (270 000 inhabitants), Bruchsal (38 000 inhabitants), Mosbach (24 000) inhabitants. Ansbach (40 000 inhabitants) and South of Hess (280 000) inhabitants) are additional demonstration regions for testing the intervention and the methods of evaluation. Private practitioners introducing the model “Community Based Behavioural Medicine”.
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Hungary: Pecs city (160 000 inhabitants), Baranya county (240 000 inhabitants), Komaron- Esztergom county (300 000 inhabitants). A new breast cancer prevention program was started in Baranya county. In demonstration areas several health education activities was carried out. Special focus was on adolescents.
Italy: No demonstration area has yet been defined.
Kazakhstan: Almatinsky region in Iliysky district. Almaty and Semipalatisnk have expressed desire to participate in a “Healthy cities” programme. In the demonstration area the main emphasis was on the hypertension prevention activities
Latvia: Kuldiga, 40 000 inhabitants. Risk factor survey was carried out in Kuldiga. “Health Week” was held in April. In connection with this week activities such as family sports days and antismoking events were carried out. Tobacco-free Day was organized for May 31st. Training for health professionals was organized. Several educational and mass media activities were carried out.
Lithuania: Kaunas, Kaisiadorys, Varena, Kretinga, Kupiskis, Jiniskis. A “Primary prevention of cardiovascular disease” programme was launched in Kaunas by the initiative of CINDI team. In Kaisiadorys region the “Development of community based and family oriented mental health” project was launched. The conference “Health Day” was held in Varena in November. Several projects including health related services, educational activities, community organization and regulatory and structural activities were carried out in Kaunas with support of the Health Council of Kaunas city.
Poland: 12 demonstration areas covering a population of above 500 000 inhabitants. In Ostrow several projects concerning public health and disease prevention were carried out. Special attention was paid to the hypertension detection and treatment program, to the physical activity program among children and young people and, to alcohol prevention projects. In Torun significant financial support was received from the local authorities to help several intervention programmes and the establishment of 11 health promotion centres.
Romania: Pucioasa, 16 300 inhabitants. Baseline survey was carried out and data will be transferred to the CINDI data management centre in near future. In connection to the “Day of the Heart” several media campaigns and other health education activities were organized. The CINDI Club for Youth and Health was inaugurated to involve volunteer adolescents in health promotion work. A CINDI stand was established in the town library. Proposals for reinforcement of tobacco regulations and for new regulations concerning, for example, alcohol sales were presented to the City Council. Preparations to establish several new demonstration areas were made.
Russia: 15 demonstration areas: Chelyabinsk (3.5 million inhabitants), Electrostal city (150 000 inhabitants), Krasnodar, Kostomuksha (32 200 inhabitants), Mirny (165 800 inhabitants), Novosibirsk, Orenburg, Pitkyaranta (27 400 inhabitants), Rostov on Don, Pontonnaya City (11 300 inhabitants), Tomsksk and Ufa. The association of Medical Institutions was established in Orenburg. A training workshop on “Public Health in a Transition period” was conducted in Kostamuksha. The chair of preventive medicine was created in the Medical Institute in Novosibirsk. Establishment of the School of Public Health is ongoing in Chelyabinsk. Several educational activities and media contacts in many demonstration areas. A hypertension worksite programme was approved in Perm. In Novosibirsk “the hot telephone line” opened in the EUR/01/5015946 page 53
regional Centre for Preventive Medicine. In Orenburg a family centre for prevention was established as was a school for the training of teachers, children, and their parents. An association of nursing was founded.
Slovakia: Banska Bystrica, Trebisov (101 700 inhabitants). Trebisov is a new demonstration area. Telephone advisories on risk factors were performed successfully. Several educational activities occurred in both areas along with the establishment of media contacts.
Slovenia: Ljubljana. Discussions for establishment of new demonstration areas are in progress. “Health-friendly food” campaign was organized in Ljubljana on World Nutrition Day in October.
Spain (Catalonia): Girona. Completion of the second risk factor survey. The completion of the protocol for the development of the CINDI-EUROPHARM Forum hypertension programme.
Turkmenistan: A risk factor survey was carried out in demonstration area. A five-day workshop on health promotion and lifestyle change was conducted in June and an other workshop on prevention experience among high-risk social groups was conducted in December. A library was established within the CINDI centre. Training courses on tobacco prevention were carried out in schools. NGOs were involved in many activities.
Ukraine: Kharkiv, Vinnitsa, Odessa, Zaporizhzhya and Kiev. Scientific-practical conferences for physicians on hypertension control. Two regional conferences on hypercholesterolemia control in Odessa and in Kiev.
Resources and financing
Belarus: Demonstration project funding was received from the spheres of Healthcare and from the local budgetary resources. Centralized financing of the demonstration projects was lacking.
Bulgaria: Funding of program in the CINDI areas received from the Ministry of Health, from local governments, and from various NGOs and companies.
Canada: Funding was obtained for the dissemination phase of the Canadian Heart Health Initiative. Ongoing funding was obtained for the Canadian Breast Cancer Initiative.
Czech Republic: The basic activities of the coordinating centre are financed from the budget of the National Institute of Public Health. Basic activities at the district level are covered by the budget of hygiene stations. Resources for different programmes are received as grants from the Ministry of Health, grants from the National Programme for Health, community budgets and sponsors.
Cyprus: Programme is mainly financed by the MOH. The second risk factor survey received support from the EMRO Office.
Finland: Resources for the national programme received as budgetary and extra budgetary resources of KTL. Resources for the programme in the demonstration area received from various sources.
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Germany: Scientific measures were funded by sponsor. No external resources were used for the intervention or evaluation.
Hungary: National resources were very restricted. The CINDI demonstration areas had separate budget for preventive activities from the county Institutes of Public Health and Medical Officer Services.
Italy: Resources and financing were only of local origin.
Kyrgyzstan: The CINDI-Kyrgyzstan programme was not financed in 1999. Activities were implemented on a volunteer-basis.
Latvia: Resources received from Finnish-Latvian Project on CVD prevention, local manufacturers and companies, Latvian Institute of Cardiology, and Kuopio University.
Lithuania: Resources received from the state budget, Kaunas City Municipality Health Fund, and occasional support from WHO.
Malta: Budgetary allocation for 1999 was increased.
Romania: There were no budgetary appropriations in 1999. Resources received from extra- budgetary sources and from small sponsorships.
Slovakia: Relative increase in budget received from the State Fund of Health.
Slovenia: Resources received from the Institute of Health Insurance of Slovenia. A proposal for financing by WHO Liaison Office of Ministry of Health of Slovenia was submitted.
Spain (Catalonia): Resources received from the budget of the Public Health Division of the Department of Health and Social Security. Some external funding also received.
Turkmenistan: The CINDI Centre activities were financed by UNHCR and USAID Projects. Anti-tobacco activities were financed by sponsors.
Reports and publications The CINDI Handbook on Process Evaluation prepared by the CINDI Working Groups on Policy Development and on Monitoring and Evaluation was released by the WHO-CINDI Office Regions for Europe. CINDI Canada has prepared a publication version that will appear by March 2000.
“The Singapore Declaration – Forging the Will for Heart Health in the Next Millennium” was printed.
For the “Quit and Win 2000 campaign” the coordination centre in Finland (responsible for the smoking working group of CINDI) prepared a comprehensive manual and other materials.
Internal reports, manuals, guidelines, newspaper articles and local and scientific papers were published by all CINDI countries. EUR/01/5015946 page 55
Other topics
The third CINDI WINTER SCHOOL was organized in December 1999.
An EU funded project “Bridging the East-West Health Gap” was finished on the 30th of April 1999. The final report was submitted to the EU in June 1999.
The North Karelia Project International Visitors’ Programme was organized twice in 1999.
Collaboration with the Pan American Health Organization (PAHO) in the development of CARMEN/CINDI programme in Latin America was continued. Consultations by Health Canada were provided through a site visit to Costa Rica and the hosting of a Technical Workshop in Montreal in November 1999.
The Project G7/G8 “Promoting Heart Health Telematics Application” to disseminate know-how and the best practices for implementation of heart health interventions through the INTERNET is ongoing. The improved prototype website was completed.
Report received from
Austria Belarus Bulgaria Canada Croatia Czech Republic Cyprus Estonia Finland Germany Hungary Italy (associate member) Kazakhstan Kyrgyzstan Latvia Lithuania Malta Poland Romania Russia Slovakia Slovenia Spain (Catalonia) Turkmenistan Ukraine
Report missing from
Portugal United Kingdom (Northern Ireland)
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Annex 4
GLOBAL FORUM ON NCD PREVENTION AND CONTROL
Summary of the draft report of the WHO Informal Consultation on Regional Networks and the Global Forum on NCD Prevention and Control, Joensuu, Finland, 2–4 May 2000.
Dr G. Goldstein, WHO headquarters, HPS/NMH
Current needs in networking
Two networks of community-based NCD prevention programmes, CINDI and CARMEN are active in European and American countries. These networks have been important in the initiation and shaping of the WHO Executive Board resolution. On NCD prevention and control networking of individuals and institutions was found to facilitate the exchange of information on technical and management issues, and help network members to plan and coordinate cooperative ventures. The regular reporting at the network meetings provided reliable feedback on progress and stimulated brainstorming, problem solving, innovation and launching of new activities.
NCD prevention and control programmes are emerging as a priority in many developing countries and there is therefore a pressing need to strengthen and link NCD prevention and control initiatives in the presently under-served regions. An initial step is to establish networks in the African, Eastern Mediterranean, Western Pacific and South-East Asian Regions. In addition, the existing networks will need to be reinforced; subsequently, regional networks in all six Regions will need to be linked in a forum to ensure global coordination and strengthen exchange of experiences.
Objectives of the GF
The goal of the GF is to develop and strengthen regional networks on NCD prevention in all Regions, and to promote collaboration and coordination of NCD prevention and control activities within and between Regions.
The activities of the Forum will focus on the four priority noncommunicable diseases: cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases.
The following specific objectives of the GF have been formulated:
1. To encourage the development of regional networks of community-based initiatives in support of national NCD control strategies and programme development in all six Regions of WHO. 2. To support regional networks through interregional collaboration and international partnership. 3. To disseminate scientific evidence and experience and provide updated guidance on primary and secondary prevention of NCD. 4. To increase awareness of NCD prevention and control initiatives through advocacy. EUR/01/5015946 page 57
5. To develop a comprehensive directory of all ongoing and planned community-based initiatives to assist regional networks and the forum to respond to the global NCD prevention and control situation. 6. To promote the harmonization of monitoring and surveillance methodologies 7. To promote collaborative research and capacity building in relation to primary and secondary prevention. 8. To advocate and develop links with other development sectors and global organizations of potential importance to NCD prevention (including United Nations bodies such as UNDP and UNESCO and organizations concerned with: sustainable development; cities and local government; workplace conditions; physical activity; and many others).
Sharing among the Regions of the experiences and products of network activities can facilitate rapid progress. For example, the CINDI network has produced a manual of programme operation, monitoring and evaluation and also regional dietary guidelines that, while not directly applicable in other Regions, nonetheless provide a useful template or framework for the production of similar guides in other Regions.
Governance
The GF will be integrated with a coordinated by the Noncommunicable Diseases and Mental Health (NMH) Cluster at WHO headquarters in close partnership with NCD Regional Advisers. The plan and activities of the GF will be set by a steering committee in which all Regions will be represented. The committee will discuss, through telephone conferences, e-mail networking and if possible a formal meeting¸ issues related to the initiation of regional networks and the organization of the first meeting in 2001.
Potential tools of the GF
Tools that could be used to achieve the objectives of the GF and regional networks include some or all of the following:
S regular meetings of the steering committee; S telephone conferences; S newsletter (translated into several languages by regional networks) S electronic links within the forum and with existing NCD prevention links, e.g. a web page or CD ROM; S periodic meetings which could be organized in conjunction with international NCD meetings, e.g. Preventive Cardiology Conference (important meetings/events need to be identified); S strategic position papers; S training workshops; S a pool of experts and short-term consultants; S short-term working groups on specific areas identified by the GF; S promotion of new model projects and the allocation of specific research tasks.
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Annex 5
CINDI HEALTH MONITOR QUESTIONNAIRE
Category of the importance of the question in brackets after the number of each question: (1)=Obligatory, (2)=Highly recommended
1. BACKGROUND INFORMATION 2. HEALTH SERVICES AND STATUS
1.1 (1) Sex? 2.1 (1) How many times did you visit the 1 male doctor during the last year (12 2 female months)? (Include hospitalization or visits to 1.2 (1) Year of birth? the outpatient department; do not include visits to the dentist.) 19└─┴─┘ └─┴─┘ times 1.3 (1) Marital status? 1 married or living in a 2.2 (1) Do you receive disability pension? partnership 1 no 2 single 2 yes, partial pension 3 separated or divorced 3 yes, for a limited period 4 widowed 4 yes, permanently
1.4. (2) How many children under the age 2.3 (2) During the last year (12 months), of 18 are living in your home? how many days were you absent └─┴─┘ persons from work or unable to carry out normal duties because of illness? 1.5 (1) Total number of years of full-time (If you do not remember exactly, education (including school, please give an estimate. Do not study)? include absence owing to a normal pregnancy.) └─┴─┘ years └─┴─┴─┘ days 1.6. (2) Occupation? 1 farming, cattle-raising, forestry 2 industrial, mining, construction or other similar type of work 3 office work, intellectual work, services 4 student 5 housewife 6 pensioned 7 unemployed
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2.4 (2) During the last year (12 months), 2.7 (1) How would you assess your present have you been diagnosed as state of health? having, or been treated for, any of 1 good the following conditions? 2 reasonably good yes no 3 average High blood pressure 4 rather poor (hypertension) ...... 1 .... 2 5 poor High blood cholesterol (hypercholesterolemia)...... 1 .... 2 2.8 (1) Have you taken any tablets, pills or High blood sugar/diabetes.....1 .... 2 other medication during the last Heart attack week (7 days)? (myocardial infarction) ...... 1 .... 2 yes no Chest pain during exercise for high blood pressure ...... 1.... 2 (angina pectoris)...... 1 .... 2 for high cholesterol ...... 1.... 2 Heart failure ...... 1 .... 2 for headache...... 1.... 2 Rheumatism or arthritis...... 1 ....2 for other aches and pains...... 1.... 2 Back illness ...... 1 .... 2 for cough ...... 1.... 2 Chronic bronchitis or sedatives...... 1.... 2 emphysema...... 1 .... 2 vitamins, minerals or Bronchial asthma...... 1 .... 2 trace elements...... 1.... 2 Gastritis or ulcer...... 1 .... 2 contraceptives ...... 1.... 2
2.5 (2) During the last year (12 months) 2.9 (1) Have you been feeling tense, have you had persistent coughs stressed or under a lot of pressure with phlegm that persist for a while during the last month (30 days)? and that occur almost daily? 1 not at all 1 no 2 yes – somewhat but not more 2 yes, for less than 1 month than is usual for people in 3 yes, for a period of 1–2 months general 4 yes, for a period of 3 months or 3 yes – more than is usual for longer people in general 4 yes – my life is almost 2.6 (1) Have you had any of the following unbearable symptoms or complaints during the last month (30 days)? 2.10 (1) When was the last time your blood yes no pressure was measured? chest pain during exercise.....1 .... 2 1 during the previous year joint pain ...... 1 ....2 2 between 1 and 5 years ago back pain ...... 1 .... 2 3 more than 5 years ago neck/shoulder pain ...... 1 .... 2 4 never swelling of feet...... 1 .... 2 5 I do not know varicose veins...... 1 .... 2 eczema...... 1 .... 2 2.11 (1) When was the last time your blood constipation ...... 1 .... 2 cholesterol was measured? headache...... 1 .... 2 1 during the previous year insomnia...... 1 ....2 2 between 1 and 5 years ago depression...... 1 .... 2 3 more than 5 years ago tooth-ache...... 1 .... 2 4 never 5 I do not know
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2.12 (1) How many teeth are you missing? 3.5 (1) Have you ever smoked daily 1 none (= almost every day for at least one 2 between 1 and 5 year)? If so, how many years 3 between 6–10 altogether? 4 more than 10 – but not all 1 no 5 all your teeth are missing or 2 yes, I have smoked daily for a you have dentures total of └─┴─┘ years
2.13 (1) How often have you seen a dentist 3.6. (1) Do you smoke at the present time during the last year (12 months)? (cigarettes, cigars, pipe)? 1 yes, daily └─┴─┘ times 2 occasionally 2.14 (1) How often do you brush your 3 not at all teeth? 1 more than once daily 3.7 (1) When did you last smoke? 2 once daily (If you smoke currently, please 3 less than once daily circle alternative 1) 4 never 1 yesterday or today 2 days – 1 month ago 3. SMOKING 3 1 month – half a year ago 4 half a year to one year ago 3.1. (1) Do you or any family members 5 1–5 years ago smoke at home? 6 5–10 years ago no, nobody smokes 7 more than ten years ago yes, somebody smokes 3.8 (2) How much do you smoke, or did 3.2 (1) How many hours a day do you you smoke before you stopped, on spend at your workplace where average per day? somebody smokes? (Please give an answer to each 1 more than 5 hours item) 2 between 1and 5 hours manufactured cigarettes 3 less than one hour a day └─┴─┘ cigarettes per day 4 almost never self-rolled cigarettes 5 I do not work outside the home └─┴─┘ cigarettes per day pipe 3.3 (1) Have you ever smoked in your life? └─┴─┘ pipefuls per day 1 no cigars 2 yes └─┴─┘ cigars per day
3.4 (1) Have you ever smoked at least 100 NOTE FOR TRANSLATORS! Local cigarettes, cigars or pipefuls in categories on other types of tobacco allowed! your lifetime? 1 no (proceed to question 4.1) 3.9 (1) Would you like to stop smoking? 2 yes 1 no 2 yes 3 I am not sure 4 I do not smoke at present
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3.10 (1) Have you ever tried seriously to 4.3 (2) How often do you prepare food at stop smoking and been without home? smoking for at least 24 hours? 1 never If so, when was the last time? 2 a few times a year 1 during the last month 3 2–3 times a month 2 a month to half a year ago 4 once a week 3 half a year to one year ago 5 several times a week 4 more than one year ago 6 daily 5 never 4.4 (1) What kind of fat do you use on 3.11 (1) Are you concerned about the bread mostly? harmful consequences that (please circle only one alternative) smoking can have on your health? 1 none 1 very concerned 2 low fat margarine 2 somewhat concerned 3 ordinary margarine 3 not much concerned 4 butter product consisting 4 not at all concerned mainly of butter 5 lard or other animal fat 3.12 (1) During the last year (12 months) 6 butter have you been advised to stop smoking by any of the following? 4.5 (2) If you drink milk do you usually yes no use 1 a doctor...... 1 .... 2 (please circle only one alternative) 2 a dentist...... 1 .... 2 1 whole milk (ordinary cow’s 3 other health care milk, about 4.3 % fat or more) personnel ...... 1 .... 2 2 consumer milk (ordinary shop 4 a family member ...... 1 .... 2 milk, about 3.9 % fat) 5 others...... 1 .... 2 3 low-fat milk (about 1.9 % fat) 4 skim milk (about 0.05 % fat) 4. FOOD HABITS 5 I do not drink milk NOTE FOR TRANSLATORS! please 4.1 (2) Do you eat breakfast at all? replace with local alternatives, if needed! 1 no 2 yes 4.6 (1) How many cups of coffee or tea do you usually drink a day? 4.2 (1) What kind of fat do you mostly use (please answer both items) for food preparation at home? coffee...... └─┴─┘ cups (please circle only one alternative) tea ...... └─┴─┘ cups 1 vegetable oil 2 margarine 4.7 (2) How many lumps of sugar or 3 butter or product consisting spoonfuls of granulated sugar do mainly of butter you use for one cup of coffee or 4 lard or other animal fat tea? 5 no fat at all (please mark 0 if you don’t use 6 I do not know sugar) 7 I do not usually prepare food lumps or teaspoonfuls in └─┴─┘ a cup of coffee └─┴─┘ lumps or teaspoonfuls in a cup of tea
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4.8 (2) How many slices of bread do you 5. ALCOHOL usually eat per day? rye bread └─┴─┘ slices a day 5.1 (2) During the last year (12 months) have you consumed any alcoholic white bread └─┴─┘ slices a day drinks (beer, wine or spirits)? other bread slices a day └─┴─┘ 1 yes
2 no 4.9 (2) How often during the last week
have you consumed the following 5.2 (1) How many glasses (regular foods and drinks? restaurant portions) or bottles of
never 1–2 3–5 6–7 the following drinks have you had times times times during the last week (7 days)? boiled potatoes 1 2 3 4 (If you have not had any, mark 0.) fried potatoes 1 2 3 4 medium strong or strong beer (excl. crisps) rice/pasta 1 2 34 └─┴─┘ bottles cereals (cornflakes, 1 2 3 4 free-mixed highballs porridge) cheese 1 2 34 └─┴─┘ bottles chicken 1 2 34 strong alcohol, spirits fish 1 2 34 restaurant portions (4 cl) meat 1 2 34 └─┴─┘ meat products 1 2 3 4 wine or equivalent (sausages etc.) └─┴─┘ glasses fresh vegetables 1 2 3 4 other vegetables 1 2 3 4 NOTE FOR TRANSLATORS! local fresh fruit/berries 1 2 3 4 drinks/categories/portions allowed! other fruit/berries 1 2 3 4 sweet pastries 1 2 3 4 (cookies, cakes) 5.2 (1) How often do you usually have sweets 1 2 3 4 strong spirits? (candy, chocolate) soft drinks 1 2 3 4 1 never eggs 1 2 34 2 a few times a year 3 2–3 times a month 4.10 (2) Do you add salt to your meals at 4 once a week the table? 5 2–3 times a week 1 never 6 daily 2 when the food is not salty enough 5.2 (2) How often do you usually drink 3 almost always before tasting wine? 1 never 4.11 (1) During the last year (12 months) 2 a few times a year have you been advised to change 3 2–3 times a month your dietary habits for health 4 once a week reasons by any of the following? 5 2–3 times a week yes no 6 daily a doctor...... 1 .... 2 other health care personnel ...1 .... 2 a family member ...... 1 .... 2 by others...... 1 .... 2
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5.3 (1) How often do you usually drink 6.4 (1) How many minutes a day do you beer? spend walking or riding a bicycle 1 never to and from work? 2 a few times a year (Combine time spent both ways.) 3 2–3 times a month 1 I do not work at all or I work 4 once a week at home 5 2–3 times a week 2 I go to work by car 6 daily 3 less than 15 minutes a day 4 15–30 minutes a day 5.4 (1) How often do you drink six glasses 5 30–60 minutes a day (regular restaurant portions) or 6 more than one hour a day bottles of alcohol, or more, at once? 6.5 (1) In your leisure time, how often do 1 never you do physical exercise for at least 2 less than once a month 30 minutes which makes you at 3 once a month least mildly short of breath or 4 once a week perspire? 5 daily or almost daily 1 daily 2 4–6 times a week 5.5 (1) During the last year (12 months) 3 2–3 times a week have you been advised to drink less 4 once a week by any of the following? 5 2–3 times a month yes no 6 a few times a year or less a doctor...... 1 .... 2 7 I cannot exercise because of other health care personnel ...1 .... 2 illness a family member ...... 1 .... 2 8 I cannot exercise because of others...... 1 .... 2 disability
6. HEIGHT, WEIGHT AND 6.6 (1) How physically strenuous is your PHYSICAL ACTIVITY work? 1 very light (mainly sitting) 6.1 (1) How tall are you? 2 light (mainly walking) 3 medium (lifting, carrying light └─┴─┴─┘ cm loads) 4 heavy manual work (climbing, 6.2 (1) How much do you weigh in light carrying heavy loads) clothing? └─┴─┴─┘ kg 6.7 (1) During the last year (12 months) have you been advised to increase 6.3 (2) In your opinion, are you? your physical activity by any of the 1 underweight? following? 2 normal weight? yes no 3 overweight? doctor ...... 1.... 2 4 I do not know other health care personnel ... 1.... 2 family member...... 1.... 2 other ...... 1.... 2
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7. TRAFFIC SAFETY 8. OTHERS
7.1 (1) Do you use a reflector when 8.1 (1) During the last year (12 months), walking on streets without lights have you changed your diet or when it is dark? other habits for health reasons? 1 almost always yes no 2 sometimes I eat less fat ...... 1.... 2 3 never I have changed 4 I never walk on unlit streets type of fat I eat ...... 1.... 2 when it is dark I eat more vegetables ...... 1.... 2 I eat less sugar...... 1.... 2 7.2 (1) Do you use a seat-belt when I eat less salt ...... 1.... 2 driving or as a passenger in the I have been on a weight- front seat? reducing diet ...... 1.... 2 1 almost always I drink less alcohol...... 1.... 2 2 sometimes I do more physical exercise... 1.... 2 3 never 4 I never use a car 8.2 (1) In your opinion what is the most important reason for the rather 7.3 (1) Do you use a seat-belt in the back high death rate among the adult seat? population in our country? 1 almost always (Please mark only one alternative.) 2 sometimes 1 wrong diet 3 never 2 stress 4 there is no seat-belt in the 3 difficult living conditions back seat 4 strenuous work 5 I never travel in the back of 5 smoking the car 6 lack of physical exercise 7 lack of vitamins, minerals, 7.4 (2) Are you aware if any of your close etc. friends have driven a car under the 8 overweight influence of alcohol during the last 9 genetic factors year (12 months)? 10 alcohol 1 no 11 lack of health services 2 yes 12 other, please specify 3 difficult to say ______
8.3 (2) Do you know anyone who has tried drugs (hashish, marihuana, amphetamine, heroine) during the last year (12 months)? 1 no 2 one person 3 2–5 persons 4 more than five persons
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Annex 6
SUMMARY ON RF AND PE DATA AVAILABLE IN THE CDMC (31 MAY 2000)
Years of surveys are given: “?” – means “to be checked”; (P) – “is processing now”; (E) – “expected”. If survey data are available for several Demonstration Areas, the information is given on separate lines.
Process Risk factor Country evaluation Comments data data Austria 86, 91 91 Belarus 86, 98 Bulgaria 85? Canada 85, 95 94 Croatia Cyprus Czech Republic 94(P) Estonia 92 93 Finland 82, 87, 92, 97 89 North Karelia Germany 86, 89, 91 91 Hungary 85, 95 Kazakhstan Kyrgyzstan Lithuania 83, 87, 92 90 Malta 85 Poland 92 Portugal 85? 84 Moscow city Russian Federation 1:87 Yes(P) Worksites 2. 86, 89, 94 3: 86, 89, 94 92, 97 Pitkjaranta 84, 87, 92 Novosibirsk Slovakia ?(P) Slovenia Spain 92 Turkmenistan 98(P) Ukraine 98?(P) United Kingdom 84, 87, 91 91 MONICA Yugoslavia 82 MONICA?
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Annex 7
DRAFT PROTOCOL: ACCESS TO AND USE OF THE WHO CINDI DATABASE
The WHO CINDI Database is taken to mean the set of core data as derived from the WHO CINDI Protocol collected by CINDI Member Countries and assembled using a common format with standard documentation under the specific collaborative arrangements among Member States as outlined by the WHO CINDI Programme Protocol. All CINDI member countries are encouraged to access the CINDI data base.
Principles
1. The WHO CINDI Database may, in principle, be accessed by anyone individual or organization for purposes of advancing NCD prevention and control research that may be presumed to further the knowledge of the prevention and control noncommunicable disease.
2. Access to the database will be granted as part of an agreement or understanding, which directly or indirectly does not result in personal economic gain for an investigator or group of investigators and which specifies the purpose and use of the data.
3. Access to the data base may be granted only to an investigator participating in the WHO CINDI Programme of a Member State which has contributed data to data base and who secures written approval of Programme Director of the Member State.
Procedures
4. Prior to granting access to the database, a CINDI Programme Director will request of the proposed user a written proposal which outlines the nature of the work to be carried out, an outline of the study design publication plan and a statement certifying that the access to the database is not for the purposes of commercial exploitation.
5. It is understood that a Programme Director will communicate and if necessary discuss with the Chair of WHO Working Group on Monitoring and Evaluation, each instance where access to the data has been granted along with the purpose and the study design of the work to be carried out.
6. The WHO CINDI Programme Directors, The WHO Regional Adviser for Noncommunicable Disease and other recognized representatives of WHO EURO will have unrestricted access to the data base subject the noncommercial exploitation provision discussed above.
7. It is understood that the Programme Directors will comply with any and all Member State legislative and WHO administrative requirements that govern the release of survey data.
8. The WHO CINDI Working Group on Monitoring, Evaluation and Research will resolve issues of interpretation of the above and oversees the implementation of the above provisions and where appropriate in conjunction with the Management Committee.
9. All Publications will specifically acknowledge the CINDI Programme as the source of the data and comply with the approved publication plan. The final manuscript should be cleared by the WHO CINDI Working Group on Monitoring, Evaluation and Research.
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Annex 8
TERMS OF REFERENCE: CINDI WORKING GROUP ON MONITORING, EVALUATION AND RESEARCH
Chair Professor David R. MacLean (Canada)
Members Professor Igor Glasunov (Russia) Professor Vilius Grabauskas (Lithuania) Professor Endre Morava (Hungary) Professor Egbert Nüssel (Germany) Professor Helios Pardell (Spain) Dr Andres Petrasovits (Canada) Professor Pekka Puska (Finland) Dr Aushra Shatchkute (WHO EURO)
Mandate The Working Group is formed to direct and support CINDI monitoring and evaluation procedures; to coordinate research related to CINDI priority issues; and to advise on, initiate and work upon the preparation of publications and reports.
Composition The Chair and members of the Working Group are appointed by the Council of CINDI Directors in consultation with EURO. Experts from outside CINDI may from time to time be invited to meetings of the Working Group.
Functions The Working Group coordinates in the general area of monitoring, evaluation and research for the CINDI programme with particular emphasis on
Methodology S defining core data sets to be collected and analysed in support of the monitoring and evaluation of CINDI programs and in support of publications to advance the field with respect to integrated activities for NCD prevention and health promotion at the local, regional, national and international level S ongoing methodological development and technical adjustment with regard to existing CINDI protocols S the preparation of guidelines and establishment of procedures for appropriate applications particularly with respect to indicators and standards for programme evaluation and the monitoring of programme outcomes
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International CINDI Database S to supervise the operations of the CINDI Data Management Centre (CDMC) including the definition and coordination of the analysis plans of the CINDI core data; preparation of annual plan of work and assessment of output S to develop and coordinate the activities of a network of CINDI Data Analysis Centres S to develop policy and take strategic decisions with regards to data collection, processing and publication
Health Information Systems S to foster further developments of CINDI information systems S to provide for and coordinate ongoing consultations on technical and methodological issues with respect to monitoring, evaluation and research
Overall Evaluation of CINDI Progress in Participating Countries S to elaborate policy guidelines and procedures regarding the overall assessment of program development in CINDI participating countries S to perform periodic assessments of the monitoring and evaluation functions of other working groups e.g., CINDI Children’s Data Management Centre
Activities Specific activities are planned for short-term periods of one or two years only and should be approved by the Programme Directors at their annual meetings. The Working Group should formulate appropriate proposals which have a realistic relationship to the long-term priorities set by the Programme Directors and the Working Group itself in the context of the allocation of human and financial resources and logistic realities.
The Working Group will meet at least once per year but may meet more often as necessary to complete its responsibilities.
Reporting relationship The Working Group reports to the Council of CINDI Directors. The CDMC prepares annual progress reports to be included in the annual report of the Council of CINDI Directors. It also provides progress reports to the Programme Management Committee and to WHO EURO as appropriate. In addition, the Working Group has the responsibility to inform CINDI programs in a timely fashion about major decisions taken.
The Working Group may appoint sub-groups with the provision of a mandate and specific terms of reference. The Working Group may, from time to time, assign specific tasks to existing sub-groups. Sub- groups are expected report their progress and major recommendations to the Working Group on a timely basis.
Table 1. Alcohol consumption (AC) in CINDI countries 1. 2. 3. 4. 5a. 5b. 6. AC How How often? How many usually? How many in the How many per week on average Other Country No/yes often last week (7 days)? info. ? about AC Liqueur Beer Wine Spirits Beer Wine Spirits Beer Wine Spirits Beer Wine Spirits Must Aperitif Austria + + + + + 6.1 6.2 Belarus Bulgaria Canada + and +* +* 6.3 Croatia Cyprus Czech Republic Estonia +* + – – – + +() + + +() + Finland + + + Germany Hungary – – – – – – – – + + + 6.4 Italy Kazakhstan Kyrgyzstan Latvia Lithuania – – ^ ^ + ^ ^ + – – – Malta Poland +* + – – – + + + Portugal Romania Russia Slovakia ? – – – – – – – + + + Slovenia Spain Turkmenistan Ukraine United Kingdom
Explanation of symbols relating to questions asked:
+ = Did you consume alcohol (beer, wine, spirits)? +* = Did you consume alcohol (beer, wine, spirits) in the past 12 months? +() = How many glasses of wine? How many glasses of strong wine? (2 questions) ? = Coding of reply unclear ^ = These data are available, but not yet sent to CDMC 6.1 = Austria: has somebody influenced you within the last month to drink less alcohol? (no, yes – my family, friends, fellow worker, medical staff, a doctor, others) 6.2 = Austria: have you tried within the last 12 months to drink less alcohol? (yes, no) 6.3 = Canada: how often have you had >=5 drinks in past 12 months? Largest # of drinks consumed in 1 day in the past 12 months? # of drinks you had yesterday? of drinks you had 2 days ago? of drinks you had 3 days ago? of drinks you had 4 days ago? of drinks you had 5 days ago? of drinks you had 6 days ago? of drinks you had 7 days ago? of drinks refusal variable 6.4 = Hungary: How well can you take alcoholic drinks? (cannot take at all, I can take them on average, I have abstained for one year at least) How many alcoholic drinks did you consume yesterday?(dl beer, dl wine, dl hard liquor) Did you drink more or less alcohol than on average? (less, more, as on average) How many alcoholic drinks it is allowed for you to consume while taking care of your health?
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Table 2. Year and number of records in data files of CINDI countries with data on AC No. of records in Country Year data file Austria 1991(?) 1863 Canada 1995 3225 Estonia 1992–94 2155 Finland POOLED FILE 347 Hungary ? (PECS city) 2163 1983–84 3783 Lithuania 1986–87 4564 1992–93 2917 Poland 1994 1894 Slovakia 1992 2182
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Annex 10
LETTER TO THE REGIONAL DIRECTOR, WHO REGIONAL OFFICE FOR EUROPE
17th annual meeting of the CINDI Programme Directors Qawra, Malta, 9–10 June 2000
Qawra, 10 June 2000
Dear Dr Danzon,
During the 17th annual meeting in Qawra, Malta, on 9–10 June 2000, we the CINDI Programme Directors had the privilege and pleasure of discussing the report of the Director-General of WHO on Global Strategy for the Prevention and Control of Noncommunicable Diseases presented at the 53rd session of the World Health Assembly, as well as Resolution WHA 53.17 which was adopted unanimously by the Assembly.
We feel that WHO Headquarters has taken a major step in recognising that noncommunicable diseases are now a priority which must be dealt with globally and that inviting all Member States to take action should result in a decrease in the global burden posed by this group of diseases. We note that the Global Strategy is based on concepts and principles similar to those of the CINDI programme. This is not by chance as the CINDI Programme contributed to the formulation of the Strategy through its expertise in this area. Thus, CINDI participating countries are well positioned to assist WHO in the implementation of the strategy.
We the undersigned feel strongly that the WHO European Region should retain leadership in the generation and implementation of innovative approaches in this priority area of health improvement and that the CINDI programme should be used as a well-established mechanism to assist in translating the Strategy into action.
We are delighted to see that, as part of the Strategy, WHO Headquarters has already taken steps to establish CINDI- and CARMEN-type networks in other Regions and to establish a Global Forum for the exchange of experiences and strengthening global partnerships.
The undersigned wish to assure you of their support to WHO/EURO in the implementation of this important Strategy and look forward to a fruitful collaboration.
Yours sincerely, CINDI Programme Directors
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Annex 11
CINDI MILLENNIUM INITIATIVE: SMOKING PREVENTION AND REDUCTION IN HEALTH PROFESSIONALS
Informal planning consultation, EURO, 6 April 2000
Minutes Participants
Dr Carlos Brotons, Spain Professor Helios Pardell, Spain Professor Pekka Puska, Finland Ms Patsy Harrington, WHO/EURO Dr Aushra Shatchkute, WHO/EURO
The CINDI Millennium Initiative on smoking reduction in health professionals is planned as a five-years project for the reduction of smoking among health professionals.
The objectives of the project are:
to reduce the prevalence of smoking among health professionals; to encourage health professionals to act as role models for the public in relation to smoking cessation; to exemplify smoking prevention and cessation as a case model for NCD prevention and control; to identify and document innovative practices/approaches.
At present the following 14 CINDI countries are interested in participating: Austria, Belarus, Canada, the Czech Republic, Finland, Italy, Latvia, Lithuania, Malta, Portugal, Romania, Slovakia, Slovenia and Spain.
The aim of the consultation was to elaborate details of the proposed strategies for smoking prevention and reduction in health professionals, and to identify a plan of work, funding and further action related to the project.
The following was agreed:
1. The project will focus on smoking in physicians (including students). Later it might be expanded to other health professionals such as nurses, pharmacists.
2. The CINDI WG on Smoking and the WG on Guidelines and Training for Preventive Practice will be responsible for this initiative.
3. The project will be implemented in partnership with the WHO/EURO Tobacco or Health programme.
4. Collaboration will be established with EuroPrev. This is an international network of physicians on health promotion and disease prevention affiliated to WONCA which promotes evidence-based prevention in clinical practice of GPs. Prevention of tobacco and abuse of alcohol are priorities of the agenda of EuroPrev.
5. Collaboration with other relevant organizations and projects might be established (e.g. the World Medical Association).
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6. The following components of the project were identified.
S Monitoring and evaluation o Establishing a system of monitoring and evaluation of the project (analysis of existing questionnaires – e.g. WHO questionnaires, preparation of a manual on monitoring and evaluation) o Building a database (exploring existing information, using the results of the current survey on smoking prevention and control policies in CINDI and CARMEN, conducting a survey) S Policy and strategy of smoking prevention and cessation in health professionals o Analysis of existing guidelines o Preparation of a policy document on smoking reduction in health professionals and guidelines on smoking cessation S International Quit and Win smoking cessation campaign for health professionals S Demonstration projects o E.g. Involvement of medical students in activities on smoking prevention
7. Plan of work Preparatory work: 1 July 2000 – 1 June 2001.
S 9–10 June 2000, Qawra, Malta – The annual meeting of the CINDI Programme Directors . The project will be introduced and discussed with the Directors. Professor Pardell will present the preliminary results of the survey on tobacco prevention and control policies in CINDI and CARMEN, a survey which also addresses smoking in health professionals. A EuroPrev representative will be invited to the meeting to establish collaboration with CINDI. S November 2000 – preparation of the above policy document (Responsible – Professor Pardell). S 24–25 November 2000, Barcelona, Spain – a meeting on EuroPrev on the results on the WONCA survey on smoking habits in health professionals to which Professor Pardell will be invited to discuss collaboration on this project. S January–February 2001 a WHO/EURO consultation on preparing a manual on project monitoring and evaluation. S June 2001 (at the 3rd European Conference on Tobacco or Health/the WHO/EURO Ministerial Conference on Tobacco, Warsaw) – Launch of the project. S Quit and Win smoking cessation campaign for health professionals – 2002. S It was agreed that in parallel it would be very useful to develop demonstration projects on reducing smoking prevention in health professionals.
8. Search for funds: Pharmaceutical companies in official relationship with WHO regarding smoking cessation will be approached. Professor Pardell will submit an application to the European Network for Smoking Prevention within the “Europe against Cancer” programme.