• REDUCTION OF HEALTH INEQUALITIES 1 IN LOVECH MUNICIPALITY – BULGARIA USING A HEALTH PROMOTION LIFE-COURSE PERSPECTIVE

An Action Plan • 2 The region of Lovech is situated in North Central Bulgaria. The population size of Lovech region is 139609 people, 49% males vs. 51% females1, accounting for 1,9% of the total population. The demographic situation of Lovech region in terms of sex/age structure and downward population trends is unfavorable and worse than national average. The analysis of the three age groups (0 – 17, 18 – 59 and over 60) proportions shows that the first group has a very low percentage (less than 20%), while the third group has a high percentage of over 40%, thus demonstrating the aging population structure in Lovech region. The percentage of people living under the poverty line in Bulgaria is 21,8%, 3 • with this share being higher for Lovech Region – 23,9%. The proportion of the poor estimated by the poverty line in 2010 for the Lovech area is even higher, namely 23,9%. 66,6% of the population (men (69,9%) and women (63,8%)) are at risk of poverty or social exclusion in Lovech2. To compare, the total country’s population at risk of poverty or social exclusion is 49,2%, men (47,3%) and women (50,9%). Aging population, unemployment and deteriorated social status are factors that directly affect health status and increase incidence of chronic non- communicable diseases: cardiovascular, oncological, pulmonary diseases and diabetes, both at local and national level. The leading risk factors for these diseases are lifestyle factors, e.g. smoking, low physical activity, alcohol consumption, unhealthy nutrition & overweight/obesity and age (60 years and older), and could be influenced by health promotion and to some extent by the health system (timely diagnostics). The Regional Health Inspectorates have current data on all disadvantaged social groups, including the Roma community in the region, such as employment and educational level, routine examinations, immunizations, as a result of regional strategy monitoring activities. These data could be of help in developing and implementing the Action Plan on Reducing Health Inequalities. Facilitating factors for the Action Plan are the existence of the current Regional Strategy for Roma Integration (2012 – 2020), existing expertise, good training practices, commitment as well as NGO’s presence in the Roma community. Challenges that should be taken into account with respect to the

1 National Statistical Institute, 2011 Available at: http://www.nsi.bg/bg/content/797/ 2 National Statistical Institute, 2011 Available at: http://www.nsi.bg/bg/content/797/ implementation of the Action Plan are the organization and coverage of the Roma population and the lack of health mediators for the Roma population in municipalities. Other barriers are uncertain funding, lack of mechanisms to involve physicians in the Action Plan and a poor coordination between institutions. In order to implement the action plans, an active participation of municipalities and sufficient human and financial resources are needed. The situation described above and the new programming period (2014 – 2020) for the Operational Programme Human Resources Development necessitates further specification of the established priorities so that • 4 national goals are achieved. They suggest significant, measurable and sustainable progress in reducing the high risk of poverty and social exclusion faced by Bulgarian citizens. Particularly important is that such progress be reached within a certain category of regions (less developed regions). In order to address the majority of the preconditions for the exclusion of the target groups from the labor market and public life, an integrated approach is required. Over the past few years, the financial and economic crisis has exerted a significant negative impact on the most vulnerable groups in Bulgarian society. In terms of economic status, the risk of poverty is highest for the unemployed, pensioners and the other economically inactive persons. Mostly affected is a large part of the Roma community living isolated and in very difficult living conditions. Ensuring access to basic health and social services is a key tool for overcoming the effects of poverty and social exclusion. Operational Programme Human Resources Development emphasizes on the following: improving access to employment, education, social and health services for the Roma, a targeted and integrated approach to vulnerable citizens of Roma descent, not necessarily excluding the provision of support to disadvantaged persons from other ethnic groups, the disabled as well as people at risk of discrimination and other forms of social exclusion, the homeless or those living in poor housing conditions, people with addictions, children, youth and families at risk and other people or groups in need of support. In compliance with the requirements of the Operational Programme Human Resources Development, the current Action Plan covers only activities aimed at improving the quality of life and ensuring sustainable integration of marginalized communities. It takes into account the reasons for the selection of thematic objectives and investment priorities under the Operational Programme Human Resources Development (2014 – 2020). Its main objectives can be viewed as a specification of the thematic objective “Promoting social inclusion and combating poverty”. Planned actions are consistent with its priorities “Integration of marginalized communities such as the Roma” and “Active Involvement”, whereas leading role play two directions: “Improving access to employment” and “Access to social and health services”. Of the activities defined as key in the OP “Human Resources Development”, namely providing access and delivery of quality health and social services and improving access to healthcare and 5 • enhancing health culture of marginalized communities, including through health awareness campaigns, the primary focus is placed on the second key activity. The Action plan aims, through health promotion, to impact on health inequalities, both on regional and national level. Five objectives have been highlighted, each of which has been justified and includes specific objectives, activities and indicators for their implementation. The key concepts for the strategy and action plan implementation are listed below:

 Viewed as a contribution to society and the long-term benefits to it, the project GOAL is to affect health inequalities on regional and national level (for example, reducing mortality from cardiovascular, lung and oncological diseases as well as reducing health inequalities across different social groups of the population).  OBJECTIVES are more specifically defined areas to be affected, for example, related to the needs and situation of certain target groups.  PLAN TASKS represent the next level of specification following objectives and how they will be achieved has also been defined.  SPECIFIC OBJECTIVES describe the actions, the expected outcomes as well as the related deadlines. Their implementation can be quantitatively measured.  The INDICATORS are selected so as to measure not only the advancement to the preliminarily set goal, but its efficiency and sustainability of achievements as well. PRIMARY GOAL: REDUCING HEALTH INEQUALITIES BOTH WITHIN THE REGION AND BETWEEN IT AND THE COUNTRY THROUGH HEALTH PROMOTION

As already mentioned, we can observe health inequalities both within the regions of the country and between the regions themselves. The interregional health inequalities are differences in the health status of the population in the various regions. The population of the region as a whole can be considered a risk group of adverse health status compared to the the population of the central regions. This is expressed, for instance, in • 6 lower life expectancy in the region.

Differences in the health status of the population reflect health inequalities in the region.

Examples of adverse health status risk groups are the persons with low education, the unemployed, the elderly and the ethnic minorities. These groups are characterized by a significantly higher risk of adverse health outcomes. One of the goals of the present action plan is that the health status in the region be as close as possible to the one in the central regions, with the regional population and, in particular, the vulnerable groups being supported in building healthy behavior and environment.

AIM 1: PLACING HEALTH INEQUALITIES IN THE PUBLIC SPOTLIGHT. CHANGE IN THE LEVEL OF AWARENESS, KNOWLEDGE AND ATTITUDES OF INDIVIDUALS TO THEM

Community and its members must possess a certain level of awareness and health knowledge as “a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity”3, and make it a priority so as to enable work on reducing health inequalities. The health model recommended by the WHO indicates that health is affected by a number of factors4. They range from genetics and individual lifestyle to macroeconomic, social, cultural and environmental conditions,

3 According to the WHO definition. 4 Age, gender, hereditary factors, individual lifestyle, social and community influences, working and living conditions, socio-economic macrofactors, cultural and environmental factors. with social cohesion playing a key role, particularly in vulnerable communities. The overall health responsibility is shared between the individual, the family, the community, the administration at all levels and the respective governmental institutions and organizations. Understanding health as a potential for development has been gaining wider support in the region. Negative demographic trends in Lovech Region, marked by greater than the average decline in the population structure by age and sex with the percentage of people over 60 exceeding 40%, lead to the awareness of the fact that investment in better health will affect the economic potential 7 • of the region. This basic awareness of the importance of health for the welfare and development of the region is crucial for the initiation of specific interventions, such as achieving healthy behavior and healthy environment. Reaching such level of awareness and knowledge of the importance of health both among the population and among stakeholders and key players in the region is one of the aims of the Action Plan, where specific outcomes are expected to be a broader integration of health issues in the policies and activities of all regional authorities. Health needs and existing health inequalities can be adequately presented to all parties involved mostly based on scientific data.

OBJECTIVE 1.1 Raising awareness and responsibility of stakeholders and key players in the region on health inequalities and the importance of good health for regional development.

Activities  Establishing and maintaining regular contacts with local key actors and stakeholders (politicians, the Regional Health Insurance Fund, employers, representatives of ethnic minorities and target social groups, NGOs, the media);  Development and implementation of joint initiatives to raise awareness on health disparities.

Indicators  Performed activities for health communication (meetings, work groups, roundtables);  Contacts established between stakeholders, particularly regarding issues on health inequalities as well as issues concerning the Action Plan itself and interventions envisaged in it.

OBJECTIVE 1.2 Integrating health as a structuring element in other strategies and regional programmes of other sectors. Specific objective 1: Enhance the adoption of the strategy for reducing health inequalities by stakeholders and key players in the region.

• 8 Activities  Presentation of the strategy to stakeholders and key players in the region;  Lobbying for the adoption of the strategy at the regional level.

Indicators  Official statements in support of the strategy.

Specific objective 2: Increasing the presence of health issues in the policies, programmes and activities of other agencies.

Activities  Strengthening interagency cooperation in the elaboration of the strategy by involving real-working members of other authorities;  Coordination of existing and development of joint interagency activities, projects and programmes;  Integrating health inequalities issues in regional development plans.

Indicators  Number of developed and implemented joint activities, projects and programmes;  Scope and amount of problems associated with health inequalities presented in regional development plans.

OBJECTIVE 1.3 Raising awareness, knowledge and capacity for taking responsibility for one’s own health in the region and increasing his/her motivation to participate in area-related activities. Activities  Organization of a comprehensive system of activities for health promotion in area-related context;  Motivation of local stakeholders and key players to engage in field- related health promotion initiatives;  Motivating people in the region to involve in field-related health promotion initiatives.

Indicators  Range and number of persons involved in field-related health promotion activities. 9 •

AIM 2: ENHANCING THE CAPACITY OF THE COMMUNITY IN THE HEALTH FIELD

Such capacity-building is a systematic activity that strengthens the ability of a community to create structures and provide organizations and individuals with the necessary competences so as to enable them to set and achieve health-related goals by involving others and, in solving problems together, to build community awareness. This systematic activity comprises a variety of initiatives – from awareness campaigns to trainings in organizational and personal development and development of educational and methodological materials in a manner that is based on the principles of target groups empowerment and equality. The capacity of the community can be seen as composed of four components that reflect the main characteristics of the network and its ability to implement and maintain a health improvement programme. These four components are listed below: 1. Participants in the network – relationships between groups and organizations within the community or network. This includes both their complexity and quality; 2. Exchange of experience and knowledge – extracting, sharing and use of information within and between groups and organizations in the network or community; 3. Problem solving – the ability to use established methods for detecting and solving problems; 4. Infrastructure – including investments in the network or community groups, or organizations that create it. It covers both tangible and intangible investments, such as investment in the elaboration of a strategy and procedures, social capital, human capital and financial capital. Community development, capacity building of taking responsibility and health promotion are based on the principle of empowerment and the use of available regional resources. They are carried out through actions at the community level, such as priority setting, decision-making and implementing them to achieve better health. At the core of this process lies the empowerment of communities and the observance of their right and control over their own goals and initiatives. • 10 The preliminary assessment of the community capacity shows that in the relevant region it is at an acceptable level. However, there are some areas to be improved, such as the degree of connectivity with other stakeholders, horizontal communication and coordination of initiatives, community involvement and the exchange of experience and knowledge in it. Enhancing the community capacity stands out as an aim, which in turn will directly affect health by empowering individuals to assume responsibility for their own lifestyle and enhance the ability to solve community problems, which then, in turn, will have an indirect impact on health.

OBJECTIVE 2.1 Improving the network in support of health formed by local institutions, NGOs and individuals.

Activities  Finding stakeholders and potential members of such a network in field-related context;  Establishing common interests in order to motivate potential members to join the network;  Providing knowledge of health promotion as a way to improve network members’ health;  Organizing network management.

Indicators  Number of network members;  Number of active network members involved in interagency activities and programmes. OBJECTIVE 2.2 Encouraging stakeholders and key players to involve community members in the decision-making process related to their lifestyle and health.

Activities  Informing and discussing the significance and opportunities for participation in decision-making among the population of the region;  Lobbying before the administration and those responsible for policy- making for the importance of public participation in the decision- making process among key actors; •  Training through participation and experience of the persons, 11 responsible for the development of policies, to involve the public in the decision-making process at an early stage.

Indicators  Frequency of procedures for participation in decision-making;  Number of initiatives by the participants in the training;  Measurable change in the participation in the decision-making process.

OBJECTIVE 2.3 Enhancing the capacity of health professionals and non-medical professionals in health promotion.

Specific objective 1: Enhancing the health promotion capacity of public health professionals.

Activities  Providing qualification and training in health promotion for GPs, nurses and midwives as well as physicians dealing with occupational medicine and those working in inpatient and outpatient medical facilities in order to increase their capacity to prevent health risk and promote healthy lifestyle among the regional population;  Developing effective training programmes for those working in educational institutions, sports and recreation facilities, including social workers and media professionals;  Training public health professionals in methods used for the assessment of the effectiveness of health promotion initiatives. Indicators  Number of trained and qualified persons;  Measurable change in health promotion competency;  Number of programme assessments.

AIM 3: REDUCING HEALTH INEQUALITIES ACROSS REGIONS THROUGH HEALTH PROMOTION ACTIVITIES

In general, the population of Lovech Region can be considered a risk group • 12 of adverse health status compared to the population in the central regions. Disparities in the health status of the population in the different regions correspond to the relative poverty indicators. In Lovech Region, the total monthly income per household member is 10% lower than the country, and the risk of poverty is 70% for men and 64% for women, respectively, which is well above the national average of 49.2%. In view of these data, all opportunities for reducing health inequalities, which are not directly related to increased levels of economic development of the region and can be utilized as quickly and as efficiently as possible, are crucial. In this relation, health promotion can be a significant contribution to overcoming health status disparities in different regions. Health promotion is a process that enables people to take responsibility for their own health and improve it. To achieve a state of complete physical, mental and social well-being, an individual or a group must be able to identify and realize their aspirations, satisfy needs and either change the environment or adapt to it. Health promotion is the responsibility not only of the health sector; rather, its goals extend beyond simply maintaining a healthy lifestyle, thus encompassing overall well-being and more. By placing the emphasis on health promotion and disease prevention, healthcare costs can principally be reduced. Results of numerous epidemiological studies explicitly state that non-communicable diseases (NCDs) or events leading to them are rooted in an unhealthy lifestyle or unfavorable social and physical environment. Their determinants related to lifestyle – smoking, alcohol consumption and nutrition, are multidimensional. These determinants are associated with many serious health problems.

OBJECTIVE 3.1 Healthy lifestyle promotion. Nutrition and physical activity are crucial to health and disease prevention. Diseases due to poor diet and immobilization cover cardiovascular diseases, type 2 diabetes, arterial hypertension, osteoporosis, and certain types of cancer. Studies show that people in the region eat relatively unhealthily, with 13% of children under 10 being underweight. Therefore one of the goals of this plan is to improve eating habits and physical activity of the population.

Specific objective 1: Healthy nutrition promotion.

Activities 13 •  Annually organizing and conducting public awareness campaigns and other activities to inform the population on healthy eating (in support of breastfeeding, to combat obesity, on NCDs, etc.);  Printing, distribution and promotion of information materials on healthy diet for various population and age groups;  Introducing healthy nutrition classes for children and students through the integration of relevant age information in appropriate forms.

Indicators  Conducted campaigns and activities for certain target groups; number of partners involved; number of persons covered by campaigns/ activities;  Number of printed, distributed and presented recommendations for healthy eating and information materials;  Number of schools that have introduced healthy eating classes; number of students involved; awareness on healthy food among children and adolescents.

Specific objective 2: Increasing the amount of daily moderate physical activity.

Activities  Implementation of educational programmes for regular physical exercises, sports and tourism among various age groups tailored to their specific needs and opportunities (at workplace, schools, kindergartens, etc.);  Preparation and distribution of information materials intended for the population (leaflets, brochures, etc.) regarding opportunities to practice physical exercises, sports and tourism at the place of residence;  Establishing communities of people having similar interests: clubs for those keen on maintaining optimum physical status, weight control, mutual assistance and more; providing knowledge and practicing skills for physical activity;  Including activities regarding physical activity in different events.

Indicators  Number of implemented educational events;  Number of developed and distributed educational materials; • 14  Information provided on opportunities for practicing physical exercises, sports and tourism at the place of residence;  Number of large-scale public physical activities;  Established and operating communities.

Abuse of substances, whether legal or illegal, may cause damage to both the physical and mental level, not only affecting the individual, but also the family and the wider community. Smoking is an explicitly established risk factor for cardiovascular diseases, stroke and cancer. Environmental tobacco smoke poses a risk to non-smokers’ health. Tobacco use is the only preventable cause of death and diseases. Alcohol is widely consumed and enjoyed, being often associated with celebration, social interaction and cultural ceremonies. Risk or high-risk alcohol consumption has been linked to cardiovascular diseases, stroke, liver diseases, certain types of cancer, pancreatitis, gastritis, certain psychotic conditions, and injuries.

Specific objective 3: Promoting drug-free, alcohol-free and tobacco-free lifestyle among youth.

Activities  Organizing and conducting educational campaigns/activities to raise public awareness on the health risks associated with the use and abuse of alcohol and drugs, substance addiction and its health, social and economic consequences;  Providing knowledge of the legal implications and risks of alcohol and drug abuse;  Promoting a positive image of non-abusive behavior;  Conducting annual competitions for the development and implemen- tation of health education projects by NGOs, schools, youth clubs, RHI, medical and healthcare facilities and more so as to prevent early use or abuse of alcohol and other drugs for all target groups.

Indicators  Number of conducted campaigns, number of partners involved, number of persons covered by campaigns;  Number of submitted projects, number of funded projects, number of persons covered;  Increased awareness of the legal consequences of alcohol and other drugs abuse. 15 • Specific objective 4: Establishing a supportive environment for healthy and safe lifestyle.

Activities  Promoting the use of appropriate protective equipment;  Supporting programmes of other agencies for the safe use of electric household appliances, agricultural tools and machinery.

Indicators  Number of partner organizations involved in the verification of safety in the homes of the elderly;  Number of interagency safety programmes.

OBJECTIVE 3.2 Improving early diagnosis of non-communicable diseases (NCDs).

Early diagnosis and proper follow-up and treatment of NCDs can reduce the negative effects of the diseases. Particular importance is attached to the promotion of regular check-ups, especially in vulnerable groups as well as the early demand for treatment in the event of health problems.

Specific objective 1:Training people to recognize early signs of diseases and seek medical consultation.

Activities  Providing accurate and clear information on early symptoms of diseases;  Encouraging people to seek medical advice at the earliest onset of symptoms. Indicators  Increased number of diagnosed cases of NCDs.

Specific objective 2: Increasing the number and improving the access to screening programmes for early detection of NCDs.

Activities  Providing information on the benefits of early diagnosis;  Organization of screening and active involvement of groups at risk;  Increasing the effectiveness of prevention by screening (preventive • 16 services).

Indicators  Increased number of diagnosed cases of NCDs.

AIM 4: REDUCING HEALTH INEQUALITIES IN THE REGION BY SUPPORTING GROUPS AT RISK

In general, the regional population not only constitutes a group at risk of deteriorated health and adverse health status, but disparities both in the degree of social inclusion and the health status, exist within the population as well. At different life stages, depending on age and specific life circumstances, people have different needs. Particularly when being more vulnerable and in need of special care. Furthermore, for many representatives of various ethnic groups operate additional factors of social exclusion, thus aggravating health inequalities. Such factors include poverty, poor housing, unemployment, low education, financial difficulties, etc. Identifying and meeting the diverse needs of the different groups of the population contribute to the development of a community and region that are more socially stable and more sustainable over time. The aim is to reduce health inequalities within the region by supporting healthy behavior of disadvantaged groups through programmes specifically tailored to them. It is necessary to avail of the opportunity to improve health status that has affected the causes of the differences therein, such as social exclusion. Priority target groups in this regional plan are children and mothers, school dropouts, the unemployed, people with special needs, the elderly and persons of minority descent. Support for children and mothers Childhood health has a major impact on adult health. Therefore it is essential for pediatric healthcare to cover the entire period from pregnancy until the end of adolescence. Over this period, crucial to good health are both the healthy lifestyle and the healthy environment. Adequate and optimum nutrition is closely linked to the full growth and development, good performance at school and entire health throughout life, which in turn is a guarantee of economic and social welfare. There is evidence that poor nutrition during fetal stage not only affects growth and development of the child, but increases the risk of obesity, type 2 diabetes 17 • and CVDs as well. Breastfeeding up to the sixth month provides the best feeding for the infant, and it has been found to greatly improve newborn’s health both in the short and long term. Another milestone in this respect are the early years of life that are crucial to building eating habits and attitudes. Active smoking during pregnancy is associated with low birth weight and prematurity. Exposure to environmental tobacco smoke increases the risk of respiratory diseases and the sudden infant death syndrome in the baby crib. Therefore, an important purpose is to promote healthy eating among children and ensure a tobacco-free environment.

OBJECTIVE 4.1 Promoting smoke-free pregnancy and smoke-free environment for children.

Activities  Supporting primary care programmes for smoking cessation during pregnancy and providing individual consultations;  Providing knowledge of the harmful effect of direct tobacco smoke and environmental tobacco smoke during pregnancy and childhood.

Indicators  Number of cessation programmes;  Number of campaigns/activities among target groups;  Level of awareness on the harmful effect of smoking.

OBJECTIVE 4.2 Promoting healthy eating during pregnancy and childhood. Specific objective 1: Increasing healthy food supplies in schools and institutions.

Activities  Support for the implementation of standards/legal regulations for healthy eating in schools, kindergartens and other educational institutions in the region;  Implementing a whole-school approach to healthy eating in the school environment;  Healthy eating training for teachers and the school staff responsible • 18 for nutrition.

Indicators  Number of institutions implementing standards for healthy eating;  Number of schools involved in the implementation of a whole-school approach;  Number of participants in the training.

Support for older people Similar to the processes in the country, in Lovech Municipality in the past 10 years, the population decreased due to the negative natural growth, which reached 9,7 in 2011. Mechanical growth is also negative and over the years has exceeded 4 . The peak of the abandonment of the region was in 2010, when mechanical growth rate reached a negative value of over 9 . This places the region second to last in terms of demographic characteristics among all 28 regions in the country. In the age structure of the population, those aged over 60 years exceed 40%, thus prevailing over the young (under 15 years) who reach 16%. Preventing social exclusion of this large group of elderly people is of major importance while supporting them and encouraging them to preserve their independence and participate more actively in community life. Older people in smaller settlements are often left to live alone or, far more rarely, are admitted into nursing homes. Economically disadvantaged families often do not have the money to pay for specialized care at nursing homes. On the other hand, rest homes lack enough place and social services at home also have insufficient capacity. Correspondingly, there is a great demand of homecare, thus the preparation to provide domiciliary care is a serious purpose. Prolonged and sufficient homecare may improve the quality of life and social contacts by furthering mobility and maintaining a safe home environment for the elderly.

OBJECTIVE 4.3 Promoting social contacts, mobility and autonomy of older people.

Specific objective 1: Promoting participation of older people in community initiatives.

Activities •  Developing programmes and activities/actions for the full inclusion of 19 the elderly in community initiatives;  Implementation of these programmes;  NGOs involvement in the programmes.

Indicators  Number of programmes/activities/actions supporting older people’s involvement;  Number of NGOs involved;  Number of older people involved.

Specific objective 2: Improving the ability of families to provide care at home.

Activities  Developing and implementing a training programme intended for family members and friends.

Indicators  Number of participants in the training;  Level of knowledge and skills of participants.

Specific objective 3: Maintaining a safe environment at home.

Activities  Providing knowledge and skills to create a safe home environment;  Building partnerships to implement safety verification in the homes of the elderly. Indicators  Level of knowledge and skills of the participants in the trainings;  Number of partner organizations involved in the safety verification in the homes of the elderly.

Support for persons with special needs Despite the fact that persons with special needs have legal access to work, social benefits and healthcare, they face another type of obstacles apart from the contacts with the relevant services and the stigma. Many of these obstacles are of financial and physical character, such as inaccessible • 20 urban environment, transportation over short and long distances as well as lack of opportunities for physical activity. All this inevitably decreases their social inclusion. Due to their specific needs and comparatively small number, they are often ignored as a concrete target group for preventive health initiatives. Therefore, an important aim is the development of specifically tailored programmes for them including relevant special methods.

OBJECTIVE 4.4 Supporting the improvement of health of persons with special needs.

Specific objective 1: Promoting a healthy lifestyle among persons with special needs.

Activities  Development of an adequate approach, methods and programmes to promote health among persons with special needs;  Finding local initiatives involving citizens with special needs and integrating a health component into them.

Indicators  Number of promotional activities carried out;  Number of persons with special needs involved in local initiatives with a health component in them.

Support for minorities and ethnic groups In the region have settled 5705 Roma. There are a language barrier and cultural differences leading to social exclusion and adverse health status. Every culture has a system of values and norms that directly or indirectly determine behavior. Of key importance to intercultural health promotion is the knowledge and understanding of the value system of other cultures and their impact on health. The approach to community empowerment involves ethnic minorities in health promotion programmes, thus aiming at the improvement of the quality of life in the community. In general, communities identify their own major development challenges and propose initiatives aimed at solving problems. These initiatives lie at the core of local, regional and national programmes. The approach particularly emphasizes on marginalized groups in the community, including women. However, it does not exclude the participation of anyone else. Community empowerment is a cyclic 21 • process of interaction in which community members collaborate in formal or informal groups by sharing their knowledge and experience to achieve a common goal. This process is based on four key principles: economic opportunities, sustainable development, community partnership and a strategically planned change. For the Roma minority, depending on the degree of integration, the plan aims to overcome the language barrier in health promotion activities. Also, community empowering is essential so as to identify and find solutions to health-related problems. This will allow for the development of targeted programmes regarding the issues identified.

OBJECTIVE 4.5 Promoting healthy behavior in ethnic and minority groups.

Specific objective 1: Overcoming language barriers for health promotion programmes intended for the Roma minority.

Activities  Ensuring the implementation of health promotion activities in Romani language;  Development of printed health promotion materials in Romani language;  Media involvement to ensure the maintenance of health promotion activities in Romani language.

Indicators  Number of health promotion activities in Romani language;  Distribution of printed materials in Romani language;  Media coverage of health promotion in Romani language. Specific objective 2: Mobilizing the Roma community on health issues through the empowerment approach.

Activities  Establishing a permanent working partnership with the Roma community;  Implementation of the empowerment approach to mobilize the Roma population.

Indicators • 22  Level of partnership with the Roma community.

Specific objective 3: Identifying health needs of the Roma minority.

Activities  Planning and conducting periodic surveys on lifestyle;  Providing opportunities for the Roma community to identify its own needs.

Indicators  Report on lifestyle;  Health status of the Roma community.

Specific objective 4: Increasing the amount of culturally appropriate health promotion for the Roma.

Activities  Development of health promotion programmes for the Roma community with their active participation in the process;  Implementation of Roma health promotion programmes.

Indicators  Developed health promotion programmes for the Roma community;  Number of implemented programmes.

Specific objective 5: Increasing the involvement of the Roma in screenings for various health problems. Activities  Incorporating screenings for various health problems in health promotion programmes for the Roma;  Training health professionals to work with the Roma.

Indicators  Number of participants in the training;  Measurable change in the number of the Roma covered by screenings for various health issues 23 • OBJECTIVE 4.6 Improving the demand and access to health services for disadvantaged persons belonging to ethnic minorities.

Despite the fact that almost two-thirds of Roma people are children or young people where long-term health problems occur relatively more rarely compared to adults due to the difficulties and often the failure to provide timely and continuous treatment for the needy, life expectancy in the Roma group is 10 years less than that of the general population. The share of the elderly – the persons over 60 years in the Roma community is about 4 times lower than the Bulgarians. A trend of very early marriages, birth of a first child during adolescence and subsequent births with a short interval between them is kept. Early births are an additional risk factor for fetus prematurity, severe birth defects, high infant mortality in the first year of life and high maternal mortality as well. In the Roma minority groups, lethality regarding diseases such as heart attack, stroke, pneumonia or malignancy is higher. The peak of mortality is in the range of 40-49 years of age, with the main causes being cardiovascular and cerebrovascular diseases. According to a study conducted during the elaboration of the Health Strategy for Disadvantaged Persons Belonging to Ethnic Minorities5, there is a chronically ill person in 68% of the Roma households; 58% are deprived of access to dental care; 55% indicate that the difficult access to physicians due to far-away locations pose a danger to their health, with villagers more often stating remoteness as a risk factor; 46% of Roma people lack health insurance. These trends have been observed for over 15 years; however, have especially deepened recently.

5 http://www.ncedi.government.bg/zdravna%20strategia_prieta.htm GDP per capita for Lovech Municipality was equal to 62% of the national average (National Statistical Institute, 2009). In the same year, the number of people living in households with low intensity of economic activity exceeded 20%, which is almost 3 times higher compared to the national average. 25% of the regional population lives below the relative poverty line while 65% live in material deprivation. The region is characterized by negative socio- demographic processes: aging and regressive age structure, progressive decrease in the working-age population, unemployment rate growth as well as rise in the number of the working poor, and increase in the number of discouraged jobseekers. This expands the scope of groups at risk and • 24 impairs their access to health services, while at the same time the need of the latter is rising. Nearly half of those who used health services in 2011 were forced to abandon the district in order to receive necessary health services.6 Main factors for the deterioration of the health of the Bulgarian citizens belonging to ethnic minorities are poverty, unhealthy lifestyle associated with malnutrition, persistent distress combined with other risk factors, such as smoking, alcohol abuse, drug use, low physical activity, etc. The low purchasing power of the majority of Roma households makes paid medical services and medications inaccessible to them. A specific risk factor for this vulnerable group is also social exclusion. Representatives of disadvantaged ethnic minorities face more difficulties in the prevention and early diagnosis of cancer, cardiovascular, pulmonary and musculoskeletal diseases that are more common among them because of the labor market activities they perform. A particular problem among the Roma population is the insufficient immunization coverage of children and related cases of diseases that have been eradicated among ethnic Bulgarians. Moreover, there are also obvious ethno-cultural differences. The assessment of one’s own health status, the demand of medical advice and the attitude towards the disease are underestimated, often being undifferentiated, confined to the community or delayed for subjective reasons. Visits to the doctor are rare even in case of serious health problems. And this is due not only to family financial difficulties. Rather, the high mobility of part of the Roma groups hampers their access to medical care as well. Given the existing financial constraints, in the forefront comes up the need to seek and exploit opportunities for change in awareness, motivation,

6 http://www.regionalprofiles.bg/bg organization of demand and access to health information and health services as well as their adaptation to the disadvantaged people of minority descent. In the current socio-demographic situation, vulnerable target groups in this region, such as children and mothers, school dropouts, the unemployed, people with special needs and those with minority background overlap to some extent, which further increases their priority. This allows affecting health disparities in an indirect but effective way.

Specific objective 1: Building local capacity of health mediators as coordinators between healthcare institutions and persons from minority groups and communities. 25 •

1. Characteristics of the vulnerable group that necessitate intermediary interventions.

The selected vulnerable group has high cultural specificity, constantly growing confinement and by being a heterogeneous community, is generally stigmatized by society and discriminated against by institutions. Ongoing community processes of impoverishment, marginalization and social exclusion affect how reliable information about it may be obtained. Income of a Roma family from social benefits is 4 to 6 times lower than the subsistence level, and unemployment – over five times higher than that of the rest of the population. The majority of the unemployed lost their jobs more than 5 years ago and most of them have not been registered at labor office directorates. Community representatives enjoying a higher standard can hardly be used as a source of information and a conduit of new influences since they demonstratively deny identifying with the Roma community or reject their ethno-cultural affiliation with the dramatically increased group of the Roma who have lost their traditional culture before replacing it with another. Data on marital status and number of children in a family can be obtained solely by respondent sas in the process of community marginalization and ghettoization of the areas inhabited by compact Roma groups, the tendency among them to not conclude civil marriages in the respective municipal institutions and give birth at home is rising. Level of education, cultural specificity, encapsulation and complex relations with the institutions of the target group make access to it extremely complicated, especially on such a sensitive topic as health. 2. Health mediator – a key element of a systematic approach to reducing health inequalities among disadvantaged citizens belonging to minority groups.

Access to the target group is possible only through community intermediaries. This reality was recognized early on in the project of the Ministry of Education and Science regarding the opening of 500 jobs for educational mediators in Roma communities for the school year 2000/2001 as well as in the project funded under the “PHARE Programme” and monitored by the Ministry of Health and the Ministry of Finance named “Ensuring Roma • 26 Access to the Healthcare System” where the training of health mediators from the Roma community has been made equivalent to the preparation of physicians and nurses of the 15 health centers in the educational component of the project. Financial constraints, negative socio-demographic trends together with emigration of health professionals at all levels have led to the availability of one single mediator in Lovech Municipality. However, health mediator remains a key element for effective work in the area of the largest health inequalities, particularly those among disadvantaged persons, including minorities. A principally important role for the sustainability of the system of health mediation now that financial constraints do not afford all municipalities in need to appoint health mediators plays the fact that each of the appointed mediators prepares his/her competent, permanent and respected assistants in the community, taking into account their traditional family and social roles and expanding the adequate culturally specific access to health communication and related follow-up and interaction. On the other hand, both the municipality and the RHI create a supportive environment for mediation activity and involve future ones.

Activities  Informing the accessible part of the Roma community on health issues and healthy lifestyle through the initiative “Health Mail”;  Conducting interactive health classes and discussions in “Health Ambassador” clubs;  Involvement of all students from the community in health classes;  Organizing “Health Ambassador” clubs where volunteers are being prepared for peer educators, with all activities being carried out with the participation of an acting health mediator;  Providing financial and organizational support from the municipality and NGOs: For students of minority descent who intend to study for health- related occupations; For high school graduates of Roma descent willing to qualify as health mediators; For those who have been granted the health mediator status until being engaged as such by municipalities – meal vouchers, phone vouchers; For training credible community members on health promotion issues; 27 • For training community members to give first aid.  Engaging those who have been undergoing practical training in a certain community in municipal health centers or mobile ones provided by the Ministry of Health;  Supporting, if necessary, all members of the community who have been skilled as health mediators and medical professionals to enhance their qualification as cross-cultural mediators;  Incorporating them into the National Network of Health Mediators and assisting in establishing its units in the municipality.

Indicators  Number of “Health Mail” publications on issues related to Roma health, with information from their representatives, ideally – almost entirely illustrated;  Number of interactive classes with editions in the health class and the “Health Ambassador” clubs;  Number of Roma students covered in health classes and who have conducted independent health classes; number of those covered by “Health Ambassador” clubs; presence of such clubs in schools with predominant Roma population; number of visits and discussions held with the relevant mediator;  Number of trainings carried out and participants with a different status in the community covered by them;  Involved medical students of Roma descent to provide assistance during the summer internship to GPs who practice in neighborhoods with prevailing Roma population and dealing with mobile units;  Ensuring a health mediator in one new settlement each year. Specific objective 2: Overcoming cultural barriers in communication and all forms of discriminatory attitudes.

Activities  Providing knowledge and skills for handling patients of various cultural background and lifestyle to the general practitioners and nurses working with disadvantaged people belonging to ethnic minorities;  Conducting workshops for the medical personnel to acquaint them with the culture, traditions and health status of the Roma minority;  Informing patients from ethnic minorities on their opportunities to • 28 defend their rights and report violations of healthcare to the Regional Health Inspectorate, the Regional Health Insurance Fund, the Bulgarian Medical Association, the Helsinki Committee, the “Human Rights” Project, etc.;  Involving professional associations of physicians and dentists as well as municipal human rights organizations against any case of discrimination in providing health services to disadvantaged members of ethnic communities.

Indicators  Number of trainings conducted and number of GPs and nurses involved;  Number of workshops, therapeutic and prophylactic facilities and personnel involved; Documented participation of a health mediator, expert (for example, from an NGO) or a reputable community representative on health issues;  Number of lectures delivered, meetings with representatives of the above-mentioned organizations held, number of complaints submitted and sanctions imposed thereon;  Public statements by representatives of professional associations against discrimination, placing the relevant issue on the agenda of a regular meeting.

Specific objective 3: Mobilizing the Roma community in preventive and health promotion activities through the implementation of the empowerment approach and intersectoral cooperation.

Activities  Promoting by the Public Health Initiative Association of the establishment of branches of the large Roma organizations in the region and supporting their participation in addressing health inequalities in the area;  Establishing a permanent working partnership of the Public Health Initiative Association – a body bringing together representatives of the government, the private and the public sector as well as NGOs representing the Roma community;  Involving the Bulgarian Red Cross as a partner of the Association to prepare young people and respected members of the Roma community on health issues for giving first aid and providing basic information on disease prevention and healthy lifestyle either directly 29 • or by initially trained volunteer tutors.

Indicators  Number of branches or representatives of the main Roma NGOs at the national level;  Written agreements for cooperation or co-option in the Association of the respective organizations and credible local representatives of the Roma community on health issues;  An adopted joint programme with a timetable for the activities of the Bulgarian Red Cross on first aid training.

Specific objective 4: Increased amount of culturally adapted health promotion for the Roma community.

Activities  Development of health promotion programmes for the Roma community with the active participation of a mediator and respected local representatives of the Roma community on health issues;  Providing language accessibility of health promotion programmes intended for the Roma community;  Ensuring that health promotion activities are carried out in the mother tongue;  Development of tailored health promotion materials (visuals, pictorials);  Media involvement for maintaining health promotion activities in the Romani language. Indicators  Number of the local representatives of the Roma community involved in the development of health promotion programmes;  Number of culturally adapted programmes;  Number and scope of culturally adapted health promotion activities;  Number of materials distributed;  Number of broadcasts and publications in the media regarding the culturally adapted health promotion.

AIM 5: MAINTAINING A CLEAN • 30 AND HEALTHY ENVIRONMENT

Physical environment has a huge impact on health. Its understanding requires not only an examination of the direct pathological effects of various chemical, physical and biological agents, but also that of the wider physical and social environment, such as places of residence, urban environment, land-use and transport, manufacturing and agriculture. Recent decades have deepened the understanding that this physical environment must be valued and protected. Despite the declining industrial production and the closure of many enterprises, in terms of harmful atmospheric emissions per sq. km, the region is placed 11th among all the 28 regions. In the same year, only about 45% of the population in the region lives in settlements with public sewage, which is the second lowest among the other regions, while the use of septic tanks and absorption wells lead to groundwater pollution. The lack of sewerage in small residential areas and neighborhoods of the larger ones, the discharge of wastewater into rivers and gullies, the use of septic tanks and absorption wells, the development of irregular aggregate quarries, the individual illegal firewood logging, the tree-felling to clear building sites and the disposal of construction waste at inappropriate places all lead to the deterioration of living conditions and environmental pollution in the region. Both the population and the policy makers who elaborate policies and strategies should be encouraged to make and promote an environmentally-friendly choice.

OBJECTIVE 5.1 Promoting positive behavior of people towards physical environment.

Activities  Providing knowledge of a healthy environment and raising public awareness on its impact on people’s lives;  Developing programmes and actions to discourage polluting behavior of the population;  Implementation of the programmes;  Organizing activities to encourage people to apply measures for environmental protection and make choices conducive to the environment;  Providing media support for these activities.

Indicators •  Number of messages about a healthy environment; 31  Number of implemented programmes to prevent pollution;  Number of activities for making an environmentally-friendly choice;  Media coverage of these activities.

OBJECTIVE 5.2 Promoting an environmental protection policy at local level.

Activities  Providing knowledge and training of field-related stakeholders and key actors to develop an environmental protection policy;  Lobbying for environmental protection strategies.

Indicators  Number of environmentally-friendly strategies. • 32

Authors: Plamen Dimitrov Galya Tsolova Antoaneta Manolova Elena Teolova Anelia Koteva

Sofia, 2014

ISBN 978-954-8404-18-1

This publication arises from the project ACTION-FOR-HEALTH which has received funding from EU in the framework of the Health Programme.

Unless otherwise stated, the views expressed in this publication do not necessarily reflect the views of the European Commission.

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Health promotion action plan

For reducing health inequalities in Sellye micro-region

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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Authors:

Members of the working group participating in the development of the Action Plan: Katalin Gáspár, micro regional animator, Tutor Foundation Dr. Ildikó Barta, GP Mártonné Frank, health visitor Dr. Katalin Kováts, paediatrician Éva Mészáros, mentor Csilla Pandur, regional mentor, MMSZ

Members of National Institute for Health Development participating in the development of the Action Plan: Dr. Tamás Koós, professional leader Éva Fekécs, health visitor Éva Járomi, project assistant Eszter Lőrik, project coordinator Ágnes Taller, project coordinator

National Institute for Health Development, Budapest, November 2013

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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Contents

Executive summary ...... 4 The need for preparing the action plan ...... 6 Health inequalities in the Sellye micro-region ...... 8 Reduction of health inequalities with the tools of health promotion ...... 16 Action plan for reducing the health inequalities among the population of the Sellye micro-region ...... 18 Aim 1: Organisation of health promotion programmes, providing information to the population for decreasing health problems, developing health literacy ...... 19 Aim 2: Capacity development, human resource development ...... 27 Aim 3: Infrastructure development ...... 30 Summary ...... 32 Annex ...... 33 Annex 1: Settlements belonging to the Sellye micro-region and the population of the settlements (2012) ...... 33 Annex 2: The use of the resources of the Structural Funds in the Sellye micro-region in the period of 2007-2013 ...... 34 Annex 3: Programmes to be implemented ...... 40 Bibliography ...... 45

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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Executive summary

This action plan was prepared within the frameworks of the “ACTION-FOR-HEALTH” project (http://www.action-for-health.eu/). The project is implemented with the co-financing of the European Commission between 2012 and 2014, and is coordinated by the Institute of Public Health Murska Sobota located in Slovenia. 9 associated partners participate in the project from different European countries, including the National Institute for Health Development (hereinafter referred to as “OEFI”, according to its Hungarian abbreviation). The general aim of the project is to decrease health inequalities with the tools of health promotion, contributing to the improvement of the health and living standards of the population. In order to achieve this, the project encourages the use of resources deriving from the European Structural Funds for reducing the health inequalities in the partner countries. Furthermore, as a principal task, the partners prepare a local (regional/micro-regional/town- level) action plan for an optional regional unit in their own countries.

The objective of the action plan aiming to decrease the health inequalities (hereinafter: action plan) is to reduce the health inequalities within the population of the Sellye micro- region in Baranya county with the tools of health promotion. The action plan was prepared with the coordination of OEFI, with the cooperation of the experts of the Sellye micro-region and the Hungarian Maltese Charity Service (hereinafter referred to as “MMSZ”, according to its Hungarian abbreviation), with the support of the ACTION-FOR-HEALTH European Union project.

The Sellye micro-region was selected as the location of the action plan due to the availability of the professional resources of the region and the partnership relations operated by MMSZ, and the disadvantageous situation of the micro-region. In accordance with the project tasks, the location was selected after a country-level situation assessment concerning health inequalities. Following this, the situation of the health status and health inequalities of the population living in the Sellye micro-region was assessed, and the capacities and resources needed for preparing the action plan were explored.

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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The action plan intends to enhance the reduction of health inequalities within the population of the Sellye micro-region by relying on the tools of health promotion, local initiatives and the possibilities of using the structural funds locally, focusing on the disadvantaged groups, especially on children. The basis of preparing the action plan is a close cooperation with the stakeholders of the micro-region. The action plan reflects on the needs and problems defined by the experts of the micro-region, considering the objective requirements related to health and the needs of the population concerning health. Accordingly, its three main aims are: to organise different health promotion programmes, in order to provide information to the population for preventing and decreasing health problems, and develop health literacy; to develop capacity and human resources (among the local healthcare and social professionals); and to enhance infrastructure development. After the completion of the action plan, two selected programmes will also be implemented during the project period, from the financial resources provided by the project; and after implementation, the results will be evaluated.

The action plan prepared by the cooperation of MMSZ, the experts of Sellye and OEFI will remain in possession of the local community after the expiry of the ACTION-FOR-HEALTH project period (August 2014) and will be available for supporting further measures. The action plan can be used for elaborating other programmes, projects, and in the period between 2014 and 2020, it may enhance the professional justification of the tender programmes when submitting the bids for the utilisation of the resources of the European Union’s Structural Funds. Furthermore, it may also help and support the local implementation of the measures of the National Social Inclusion Strategy (2011-2020). In addition to the above, based on the Slovenian experiences1, with appropriate decision-maker support, the model of the successful action plan may also be adapted to other micro-regions of the country2.

1 The Institute of Public Health Murska Sobota prepared an action plan in 2005 for the Promurje region for decreasing health inequalities. Based on the prepared methodology, similar action plans were prepared later in each Slovenian region. 2 Based on the experiences of this project, OEFI plans to develop a similar action plan in another Hungarian micro-region in the project entitled “Mental Health and Health Workforce Capacity Building in Hungary” in the public health initiatives launched within the frameworks of the Norwegian Financial Mechanism. This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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The need for preparing the action plan

Some of the differences in the health status of the population derive from biological or genetic reasons, and from the consequences of the decisions made freely by the individuals. However, the other part of the differences regarding health status cannot be explained by genetic reasons or consequences of the free decisions of the individuals: “the unfair or avoidable health inequalities indicate differences in mortality and health status among and within population groups, the reasons of which are social and economic factors determining health like income, qualification, position, living and working environment; and which can be decreased by appropriate structural interventions. (…) The unfair domestic health inequalities are characterised by consistent high mortality in the northeast and southwest part of the country; by the significant differences among and within the micro-regions of the countryside and the districts of Budapest; the survival disadvantages of people with lower education compared to those with higher education levels, and the increase of the geographical and socio-economic health differences in the last three decades.”3 For example, for men at the age of 30, there is a 13-year difference in the life expectancy of those with the lowest and those with the highest education.4

The health status of the population is rather unfavourable; the health indicators of the country and life expectancy lag far behind the averages of the European Union. The tumorous and chronic diseases and early mortality are serious social and economic risks.5 All these result in the decrease of the society’s performance capacity.

3 Karolina Kósa (2009): A társadalmi egyenlőtlenségek népegészségügyi hatásai Magyarországon (The Public Health Effects of Social Inequalities in Hungary). Népegészségügy. (Public Health) Year 87, issue 4, page 329 4 Commission Staff Working Document. Report on health inequalities in the European Union. Brussels, September 2013 5 Website of the Ministry of Human Resources, State Secretariat for Healthcare. http://www.kormany.hu/hu/emberi- eroforrasok-miniszteriuma/egeszsegugyert-felelos-allamtitkarsag/felelossegi-teruletek This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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There is a kind of socio-economic difference along the east-western and south-northern axis of the country. The difference separating the country’s capital (together with its agglomeration) from the other parts of the country is also notable, which is a consequence of several reasons. These include the central nature of the geographical location, the institutional system and the transportation networks, as well as other socio-economic factors.6

Social exclusion is mainly caused by the conditions related to poverty. Nowadays, the low level of employment, the deteriorating health status and the ethnical segregation result in increasing social problems in Hungary affecting the public sector, the social coexistence and the economic growth as well.

Social inclusion and the reduction of health inequalities are supported by several national strategies. The main objectives of the National Social Inclusion Strategy7 for the period between 2011 and 2020 are to decrease the ratio of people living in poverty and social exclusion, especially considering the Roma population; to prevent the reproduction of poverty and social exclusion, to improve equal access to social and economic resources, and to strengthen social inclusion. At the national level, the National Public Health Programmes deal with the issue and reduction of health inequalities, including the “Vasgyúró” programme for children’s health specifying the tasks for the period between 2013 and 2016, the “National Programme of Mental Health” (“Lelki Egészség Országos Programja”) for the period between 2007 and 2020, and the “National Strategy for Decreasing Drug Problems” (“Nemzeti Stratégia a kábítószer-probléma kezelésére”) for the period between 2010 and 2018.

6 Magyarország társadalmi atlasza (Social Atlas of Hungary). Központi Statisztikai Hivatal (Hungarian Central Statistical Office), Budapest, 2012. 7 Nemzeti társadalmi felzárkózási stratégia – mélyszegénység, gyermekszegénység, romák – (2011–2020). (National Social Inclusion Strategy – Extreme Poverty, Child Poverty, the Roma - (2011–2020). Budapest, 2011. november. KIM Társadalmi Felzárkózásért Felelős Államtitkárság. (Budapest, November 2011. KIM State Secretariat for Social Inclusion), page 9 This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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During the 2007-2013 funding period of the Structural Funds of the European Union, mainly the funds provided within the frameworks of the Social Renewal Operational Programme (hereinafter referred to as “TÁMOP”, according to its Hungarian abbreviation), the Social Infrastructure Operational Programme (abbreviated as “TIOP” in Hungarian) and the Regional Operational Programmes (ROP) were available for decreasing health inequalities at the local level.

In the Sellye micro-region selected for the project, several projects and investments were implemented with the co-financing of the European Union which may contribute to decreasing the health inequalities of the region by enhancing social inclusion, by increasing employment, and by investing in infrastructure. Some examples are included in Annex 2. This action plan targets the reduction of health inequalities by relying on the experiences and results of the above activities and by mobilising the local capacities and resources in the Sellye micro-region which is affected notably by the aforementioned social and economic problems.

Health inequalities in Sellye micro-region

When describing the health status, health inequalities and its determinants in the Sellye micro- region, the action plan relies mainly on the document entitled “Mirror of the Sellye Micro- region”8 prepared for the MMSZ as the professional-methodology justification for the national extension of the Chances for Children Programme (Gyerekesély Program).

The Sellye micro-region is one of the poorest regions of Hungary: according to Government Decree 311/2007. (XI. 17.) on the Classification of the Beneficiary Regions, it is the country’s

8 Veronika Domokos– Mónika Tószegi– Lászlóné Turós: Sellyei kistérségi tükör (Mirror of the Sellye micro-region). Helyzetfeltárás. (Situation assessment) 2012. The document entitled “Sellyei kistérségi tükör” was prepared for the MMSZ as the professional-methodology justification for the national extension of the Chances for Children Programme and for monitoring the programme within the frameworks of the project TÁMOP-5.2.1-11/1-2011-0001. This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

9 micro-region with the third worst social and economic indicators. From among its 35 settlements, the poverty risk of 24 settlements is of the highest degree.9 The total population of the micro-region was 14,181 in 2011. (The list of the settlements belonging to the Sellye micro-region and the number of population are included in Annex 1.)

Life expectancy at birth in Sellye was 72.8 years according to the data of 2010, lagging behind the national average of 75.1 years in 2010. The life expectancy of the women in Sellye was 75.9 years in the same year, exceeding the life expectancy of men by 6.21 years.10

According to the data of 2011, the mortality of the micro-region is led by deaths caused by vascular diseases (41.8%), tumorous diseases (30.8%) and pulmonary diseases (10.4%).11 Compared to the national data of 2010 (vascular diseases: 50.5%, tumorous diseases: 25.4%, and pulmonary diseases: 4.8%)12 it can be said that the mortality data of the micro-region – except for vascular diseases – are worse than the national average in the case of the leading causes of deaths.

Among diseases, causes are led by cardiovascular diseases. The problem of high blood pressure arises at early ages, even among children in elementary schools, just like diabetes, which are caused by inappropriate diet and obesity. “The number of mental illnesses is also notable. According to the patient flow data of the Sellye Healthcare Centre’s (Sellyei Egészségügyi Központ) psychological consultation, the number of patients visiting the consultation has increased consistently in the last ten years, reaching the peak in 2010 (2358 cases). The distribution of diseases according to diagnosis clearly shows that the symptoms of depression and anxiety occur most often among the population. For example, in 2010 the

9 Veronika Domokos– Mónika Tószegi– Lászlóné Turós: Sellyei kistérségi tükör. (Mirror of the Sellye micro-region) Helyzetfeltárás. (Situation assessment.) 2012. Pages 5-6. 10 Census 2011. According to the 2013 calculations of Pannon Elemző Iroda 11 Halálozási táblák és térképek (Mortality tables and maps) – OEFI, 2011. (http://www.oefi.hu/halalozas/) 12 Központi Statisztikai Hivatal (Hungarian Central Statistical Office) – Demográfiai évkönyv (Demography Yearbook), 2010. (CD-supplement) This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

10 number of depression cases was 1129, and the number of anxiety cases was 617. These diseases are closely related to the living conditions and the life insecurity characterising the majority of the micro-region’s population.”13 (Prevalence of mental illnesses in the different age groups might be important as regards parents with small children. The mental status of parents inevitably affects children and influences both their physical and mental development.)

In 2010, 14 babies out of 123 were born with low weight (below 2500 grams).14 On the basis of this figure we can say that 11% of the infants born alive in 2010 were born with low weight, exceeding the national average: according to the data of the Hungarian Central Statistical Office, 90,335 babies were born in Hungary in 2010, of which 774215 were born with a weight below 2500 grams, which means that in 2010, 8.57% of the infants born alive were born with low birth weight.

In 2010, 140 children reached the third year of age, and on the basis of the compulsory screenings, problems were found in 41 cases, of which the most common problem was malnutrition. Problems deriving from malnutrition, obesity and unhealthy nutrition were diagnosed at 12% of the children.16 In 2011, some form of malnutrition was diagnosed in 12 cases in the under-18-years age group. The same figure increased to 16 persons in 2012.17

13 Veronika Domokos– Mónika Tószegi– Lászlóné Turós: Sellyei kistérségi tükör. (Mirror of the Sellye micro-region) Helyzetfeltárás. (Situation assessment.) 2012. page 66 14 Veronika Domokos– Mónika Tószegi– Lászlóné Turós: Sellyei kistérségi tükör. (Mirror of the Sellye micro-region) Helyzetfeltárás. (Situation assessment.) 2012. page 66 15 Központi Statisztikai Hivatal (Hungarian Central Statistical Office) – Demográfiai évkönyv (Demography Yearbook), 2010. (CD-supplement) 16 Veronika Domokos– Mónika Tószegi– Lászlóné Turós: Sellyei kistérségi tükör. (Mirror of the Sellye micro-region) Helyzetfeltárás. (Situation assessment.) 2012. page 67. 17 Data supply of the National Health Insurance Fund of Hungary, 2013. This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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121 children – in the under-18-years age group – visited the doctors with pulmonary diseases in 2012.18 According to the local expert opinions disclosed at the round table discussion held in Sellye on 12 June 2013, smoking is very popular among the population, children try smoking at a quite early age and become addicts by 10-12 years of age. The other serious problem is the effect of stove smoke getting back into homes damaging the pulmonary system.

Mainly the housing conditions, the environmental factors are the causes of the recent significant number of allergic and asthma diseases – this latter is enhanced by the fact that the symptoms of allergy are not treated appropriately as the patients cannot buy the expensive medicines.

Orthopaedic deformities (splay foot, scoliosis) are also frequent among children.19

Health inequalities and the health status in the micro-region are influenced by the following social factors:

The employment and qualification indicators of the micro-region are unfavourable. In 2012, the unemployment rate was 27.3%, more than double of the national average (10.9%). According to 2011 data, the unemployment rate of the economically active population (43.8%) and the ratio of the economically inactive people compared to the total population (37%) are extremely high. The average income of the employed people also lags behind the national average. For the majority, the only form of employment is public employment and agricultural work. The biggest problem of the micro-region is the lack of workplaces, and the ration of people with low qualification and with outdated, non-marketable qualifications. 65% of the population above 7 years have a maximum of elementary school qualification. The ratio of people with secondary school qualification was 21.7% in 201120, while the national

18 Data supply of the National Health Insurance Fund of Hungary, 2013. 19 Veronika Domokos– Mónika Tószegi– Lászlóné Turós: Sellyei kistérségi tükör. (Mirror of the Sellye micro-region) Helyzetfeltárás. (Situation assessment.) 2012. page 67. This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

12 average was 82.1%.21 10% of the population graduated from secondary school and the ratio of people completing their high school studies is very low.

In the settlements of the micro-region, the demographic processes are different. One group of the settlements has quickly vanishing, aging population, where the high rate of migration is accompanied by the natural decrease of the population. Another significant group of the settlements is formed by those settlements where the natural reproduction has a positive balance, and the age composition is young or becoming younger. In these settlements, the ratio of Roma population is typically high, which is accompanied by the notable segregation of the population. Migration can be observed in these villages as well. The ratio of Roma population in the micro-region is 32.8% according to the notary public datasheets, i.e. it accounts for one third of the villages’ population, concentrating on different extents in the settlements. In 16 settlements of the micro-region, according to the local estimates, Roma people live in majority. The employment and education indicators of these people are extremely unfavourable. In a significant part of the micro-region’s villages, the socio-ethnical homogenisation is irreversible.

The ratio of households with children and without employed family members is 13%. The family structures are characterised by a family model with two parents and three or more children.

Infrastructural facilities are scarce: the ratio of flats without conveniences and public utilities is 33% in the micro-region, and the frequency of public transport is also low. Each settlement has a bus stop for regional buses but the centre of the micro-region cannot be reached directly from 9 settlements by bus, some of which belong to the settlements in the worst situation. In 15 settlements, 1-4 bus services provide direct access to the centre of the

20 Census 2011. According to the 2013 calculations of Pannon Elemző Iroda 21 Eurostat. European Commission http://epp.eurostat.ec.europa.eu/tgm/table.do?tab=table&init=1&language=en&pcode=tps00065&plugin=1 This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

13 micro-region per day. Where there is no direct service, the duration of the travel can reach several hours due to the waiting times.

Access to the basic and specialised healthcare services is not sufficient. 11 family doctors are operating with nine seats in the micro-region containing 35 settlements. “From the seats, doctors visit the assigned settlements typically once a week or once in two weeks, for very short consultation hours lasting for a few hours only.”22

According to local experts, the biggest problem of the healthcare system is the out-of-hours service of the family doctors as currently there are 2 centres in the region (Sellye and Vajszló). Concerning financing, both of them are struggling as the financing per patient provided by OEP23 is low. However, due to the size of the area, one centre would not be sufficient for solving the task, only if more doctors would provide out-of-hours services (one of them would visit the homes and the other would remain in the outpatient clinic), but this would increase the costs. Furthermore, the out-of-hours service of Vajszló has been struggling with headcount problems for years. The reason is that most of the local doctors cannot work in out-of-hours service once or twice a week in addition to their daily works (which would even breach the law). Doctors from outside the region rarely undertake to work out of hours in addition to their own out-of-hours services at their workplaces, while the other problem is that the services shall be provided to children and adults as well and the doctors are not prepared for this professionally. The pharmacy is not always available out of hours (the pharmacies of Vajszló and of Sellye operate in weekly turns out of hours). The above problems could be solved by reorganising the out-of-hours services, and by the expansion and completion of the medicine stock of the out-of-hours services.

22 Veronika Domokos– Mónika Tószegi– Lászlóné Turós: Sellyei kistérségi tükör. (Mirror of the Sellye micro-region) Helyzetfeltárás. (Situation assessment.) 2012. page 45 23 National Health Insurance Fund

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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There is only one paediatrician in the micro-region. The paediatrician and the general practitioners with adult general practitioner qualifications provide services to the 2,184 children below the age of 14 within the frameworks of joint GP practices. The mobile paediatrician service reaches the villages approximately once per month. The availability of the district nurse is varying in each settlement; the local consultation hours are not proportionate with the number of the population using the service.

In addition to the deficiencies it shall be mentioned that the municipality of Sellye won a subsidy (of ca. HUF 1 billion) in 2008 from European Union Social Infrastructure Operational Programme funds for establishing an outpatient clinic for the micro-region in Sellye. The Ormánság Healthcare Centre (Ormánság Egészségközpont) started its operation in 2011. The centre provides specialist healthcare services in twenty field of expertise to the patients. According to local experts, the healthcare centre of Sellye provides an appropriate level of professional care and operates with shorter appointment times than most of the outpatient clinics in Pécs, and is also flexible in the treatment of problematic cases. The main problem is that some of the specialists have consultation hours in the afternoon/evening and some of the patients cannot visit the doctor at that time as there is no bus service home. (The buses operated by the village and homestead caretaker services, so called „village buses” could help to solve this problem. Unfortunately it is not consistent who shall be transported to which doctor at what time by the village buses. Furthermore, there are villages which do not operate the above mentioned service, therefore, transportation problems are not solved at all).

Another favourable initiative is that in two districts of Vajszló, blood samples can be taken once a week (on Tuesdays) in the morning at the general practitioner, and the samples are then delivered to the laboratory of Sellye by the help of the municipality, so the patients do not need to travel to another settlement to have their blood samples taken on an empty stomach.

Child welfare and family help services are provided in the micro-region by the Child Welfare and Family Help Service seated in Sellye, operating with the financing of the multi- This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

15 functional micro-regional association. The human resources of the institution lack professionals with special qualifications (psychologist, lawyer, etc.), and technical staff. The social and healthcare institutions struggle with staff shortage, the professionals work on significantly more cases than required. Therefore, the risk of burnout arises cumulatively.

Concerning the social composition of children studying in public education institutes, the ratio of disadvantaged24 and multiply disadvantaged25 children is dramatically high at the micro- regional level, however, there are significant differences among the settlements. The ratio of children eligible for regular child protection allowance in 2010 was 75.7%. 81.6% of the 517 children in kindergartens (422 children) are disadvantaged, while 41.8% (216 children) are multiply disadvantaged. 215 children receive support for visiting the kindergarten. 8 children have unique educational needs, while the number of children requiring early development is 21. The total ratio of disadvantaged students of the schools is 80.5%, while the ratio of multiply disadvantaged students is 42.8%, both of these ratios are critically high. The institutions consistently lack development professionals and pedagogic specialist services in caring for children and students. There is no grammar school education in the micro-region. Secondary education typically means agricultural training.

The social and health problems of the Sellye micro-region detailed above are very complex; therefore, the application of the effective methods of health promotion is recommended with the cooperation of several sectors. The reduction of the factors responsible for the main inequalities – i.e. the lack of workplaces, unqualified workforce –requires long-term and

24 Pursuant to the 2013 amendment of Act XXXI of 1997 on the Protection of Children and Guardianship Administration, the definitions of disadvantaged situation and multiply disadvantaged situation are included in the act on the protection of children. The child and full-aged child is of disadvantaged situation if he/she is entitled to receive regular child protection allowance and at least one of the following conditions applies: the parent or guardian has only basic (maximum elementary) education qualification; low-level employment of the parent or guardian.

25 The child and full-aged child is of multiply disadvantaged situation if he/she is entitled to receive regular child protection allowance and at least two of the conditions indicating the disadvantaged situation apply: the child is taken into care; and the young adult receives post-care services and has a student status.

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

16 large volume interventions. The disadvantageous situation of the micro-region could be mitigated by the more effective allocation of the available resources, intersectoral cooperation, involvement of the local stakeholders into decision-making and the support of civil organisations, as well as by the identification of the needs of the local population in order to increase access to services and better utilisation.

Reducing health inequalities with the tools of health promotion

The action plan intends to decrease health inequalities and to improve the health status of the population in the micro-region with the tools of health promotion. “Health promotion is the process which makes people able to increase their influence over and to improve their own health.”26 Accordingly, our main tools could be: In relation to decision-makers and professionals: • drawing the attention to the social determinants of health and to health inequalities, raising awareness in relation to the problems; • enhancement of intersectoral cooperation in order to improve health; • capacity development, development of skills. In relation to the population, especially considering the disadvantaged groups: • organisation of health promotion programmes; • disease prevention; • improvement of knowledge and skills concerning health, development of health literacy; • community development. Furthermore, it is recommended to consider and include the programmes of MMSZ realised in the recent years in the micro-region and operating currently into the action plan. Among

26 Rövid Közlemények. Javaslat az egészségfejlesztésben leggyakrabban használt szavak fordítására és értelmezésére. (Short releases. Recommendation for the translation and interpretation of the most common words used in health promotion) In: Népegészségügy (Public Health), Year 88, issue 1, page

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

17 these, the mobile playground programme is of special importance which may be suitable for being expanded with health promotion elements.

Mobile playground programme: The mobile playgrounds of MMSZ have been visiting the poorest settlements in the eight most disadvantaged micro-regions of the country (Sellye, Kadarkút, Barcs, Abaúj-Hegyköz, Encs, Bodrogköz, Fehérgyarmat, Vásárosnamény) since August 2011. This way they try to reach segregated parts of settlements and ghettos, where they try to provide opportunities for community playing to the inhabitants. The main target group of the programme are children, but most of the adults that are present get involved. Thus, besides playing, some kind of social work starts at the same time. All these are realized within the frameworks of the TÁMOP- 5.2.1 priority programme. The professionals travel to the sites by a small bus with the toys and with a programme developed in advance and tailored to local needs. The programme is implemented on the basis of the local facilities in closed or open-air places, where the possibility to play is ensured by the close cooperation of the local leaders, decision-makers and the population. During a playing programme, the organisers try to: • teach games to the children and their parents or helpers which can be played by them individually with low or no cost, and which have developing effects; • provide organised programmes with tools developing movement and movement coordination which is a new and interesting possibility for the children and which was previously impossible them to learn, given their drawbacks in socialization; • transfer norms and socialise people indirectly, develop a behaviour conforming to the community and the ability to accommodate to the system of rules; • promote socialization; • review the problems of the given settlements, to assess possible solutions and methods of community development; • initiate proper cooperation with local organisations and institutions, with “key persons” and local inhabitants.

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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Recognizing situations possibly leading to an accident is of special importance during playing as well as the prevention of these situations and the consistent management of playing.

The play bus and the game itself are used as tools, with the help of which they can reach the target groups of the priority programme, the children and parents in the micro-region. This way, the local characteristics can be known, the actually existing but often hidden problems can be discovered and specific solution plans can be prepared together with the local community so that in the meantime, the players learn to identify and utilise their own possibilities.27

Action plan for reducing the health inequalities among the population of Sellye micro- region

The action plan was prepared on the basis of the situation analysis prepared for the Sellye micro-region and the recommendations of the local experts. The health inequalities – especially among the disadvantaged population and children – are planned to be reduced by the help of three main aims. These aims can be realised approximately within 5-8 years .The first aim contains health promotion programmes for preventing and addressing the major health problems identified during preparation. The second aim is about developing the human resources of the healthcare and social professionals working in the micro-region. The third aim enhances the infrastructure development of the micro-region which is inevitable for realising the first two aims. The aims – after a short introduction – are then detailed in objectives, indicating the main activity areas. Finally, the objectives contain a specific list of activities with the related indicators. Annex 3 contains the detailed description of two programmes, including the establishment of the “Parent’s Club” (“Szülő klub”) and soft handball teams, which are realised with the support of the ACTION-FOR-HEALTH project.

27 Website of Chances for Children: https://sites.google.com/site/523help/kistersegek-tamogatasa/mobil-jatszoter This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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Aim 1: Organisation of health promotion programmes, providing information to the population for decreasing health problems, developing health literacy

In addressing the main health problems identified in the micro-region, priority shall be given to prevention, information supply and the organisation of specific health promotion programmes.

Among the population of the micro-region, a significant part of the diseases is related to smoking, nutrition and direct environmental effects. The majority of pulmonary diseases are caused by stoves smoking back into the living area during heating season, smoking and mould in the homes. The inappropriate quality and quantity of food further deteriorates the risk of diseases. Targeted prevention, the extension of the population’s knowledge concerning the prevention of diseases and the development of general hygiene knowledge are of key importance.

Mental illnesses which are closely related to the living standards and the insecurity characterising the majority of the population in the micro-region are also significant burdens in the micro-region. We recommend focusing on the community activities within the frameworks of which the different persons may gain appreciation and recognition in their own environments. The mood of people could also be improved significantly by tools increasing self-esteem. With appropriate organisation, the learning/teaching processes (willingness and openness to accept knowledge and to teach) can also be started. Women shall be given special attention. The life expectancy of women at birth is generally longer than that of men, however, they often spend these extra years in bad health condition, and hence the risk of developing mental problems is higher. In relation to the mental illnesses caused by insecurity, it is important to indicate the activities enhancing employment as goals, which aim to enable people to work. For improving the mental and physical health, it is inevitable to enhance and increase physical activity among the population.

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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1.1. Prevention of pulmonary diseases Activities: Prevention of smoking: • Organisation of programmes preventing smoking, information about the existing programmes • Organisation of programmes helping people to stop smoking, information about the existing programmes (especially considering pregnant women) • Drawing the attention to the risks of passive smoking (the smoking of parents at home is extremely dangerous to non-smoking family members as well) • Active involvement of non-smoking people into the implementation of the above tasks (non-smoking is a good example to be followed) • Raising funds for purchasing visual aids, involvement of new tools into the prevention programmes/presentations • Organising “non-smoking days”: sports events, organisation of teams (for example, the parents and the children shall not smoke that day) Prevention of problems caused by stoves returning smoke into the rooms: • Informing the population about the need for checking the technical conditions of stoves, the maintenance and cleaning of the smoke exhaust systems, the significance of chimney sweeping • Informing the population about the significance of using carbon monoxide meters Prevention of problems caused by mould: • Enhancing the yearly whitewashing and sterilisation (chlorinated lime) of homes (living areas) • Drawing the attention to the importance of frequent, short ventilation • Enhancing the drying of washed clothes outside the living area (in the open air both during the winter and the summer)

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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Indicators: • Number of health promotion programmes (e.g. programmes enhancing prevention, supporting people to stop smoking, sports events) • Number of participants in the programmes • Number of sectors/stakeholders supporting the operation of the programmes • Number of resources of the funding systems (e.g. EU, charity organisation, municipality (state) fund, etc.)

1.2. Prevention of diseases related to nutrition Activities: • Drawing the attention to the need of providing food, “free kitchen” to those in need, raising funds • Drawing the attention to the importance of supporting child nutrition, raising funds • Improving the healthiness of public catering (food provided in kindergartens, schools) (e.g. drawing the attention to avoiding food containing trans fats) • Drawing the attention to the dangerous effects of energy drinks • Subsidy system for cultivating gardens: providing seeds to those in need • Organising trainings about growing plants in the kitchen garden (winter trainings) • Supporting the planting of fruit trees, providing fruit trees within the frameworks of subsidies (sour cherry, plum, apple, etc.) • Providing animals for domestic stock-raising within the frameworks of subsidies (chicks, turkey, duck, goose, etc.) • Organising trainings about domestic stock-raising (prior to launching the subsidy system) • Providing a support system: mentoring service (financial, kitchen gardening, stock-raising, etc.)

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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• Cooperation agreement with the local secondary agricultural school about the establishment of a training garden (growing fruits and vegetables with the help of the students) • Reforming the menu of the restaurants providing school catering by using the raw materials and products of the aforementioned training garden and/or other local producers • Including the knowledge about health and healthy nutrition into the activities of the mobile play bus • Organisation of programmes developing health behaviour: joint cooking programmes, health clubs, movies, etc.

Indicators: • Number of subsidy systems and programmes • Number of the indicated funds of the subsidy systems and programmes (e.g. EU, charity organisation, municipality (state) funds, etc.) • Number of sectors/stakeholders supporting the operation of the programmes • Number of donated/planted trees • Number of planted trees which have started to grow • Number of participants in the different programmes

1.3. Enhancing the establishment of healthy living environments Activities: • Extension of theoretical and practical knowledge about the management of domestic waste within the frameworks of forums • Enhancement of environment-friendly living: extension and popularisation of selective waste collection (according to similar initiatives, e.g. free removal of selective waste every 2 weeks in special bags) • Organisation of bulk waste collection once/twice a year • Providing information about the rules of fire lighting

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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• Enhancing gardening: street cleaning, mowing, reaping • Snow removal from the pavements in front of the houses during winter (safe traffic) • Awarding “Clean Environment” signs/titles

Indicators: • Number of illegal waste disposal • Quantity of removed domestic waste • Quantity of waste removed during the bulk waste collection organised once/twice a year • Number of home fires • Number of burn injuries • Number of awarded “Clean Environment” signs/titles

1.4. Improvement of mental health Activities: • Drawing the attention to the need of expanding the psychiatry and psychology service system • Monitoring the mental health of the aging population, especially of women with the cooperation of helpers (social workers, mental hygiene professional) • Fighting against alcoholism and other addictions: organising self-help or supporting groups (e.g. group for alcoholics anonymous, group for game addicts, etc.) • For decreasing school violence and aggression: participation of students in the issue-specific performance of the Theatre of Kaposvár, after which they talk about the topic with the help of a psychologist • Organisation of joint cultural programmes, within the frameworks of which information concerning health promotion is also supplied (e.g. joint singing,

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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cooking, playing music (outside, around a campfire in summer, and in the community house in winter) • Providing information during cooking, together with nutrition advices, e.g. cooking outside in summer (simple food, by using seasonal fruits and vegetables, with new preparation methods, etc.) • Organising practical, community-building programmes in the community house (e.g. arts and crafts, painting, basketwork, etc.)

Indicators: • Number of practical programmes • Number of programmes organised in the community house • Number of participants in the different programmes • Number of sectors/stakeholders supporting the operation of the programmes • Number of the indicated funds of the subsidy systems (e.g. EU, charity organisation, municipality (state) funds, etc.) • Number of the local self-organisations (e.g. organisation of small music bands, dance teams, ball sports, e.g. football, etc.) • Number and type of people organising community development activities (e.g. charity organisation, municipality, etc.) • Number of professionals dealing with the mental health promotion of the local community

1.5. Activities enhancing employment Activities: • Organising interdependent trainings (basic, intermediate, etc.) • Training for the skills needed for employment (content: e.g. basic concepts of work culture, going to work, practicing concentration, etc.) • Organising mainly practical trainings (e.g. housewife training, stock-raising training, broom preparation, etc.)

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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• Supporting the travel of workers working in the nearby towns (e.g. community organisation, by car/village bus) • Preparing the contents of public work programmes by using the tools and methods of health promotion

Indicators: • Number of trainings • Number of training participants • Number of sectors/stakeholders supporting the operation of trainings • Number of the indicated funds of the subsidy systems (e.g. EU, charity organisation, municipality (state) funds, etc.)

1.6. Enhancing physical activity Activities: • Enhancing physical activity by involving families, with the work tools provided by the support of the public work programme (e.g. gardening, cutting firewood, construction and maintenance of systems for rainwater drainage around one’s own houses, etc.) • Supporting/initiating free sports possibilities for adults (e.g. free yoga and spinal balance exercises in Sellye) • Expansion of the operating sports teams (e.g. football sports team of Vajszló) with new sport types, forms of exercises • Enhancing the establishment of sports facilities for expanding the school sports programmes (e.g. construction of the training swimming pool in Vajszló) • Finding rooms for the sports programmes of smaller schools • Initiating new sports teams (local football team, handball, etc.) • Organising soft handball teams among the elementary schools of the micro- region

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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• Organising/developing kindergarten physical exercise (PE) programmes for preventing the frequent orthopaedic problems of the children (exercises for strengthening the sole and back muscles)

Indicators: • Number of sports teams • Number of organised PE programmes • Number of participants of sports teams and PE programmes • Number of recommendations for establishing sports facilities • Number of recommendations for providing rooms for sports • Number of kindergartens organising kindergarten PE programmes • Number of professionals participating in kindergarten PE programmes • Number of children participating in kindergarten PE programmes

1.7. Development of the health literacy of families Activities: • Providing health information to the parents of kindergarten and school-aged children within the frameworks of “Parents’ clubs” with playful, interactive tools, about different topics

Indicators: • Number of methods used for publishing the programme • Number of parents participating in the different programmes • Number of children participating in the different programmes • Number of questions asked at the different programmes, number of people answering the questionnaire/pools.

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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Aim 2: Capacity development, human resource development

The lack of professionals and the burnout and overload of the existing professionals affect several areas of the care system in the micro-region. The number of professionals working in primary care is insufficient (general practitioner, paediatrician, district nurse, social worker, lawyer, psychologist), the problem makes it impossible to fulfil the primary care needs of the population appropriately. The few professionals working in this area are overloaded and stressed. Therefore, it is important to consider the resources of the care system, to enhance its more efficient use, and to develop the mental health of the local healthcare and social workers. These objectives cannot be complete without addressing the decision-makers. Among the decision-makers, the action plan mainly enhances the awareness for the problem and reasons of health inequalities and the use of Structural Funds for improving health.

2.1. Rationalisation of the resources and tasks of the care system operating in the micro-region for better sourcing Activities: • Providing information to the population about the range of healthcare and social services • Reviewing and coordinating the available (human, financial and infrastructural) resources • Reviewing of the management of the available resources • Reorganisation of the out-of-hours service of the family doctors • Reviewing and using the possibilities provided by law (e.g. public work programme, using employment allowances, etc.) • Using the tools of health promotion in healthcare/social services, in the daily work of those providing the services (e.g. possibility of measuring blood sugar levels in domestic help/domestic medical attendance, providing information about the programmes helping people to stop smoking)

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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Indicators: • Number of recommendations for restructuring the resources of the care system • Number of recommendations for using the tools of health promotion in the healthcare/social services

2.2. Awareness raising in relation to human resource needs Activities: • Organising professional advanced trainings (social worker, district nurse, general practitioner, nurse) • Involvement of charity organisations into the reduction of health inequalities (religious and civil organisations) • Formulating the need for the employment of a person responsible for complex health promotion/health guard (e.g. consulting after screenings, etc.) • Drawing the attention of the local and national decision-makers (e.g. members of parliament) to the deficiencies of the human resources of the local care system: indicating the need for qualified employees employed with contracts of indefinite period

Indicators: • Number of recommendations for extending human resources • Number of trainings • Number of training participants

2.3. Capacity development of the local professionals, policy decision-makers Activities: • Establishing a local/micro-regional health team with the aim of preparing and implementing a settlement/micro-regional health plan • Raising awareness for the phenomenon and reasons of health inequalities

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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• Harmonising data collection in relation to health inequalities in the micro- region (e.g. in the healthcare and social areas) • Enhancing local media appearances concerning health inequalities • Professional advanced training about the methods of reducing health inequalities (e.g. considering the aspects of health protection/promotion during the preparation of the micro-regional/settlement programmes) • Following the closed programme period of 2007-2013 of the Structural Funds, reviewing the experiences of using these funds, and on the basis of this, project planning for the next programme period, e.g.: − Strengthening the professional contents for the continuous improvement of the effectiveness and success of using the resources − Planning of “complex programmes” at the local level (as in this form, there are more possibilities to influence positively ) − Partnership consultations based on personal presence (which are more successful and offer the possibility of personal debates and consultations) • Capacity development in relation to the use of the Structural Funds, monitoring of the tender funds launched within the frameworks of the operational programmes of the 2014-2020 planning period, especially considering the Operational Programme for Human Resources Development, the priorities of which include fighting against poverty, strengthening social cohesion, health protection and healthcare development, as well as the development of the quality of public education.

Indicators: • Number of media news presenting/indicating the disadvantageous situation of the region’s population (media collection, data file about media appearances in the micro-region) • Number of recommendations concerning the capacity development of the decision-makers

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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2.4. Development of the mental health of the local healthcare and social professionals Activities: • Organising trainings about different topics: conflict management, preventing burnout, team building • Supervision for the local professionals for treating the existing burnout • Improvement of communication and cooperation among the professionals working in the healthcare, social and education areas

Indicators: • Number of programmes/trainings • Number of participants in the programmes/trainings • Number of new recommendations/modifications initiated by the local professionals participating in the programmes/trainings concerning daily work

Aim 3: Infrastructure development

Each settlement of the micro-region has a bus stop for regional buses but the centre of the micro-region cannot be reached directly from 9 settlements by bus. In 15 settlements, 1-4 bus services provide direct access to the centre of the micro-region per day. These bus services are scheduled mainly in the morning and early afternoon but not in the evening. Therefore, in these settlements, the possibilities of going to work and access to healthcare services are rather limited.

The expansion of screening could be helpful in prevention. In the daily general practitioner consultation work, very little time and energy is left for prevention work after the fulfilment of the urgent tasks. However, according to previous experiences, the population is quite active during mobile screenings (e.g. based on the experiences of the one-week complex screenings held at Vajszló, containing a regular chest X-ray, and special – vascular surgery, dermatology, optometry, respiratory, gynaecologist – examinations). The patients also took part in the This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

31 urology and cardiovascular screenings organised at the general practitioner mainly by invitation.

3.1. Improving access to healthcare services Activities: • Recommendation for harmonising the local public transport services with the consultation hours of the healthcare centre • Enhancing the use of the village and homestead caretaker service (village buses) for travelling to the site of the healthcare services • Once a year, providing screening possibilities in all tiny settlements in (a well- equipped) screening bus • In small settlements, expansion of cervical screenings performed by the health visitors, motivation of the population to participate in the screenings • Recommendation for developing the basic screening equipment at the healthcare centre (sight testing “Kettesy-board”, mobile ECG, mobile laboratory, blood pressure, blood sugar and blood cholesterol meters, etc.) • Organising annual resuscitation trainings for professionals and laymen • Training about basic healthcare knowledge (e.g. decreasing fever, first aid, calling an ambulance) • Training about the use of defibrillator, drawing the attention to the availability of defibrillators

Indicators: • Number of recommendations for improving the availability of services • Number of trainings • Number of training participants

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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Summary

This action plan is a result of consultations with the professionals working in the Sellye micro-region. In cooperation with the professionals of the Sellye micro-region, it summarises the objectives and activities recommended by them.

The consultation process was started with analysing the situation and the needs focusing on the local health inequalities, followed by a roundtable discussion with the participation of the local decision-makers, the representatives of the different sectors (social, healthcare and education) and the MMSZ. The topic of the roundtable discussion was to explore the health problems and the causing factors in the Sellye micro-region, informing the local professionals about the project, and the involvement of their ideas and recommendations into the objectives of the project, as well as the establishment of a local work team.

A measure to be implemented within the frameworks of the ACTION-FOR-HEALTH project is the establishment of a so-called “Parents’ Club” on the basis of the unanimous decision of the local professional work team, which aims to provide information to the parents of disadvantaged children interactively about health promotion, during 5 events. The information will be provided to the parents so that after becoming familiar with the information and best practices during the events, the participating parents could change their life and health in a positive way and give the knowledge gained at the club events to their children.

The other objectives of the action plan can be implemented in the future by the help of different measures beyond the project period of ACTION-FOR-HEALTH by using further funds (e.g. in the 2014-2020 planning period, by using the resources of the Structural Funds).

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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Annex

Annex 1: Settlements belonging to the Sellye micro-region and the population of the settlements (2012)

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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Annex 2: The use of the resources of the Structural Funds in Sellye micro-region in the period of 2007-2013

The below listed eight programmes implemented in the Sellye micro-region under the financing of the Structural Funds cover initiatives containing the need to decrease the underdevelopment of the disadvantaged micro-region, to overcome the disadvantages and to reduce the health inequalities28. They contain completed programmes and others which are still being implemented. The aim of the list is to provide examples of initiatives because we recommend fundraising and financing of similar ones in the next, 2014-2020 planning period, and which fit into the objective system of this action plan as well.

I. Operational programme: DDOP – South Transdanubia Operational Programme Number of the invitation to tender: DDOP-5.1.3/A-11 Topic: Transport development Project title: Improving access to the region on the road no. 5821 Project elements: rehabilitation of road no. 5821 between the sections 22+273- 25+024 km Date of completing the project: 26.02.2013 Sum of the support: HUF 244,173,438 Action plan period: AT 2011-2013

The project complies with the requirements of the annex entitled “Guidelines for complex accessibility”. The support of the project does not reach HUF 1 billion; therefore, no feasibility study shall be prepared. Environmental impact study is not required either. No construction permit is required for implementing the project. The project affects the micro-region of Sellye.

28 Website of the National Development Agency: http://www.terkepter.nfu.hu/ This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

35

The access road is one of the main internal roads of the settlements located in the Ormánság region, connecting the small settlements along the river Dráva. The middle section of the road was built in the late 1980’s, with relatively good carrying capacity, while the front and the end sections were built in the 1970’s from macadam, the surface of which was covered 20 years ago for the last time. During the rehabilitation, at the end of the road, a 2751 metre section before Sellye will be rehabilitated between Drávaiványi and Sellye. In this section, both the carrying capacity and the coating have the worst qualification of 5. Due to the unevenness of the road, a significant quantity of levelling layer shall be built. The existing bus stops shall not be reconstructed due to the low traffic, but the roadside will be covered for the passengers at the bus stops. By the renovation of the road, the accessibility of the settlements located here will improve.

II. Operational programme: TÁMOP – Social Renewal Operational Programme Number of the invitation to tender: TÁMOP-5.4.9-11/1 Topic: Human development Project title: Network cooperation in the Sellye micro-region Planned start of the project: 01.05.2013 Planned completion of the project: 31.10.2014 Sum of the paid support: HUF 8,749,999 Action plan period: AT 2011-2013

The project targets the need-oriented, integrated development and functional connection of the social and child welfare primary care of the Sellye micro-region by establishing and operating an inter-professional expertise cooperation network. Main activities: organisational development of the service provider institutions, providing accessory services in addition to developing the existing ones (e.g. documentation systems), preparation of methodology toolset and recommendations, team support, monitoring activity.

III. Operational programme: TÁMOP – Social Renewal Operational Programme Number of the invitation to tender: TÁMOP-5.4.9-11/1 This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

36

Topic: Human development Project title: First step programme in the Ormánság region Date of completing the project: 31.05.2012 Sum of the paid support: HUF 37,194,236 Action plan period: AT 2009-2010 The project aims to improve the independent life of people with low employment chances who are limited in their work, their employment and social integration by strengthening the key competences needed for independent life and work. Within the frameworks of the project, a training for obtaining "C+E" category driving license is organised, supplemented with truck driver basic training, labour market training and training for using computer and internet, and a training for employees enhancing the change of their approach. Following this, the project provides a workplace for practicing for the training participants for 3 months, enhancing the obtaining of practical experiences and improving the chances of getting a job. The training is organised with the involvement of all settlements of the Sellye micro-region, i.e. 30 persons from 35 settlements will be trained, contributing to the reduction of the high rate of unemployment.

IV. Operational programme: TÁMOP – Social Renewal Operational Programme Number of the invitation to tender: TÁMOP-2.4.5-12/3 Topic: Human development Project title: Supporting local, innovative initiatives improving flexibility in Sellye town Planned start of the project: 15.05.2013 Planned completion of the project: 31.05.2014 Sum of the support: HUF 17,194,805 Action plan period: AT 2011-2013

The aim of the tender is to implement innovative projects which enhance the cooperation of the local institutions, and by considering the local needs, result in a more rationalised operation and improved quality services. It is planned to be achieved by establishing local This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

37 associations, harmonising the operation of the social infrastructure, the creation of new positions, rationalisation of the opening hours and by providing trainings to the target group.

V. Operational programme: TÁMOP – Social Renewal Operational Programme Number of the invitation to tender: TÁMOP-2.4.3/B-2-10/1 Topic: Human development Project title: Enhancing employment in the disadvantaged Ormánság region Date of completing the project: 31.08.2012 Sum of the paid support: HUF 29,226,478 Action plan period: AT 2009-2010

The goal is to harmonise the disadvantaged workforce supply available in the Sellye micro- region hit by high unemployment rates and the open positions available for this target group and to create a “quality service” in the areas of park gardening, settlement maintenance and social helpers, so that in the form of an association, the difficulties hindering work would be managed, community development would be given attention to, and the community living here would be satisfied in the long run.

VI. Operational programme: TÁMOP – Social Renewal Operational Programme Number of the invitation to tender: TÁMOP-3.3.8.B-12 Topic: Human development Project title: Change and change yourself too! Planned start of the project: 02.05.2013 Planned completion of the project: 31.08.2015 Amount approved in the contract: HUF 29,995,951 Action plan period: AT 2011-2013

The project’s objective is to provide perspective and help for students with the cooperation of the parents, teachers and the social environment, to let them start to formulate their own goals, to elaborate the strategy of achieving them, and to do their best. By the help of activities and This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

38 personality development trainings helping to cope with the cultural and social disadvantages deriving from the family background, the other aim is to prepare the students for self- advocacy with practical advices which can be used in their lives.

VII. Operational programme: TÁMOP – Social Renewal Operational Programme Number of the invitation to tender: TÁMOP-3.1.7-11/2 Topic: Human development Project title: Tücsök Kindergarten of Ormánság (Ormánsági Tücsök Óvoda) Date of completing the project: 14.12.2012 Sum of the paid support: HUF 2,976,163 Action plan period: AT 2011-2013

“Our kindergarten is a child-centred host institution, accepting multiply disadvantaged children, children with unique caring needs, those belonging to national and ethnic minorities, and children developing at different pace. Our teachers are prepared for providing reference institution services, for enhancing cooperation among the institutions, for providing experiences and best practices. Our work includes competence-based education, differentiated methods ensuring individual development. The “cornerstones” of our programme: “education by example”, informality, continuity, volunteering, individual care, physical exercise, playing, fairy tales. From the first moment of entering the kindergarten, education includes keeping traditions, the maintenance of popular traditions, including the transmission of Croatian nationality and Roma minority cultures.”

VIII. Operational programme: TÁMOP – Social Renewal Operational Programme Number of the invitation to tender: TÁMOP-5.3.5-09/1 Topic: Human development Project title: “There is a solution for everything” – preventive family monitoring programme in the Sellye micro -region Date of completing the project: 14.12.2012 Sum of the paid support: HUF 55,376,504 This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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Action plan period: AT 2009-2010

The project implements a model programme by adapting the Apartment monitoring programme of the Youth Association in the Sellye micro-region in a professional partnership, which, by providing complex support to the individuals and families living in poverty, contributes to their effective household management, the adequate management of their debt burden, the settlement of their debt so that parallel with this, their labour market situation would also improve.

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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Annex 3: Programmes to be implemented

The selected programmes of the action plan will be implemented with the support of the ACTION-FOR-HEALTH project.

The two programmes to be implemented by the professional work team connect the elements of all prepared recommendations proposed by the members of the work team. The work team elaborated the programmes to be implemented by highlighting the elements of the recommendations of all local professionals and created a “new” programme together. The selected programmes were chosen from the following programme recommendations of the professionals: • Improvement of the life quality, living environments and life prospects of children under 14 years of age treated with pulmonary diseases. Improvement of health consciousness in the families and living environments of the affected children, and advanced training of the local professionals about providing help in prevention. (Dr. Ildikó Barta) • Revealing the reasons of taking into care29 among the affected families, increasing the need for change; therefore, promoting the termination of the procedure. (Mártonné Frank) • Theatre show with artistic and pedagogic methods (directed by Géza Tóth) for managing school violence and aggression. Visiting the show of the young actors from Kaposvár with school-aged children, and then processing the experiences by the help of a psychologist. The show differs from the usual ones; therefore, it is much more effective than the traditional practice of handling aggression. (Mártonné Frank)

29 Procedure of taking into care: a professional service, an official measure belonging to child protection care. A procedure initiated in the case of a sign, initiative, announcement, request or official notice of maltreatment. The guardianship court division takes the child into care if during the hearing the child is proven to be at risk.

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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• Two-round family quiz, in the first round of which the participants become familiar with the health-related information on the basis of family puzzles and home tasks. In the second round, during a family day, the participants can present their knowledge gained in the first round playfully, within the frameworks of quizzes. Other sports events, health screenings, visiting of the play bus, health visitor and family care consulting, cooking contest from healthy raw materials can also be part of this day. (Éva Mészáros) • Limiting the access to unhealthy energy drinks among children within the frameworks of playful programmes, in the form of informal discussions (Katalin Gáspár) • Establishment of soft handball teams in the most receptive age group, among children aged 7-9 years, which can be expanded to children aged 10-14. This team game can be learned easily, and transmits lots of positive messages. It can support the love of sports and physical exercise, and enhances the development of rule consciousness and communities. (Dr. Ildikó Barta) • Organising interactive, playful shows for the disadvantaged families, including parents, with fliers, motivating, health developing gifts and entertainment. (Mártonné Frank)

Based on the above, the programme to be implemented is called the “Parents’ Club” programme. The goal to be achieved is to form the health-conscious behaviour of the parents and through this, to provide a healthier lifestyle to their children and families. Target group: parents of kindergarten and school-aged children. Method: The programmes will be organised in three settlements of the micro-region: Vajszló, Magyarmecske and Sellye. Within the “Parents’ Club”, in these three settlements, five different health promotion topics affecting the population, especially the multiply disadvantaged families will be processed according to the same agenda. Each programme will last for approx. two hours. The parents living in the nearby settlements will be transported to the club site by the village buses.

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

42

The professionals of the work team, reflecting on the local problems, chose the following five topics for the programmes: I. Parenting problems, advices – According to the reports of the local professionals, the disadvantaged families often show the total lack of consistency in several areas of life, including parenting. In many cases, this manifests in the behaviour disorders and improper behaviour of the children. A programme held by a professional would provide some basic information and techniques for handling these. II. Dietary, oral hygiene information – Providing information about healthy eating, joint preparation of the recipes of healthy dishes, learning how to clean the teeth and mouth appropriately with the active involvement of the participants. III. Basic healthcare information, prevention and treatment of pulmonary problems – Possible topics: personal hygiene, reducing fever, prevention and identification of illnesses, need for visiting a doctor. The programme will be held by a health visitor, and at the end of the programme, a healthcare package will be distributed among the participants. IV. Orthopaedic deformities, teaching preventive exercises – The problem of splay feet and bad posture, later scoliosis arise very early, among kindergarten-aged children, but the problem could be treated by different exercises easily. A professional shows these exercises and teaches the parents participating in the programme who can practice the exercises with their children at home. The positive result of the programme could be the joint experience of physical exercise among parents and children. V. “Smart financial management” (consequences of substance abuse) – The last topic is needed for preventing and eliminating the problem of debt spiral occurring frequently among the disadvantaged families. Some families are not able to solve the problem without help, alone, which is often a cause or a consequence of substance abuse in the family (smoking, alcohol, drugs, gambling).

The detailed content of the different topics of the club will be elaborated with the participation of the professional work team.

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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The monitoring and measurement of the results will be supported by questionnaire/pools to be filled in by the participants at the end of the programmes and by the reports of the professionals organising the programme. The participants of the parents’ club will be involved in the form of announcements.

In addition to the above programme, a separate programme is the establishment of soft handball teams in the elementary schools of all settlements of the region – with the cooperation of the local PE teachers –, in the beginning as a “mass sport”. The Handball Association of Baranya county (Baranya Megyei Kézilabda Szövetség) would provide the tools required for launching the programme (balls, gates) and the professional methodology materials. In the spring, soft handball championship would be organised with the participation of the teams established within the frameworks of the programme. The goal is to enhance regular physical activity, to form the community, to establish traditions, which would form the basis of further health promotion programmes in the future.

The expected result of the two programmes is that the parents and the children would participate in the programmes, parents and children will hopefully talk about the topics heard at the programmes, and parents and children will turn to the local professionals with their questions concerning the topics/experiences of the programmes. A more (health) conscious lifestyle can be developed. Positive changes can be initiated in the areas of parenting problems, diet, personal hygiene, physical exercise and health conditions. The participants of the “Parents’ Club” could form a community, the parents’ club could become a regular and popular event in the settlements.

The sustainability of the programme could be maintained by involving other funds after the expiry of the project period and could be expanded to the population of the other settlements of the micro-region as well.

Potential procedure indicators: number of methods used for publishing the programme, number of parents participating in the different programmes, number of children participating This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

44 in the different programmes, number of questions asked at the different programmes, number of people answering the questionnaire/pools.

In the first half of 2014, a civil association will be established by the members of the local expert working group which will also help the implementation of the selected actions. The members of the working group have known each other but this will be the first time they work together in this type of cooperation. Based on the positive experience of the joint work in the project, they decided to set up a civil association which will enable them to further work together and focus on reducing health inequalities.

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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Bibliography

Karolina Kósa (2009): A társadalmi egyenlőtlenségek népegészségügyi hatásai Magyarországon (The public health effects of social inequalities in Hungary). Népegészségügy (Public Health). Year 87, issue 4, page 329-335

Commission Staff Working Document. Report on health inequalities in the European Union. Brussels, September 2013.

Website of the Ministry of Human Resources, State Secretariat for Health. http://www.kormany.hu/hu/emberi-eroforrasok-miniszteriuma/egeszsegugyert-felelos- allamtitkarsag/felelossegi-teruletek

Magyarország társadalmi atlasza (Social Atlas of Hungary). Központi Statisztikai Hivatal (Hungarian Central Statistical Office), Budapest, 2012, page 5.

Nemzeti Társadalmi Felzárkózási Stratégia – Mélyszegénység, Gyermekszegénység, Romák – (2011–2020) (National Social Inclusion Strategy – Extreme Poverty, Child Poverty, the Roma – (2011–2020). KIM Társadalmi Felzárkózásért Felelős Államtitkárság (KIM State Secretariat for Social Inclusion), Budapest, November 2011 http://romagov.kormany.hu/download/8/e3/20000/Strat%C3%A9gia.pdf

Veronika Domokos – Mónika Tószegi – Lászlóné Turós: Sellyei kistérségi tükör (Mirror of the Sellye micro-region). Helyzetfeltárás (Situation assessment). 2012. The document entitled “Sellyei kistérségi tükör” was prepared for the MMSZ as the professional-methodology justification for the national extension of the Chances for Children Programme and for monitoring the programme within the frameworks of the project TÁMOP-5.2.1-11/1-2011- 0001 http://www.gyerekesely.eu/sites/default/files/tukrok/kistersegi_tukor_sellye.pdf

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

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Census 2011. According to the 2013 calculations of Pannon Elemző Iroda.

Halálozási táblák és térképek (Mortality tables and maps) – OEFI, 2011. http://www.oefi.hu/halalozas/tablak/y=2011&t=tenyleges&terseg=Kisterseg&tid=Sellyei.htm l

Központi Statisztikai Hivatal – Demográfiai évkönyv (Hungarian Central Statistical Office – Demography Yearbook), 2010. (CD-supplement)

Data supply of the National Health Insurance Fund, 2013.

Act XXXI of 1997 on the Protection of Children and Guardianship Administration

Eurostat. European Commission Database http://epp.eurostat.ec.europa.eu/tgm/table.do?tab=table&init=1&language=en&pcode=tps00 065&plugin=1

Rövid Közlemények. Javaslat az egészségfejlesztésben leggyakrabban használt szavak fordítására és értelmezésére. (Short releases. Recommendation for the translation and interpretation of the most common words used in health promotion) In: Népegészségügy (Public Health), Year 88, issue 1, pages 55-57.

Website of Chances for Children https://sites.google.com/site/523help/kistersegek-tamogatasa/mobil-jatszoter

Website of the National Development Agency http://www.terkepter.nfu.hu/

Kézikönyv a gyermekjóléti szolgáltatást nyújtók számára a gyermekekkel szembeni rossz bánásmóddal kapcsolatos esetek ellátáshoz és kezeléséhez (Manual for officers providing

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

47 child welfare services for the treatment and handling of cases related to maltreatment of children) Módszertani Gyermekjóléti Szolgálatok Országos Egyesülete (National Association of Methodology Child Welfare Services), Budapest, 2006. http://www.nefmi.gov.hu/letolt/kozokt/bantalmazas_kezikonyv_080409.pdf

This action plan arises from the project ACTION-FOR-HEALTH which has received funding from the European Union, in the framework of the Health Programme. The sole responsibility lies with the author. The executive agency is not responsible for any use that may be made of the information contained therein.

Authors: Monica O΄Mullane, Marek Psota, Veronika Šťastná, Michaela Machajová, Alžbeta Benedikovičová, Eva Nemčovská, Mária Fernezová, Denisa Jakubcová

Trnava University in Trnava, 2013

ISBN 978-80-8082 -767-0

EAN 9788080827670

This publication arises from the project ACTION-FOR- HEALTH which has received funding from European Union, in the framework of the Health Programme.

Unless otherwise stated, the views expressed in this publication do not necessarily reflect the views of the European Commission

3

Contents

Executive Summary ...... 4 I. The Development of the Action Plan ...... 6 1. The need for a strategic plan to tackle health inequalities in Trnava Town ...... 6 2. Health inequalities in Trnava town ...... 6 3. The Causes of health inequalities and how to tackle them ...... 8 a) Health determinants ...... 8 b) Tackling health inequalities and health inequities ...... 9 c) The contribution of health promotion to tackling health inequalities ...... 9 4. Structural Funds Programme in Slovakia (2014-2020) ...... 10 5. Framework of the Action Plan ...... 11 6. Planning method ...... 11 a) Situational analysis ...... 12 b) Methods for goal and target setting ...... 12 II. Content of the Action Plan ...... 13 Aim 1 Encourage inter-sectoral partnership for joined-up actions and policies in tackling health inequalities in Trnava town...... 13 Aim 2 Improve behaviours so as to tackle health inequalities of Trnava inhabitants within supportive environments...... 14 Aim 3 Improve behaviours so as to tackle health inequalities of Trnava inhabitants within vulnerable groups...... 15 Aim 4 Support a clean and healthy physical environment...... 16 III. Conclusion ...... 17 IV. References ...... 18

4

Executive Summary

Trnava town is a relatively productive and prosperous town in Slovakia. This has a lot to do with the location of various industries and foreign-owned companies in the region, all in proximity to Trnava town. Trnava is also geographically close to Bratislava, the country’s capital, thus enabling many people to easily commute and work in the capital city, where industry and economy is booming compared to the rest of the country.

Located within the Trnava region of Slovakia, the region (which has Trnava town as its centre/ capital) enjoys a lower unemployment rate (10.6 % in 2011) compared to the national average (13.5 % in 2011) (1). Trnava region has a population of 554 765 inhabitants as recorded in July 2011; 270 929.5 males, 283 835.5 females (2). Most of the inhabitants live within Trnava town.

As with all villages, towns, regions, countries and continents in the world, health inequalities persist. The W.H.O. provides an accurate working definition of health inequality, as the “differences in health status or in the distribution of health determinants between different population groups” (3). Health inequalities are accepted as wholly preventable and unjust, and they exist throughout the EU, between and within countries and regions (4). It is the group of health inequalities experienced by people who are placed at risk for cardiovascular disease (CVD) within a town in Slovakia which we are concerned with in this action plan. Although the health and wellbeing of Trnava’s residents is reasonably good there are a number of population groups which are more vulnerable and more affected by the health determinants and thus engage in health risk behaviours which lower their life expectancy and quality of life.

In Slovakia and in the Trnava region the main causes of death are respectively cardiovascular diseases (52.6% versus 50%), cancer (23% versus 25.4%), diseases of the digestive system (6,3% Trnava) and injuries (5,4% Slovakia) (1).

In Slovakia, in total, more women die from circulatory diseases (55% of total 27 306 CVD deaths in 2011) than men (1). In the aetiology of cardiovascular diseases, behavioural risk factors are more significant than biological factors – which include, smoking, poor diet associated with overweight and obesity, lack of physical activity, excessive alcohol intake and inabilities to cope with stress (5, 6). The prevalence of hypercholesterolemia was in 2011 46.2%, the prevalence of overweight and obesity was 61.8% and the prevalence of hypertension was 21.1% (7). The latter three biological factors are influenced by nutritional habits.

This Action Plan for Trnava town will adopt a health promotion life course perspective in order to address and tackle health inequalities in the town’s population. This approach is an effective way to target a specific geographic population at different stages of life in addressing health inequalities. The goal of the Action Plan will be to reduce health inequalities in Trnava town using a health promotion life-course perspective, with a focus on addressing the risk factors for CVD and promoting healthy behaviours.

Based on the needs of the population, diet and nutrition will be given a high priority within the Action Plan. Building partnerships and improving inter-sectoral working is a vital part of

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this action plan. It is important that those working in tackling CVD work together, especially in promoting healthier public policies at a local level. Health promoting skills will be developed in building healthier lifestyle behaviours within supportive environments. In order to focus the target groups, the action plan will be focused on children (in primary schools), young adults and retired people. The topic of the action plan is addressing the risk factors for CVD and promoting better health for all.

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I. The Development of the Action Plan 1. The need for a strategic plan to tackle health inequalities in Trnava Town

Health inequalities are caused by differences in social status and are increasingly a problem for modern societies (8). Trnava town does not escape the existence or presence of health inequalities. Although much data is missing in our assessment of the health status of Slovak and Trnava population, based on the information we have gathered, it is very clear that health inequalities persist in our town.

It is necessary for us to focus our efforts on addressing the underlying causes of the inequalities in health. To be able to develop an action plan for health, information from the Trnava region is needed such as health determinants which could explain the prevalence and incidence of cardiovascular disease in Trnava region. Education and health are closely linked and could be a lead to focus on in the action plan for health in Trnava region. Inter-sectoral policy making and programming could be one of the possibilities and should therefore be explored. Creating goodwill for health is cross sectoral and can be enhanced. One policy which could be supporting is that there is a current plan to build a bicycle pathway in Trnava which will greatly enable people to access a sport arena; more activities such as this can be facilitated and supported in future structural funds.

There are many promising practices available from the previous national programmes on CVD. There are some health and non-health sector professionals motivated to be involved in a possible network due to motivation for lifelong learning and for being involved in an international project. This expertise needs to be joined into a network. On the other hand there is a need for capacity building in Trnava City in the area of health determinants for CVD, inter-sectoral collaboration, creating goodwill to support cross sector and finding structural funds. These conditions and factors will be taken into account and will be subject of the Action Plan for Health in Trnava town.

2. Health inequalities in Trnava town

Trnava region is quite productive in both industry and agriculture. Its proximity to the capital Bratislava is an asset as many of the region’s residents travel daily to work in Bratislava. The main types of industry in the Trnava region include the following: motor industry, electro-technic industry, metallurgical industry, and chemical industry (9). The productivity in the Trnava region is reflected in the lower unemployment rates compared to the national average of 2011; 10.6% in Trnava region vs. 13.5% national average (1). Also the risk to live under the 60% poverty line is less prevalent in this region: 9.5% versus 13% in the Slovakia (2011) (2). In the Trnava region 40.3 % of the population finished at least upper secondary education compared to the national average of 43.4% (10). This could be a possible reason for the slightly lower average net income of €639 in Trnava compared to the national average income of €665 (2). Overall Trnava is a region in which most socio- economic factors do not differ a lot compared with the national average.

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Health and Health Inequality

In Trnava region the life expectancy at birth was on average 75.7 years old in year 2011, which is slightly higher than the national average of 75.4 years. Women in Trnava live to 79.4 years, 7.0 years longer than men (9). There is no data found which show how many years of those expected life years people in Trnava and in Slovakia live in good health. In Slovakia and in the Trnava region the main causes of death are respectively cardiovascular diseases (52.6% vs 50%), cancer (23% vs 25.4%), diseases of the digestive system (6,3% Trnava) and injuries (5,4% Slovakia). In Trnava the three main causes of death are most prevalent of all Slovakian regions (1). Information of CDC risk factor prevalence is only available on national level in Slovakia. The situation in Trnava region may be similar to national level and are therefore discussed in the next paragraph. In Slovakia more women die of circulatory diseases (55% of total 27 306 CVD deaths in 2011) than men (1). In aetiology of cardiovascular diseases, behavioural risk factors are more significant than biological factors – which include, smoking, poor diet associated with overweight and obesity, lack of physical activity, excessive alcohol intake and inabilities to cope with stress (5, 6). The prevalence of hypercholesterolemia was in 2011 46.2%, the prevalence of overweight and obesity was 61.8% and the prevalence of hypertension was 21.1% (7). The latter three biological factors are influenced by nutritional habits.

Nutrition factors

A trend in eating habits within the Slovak population which enhances these risk factors on cardiovascular disease is the increased energy intake and high consumption of animal fat and protein. Difference in energy intake was shown with ageing and between sexes. There were negligible differences in consumption of vitamin C, fluid intake, fibre, NaCl and cholesterol in the diet between younger and older women. Younger (age group 19 to 34) and older males (35-54) had higher energy intake and higher consumption of animal fats and proteins than women. Younger men had worse eating habits compared to younger women (high intake of fats, protein and salt). Older women (age group 35 to 54) consumed more animal fat and proteins. In older men, an increase in overweight and obesity were reported. In younger man the overweight and high cholesterol were twice higher compare to younger women which is directly linked to their diet (high energy intake, high intake of fat and protein) (11).

Smoking

According to European Health Interview Survey in 2009 the prevalence of daily smokers in Slovakia 19.5% (27.1% males, 12.5% females), occasional smokers 9% (10.3% males, 7.7% females), never smokers 71.5% (62.6% males, 79.8% females) (12). The prevalence of smoking is since 1993 decreasing (7).

Health Inequalities and Cardiovascular disease

There are general data for social determinants however we were not able to obtain the specific data on SES, the environment and the context describing the relationship between these factors to circulatory diseases.

Drinking water

In 2005, 84.9% of Slovak population had access to clean water from public water supply. In the Trnava region it was 84.7% (13). In Trnava city, 94.2% of inhabitants had access to clean

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water (14). According to the Slovak Environmental Agency, in SR is recorded decreasing trend in the consumption of drinking water from public water supplies. Growing number of people prefer water from their own wells or bottled water. 14 % of people in Slovakia use the water from individual resources (wells) but 80 – 85 % of these water resources does not meet the hygiene and sensory requirements and are possible hazard for health (15).

Based on this information, it is clear that Trnava residents suffer from the number of health inequalities in the town, affecting overall wellbeing and quality of life.

3. The Causes of health inequalities and how to tackle them

The previous section shows us that health inequalities exist in Trnava and in Slovakia despite our dearth of data and information on the socio-economic determinants of health. This following section will briefly outline how health inequalities evolve and how they can be tackled in general.

a) Health determinants

There are many factors which influence our health. Traditionally it was thought that the biophysical influences or determinants on health were the primary players in determining health status, however we know today that a range of social, political, psychological, and lifestyle factors as well as biophysical impact on our health, through a variety of causal pathways (16). Figure 1 is a well cited and accepted graphical demonstration of the determinants of health, and illustrates very clearly the range of factors influencing our health. The “determinants of health are factors which influence health status and determine health differentials or health inequalities.“ Thus the inequalities in health that are recognised today as lowering life expectancy for some groups over others, is determined that the factors influencing our daily lives.

Figure 1: Health Determinants Model (Social Determinants of Health), Dahlgren, G. and Whitehead, M (1991) Policies and Strategies to Promote Social Equity in Health. Stockholm: Institute for Future Studies.

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b) Tackling health inequalities and health inequities

“Lower socio-economic status is probably the most powerful single contributor to premature morbidity and mortality, not only in the United States, but worldwide” (17).

Health inequalities are “preventable and unfair differences in health status between groups, population or individuals. They exist because of unequal distributions of social, environmental and economic conditions within societies, which determine the risk of people getting ill, their ability to prevent sickness, or opportunities to have access to the right treatments.“ (18). Sometimes health inequalities are a result of biological differences or free choice; whilst others are a result of structural and environmental external conditions over which individuals and groups have no control over, thus creating health inequities. Inequity in health is grossly unjust and requires interventions at policy as well as community and individual levels. Health inequity has a moral and ethical dimension.

c) The contribution of health promotion to tackling health inequalities

Health promotion is defined as the “process of enabling people to increase control over, and to improve their health.” (19) Health promotion consists of a social and political process, focusing not only on developing person skills of individuals, but also targeting action towards changing the social, environmental, economic and political conditions in which people live. The purpose of this is to promote positive impacts on health of these conditions and to reduce the negative impacts. Health promotion therefore is a process of enabling people to increase control over the determinants of health, which would therefore improve their overall health and wellbeing. (20) As defined in the Ottawa Charter (which resulted from the First Global Health Promotion Conference), health can be promoted in practitioner work in three ways: advocacy, enablement and mediation. Through advocacy in particular, health promotion may ensure the interests of the disadvantaged are made known to the local, regional and national policy makers and practitioners. (21) Health promotion seeks to facilitate social change whilst tackling health inequalities on the ground. In the Ottawa Charter (1986) five action areas were identified. Figure 2 illustrates these action areas (Building healthy public policy; reorienting health services; creating supportive environments; strengthening community action; and developing personal skills) are facilitated by the three previously mentioned approaches to operationalise health promotion (enable, advocate, mediate).

Figure 2: Health Promotion Logo (19)

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Participation of all partners in the process is vital in health promotion; it is important that any interventions that are designed include the people they are being designed for, at all stages of creation. This is often the most difficult part of health promotion, especially in Trnava, as groups and individuals are satisfied to accept interventions available to them as determined by the relevant agencies and bodies. Health promotion, by focusing less on the individual, promotes the concept that health activities and policies should take place within the context where people live, learn, work and play- the settings of our lives. Taking a settings approach to improving health will ensure greater sustainability of actions, increased ownership of the actions by all participants in the process and will ultimately lead to healthier lives for all. (31) A life-course perspective, when addressing health inequalities, is a useful way of improving health. It is known that disease status is affected by exposures right throughout the life, from growth in utero, to the traditional adult risk factors (smoking, hypertensions, obesity, physical inactivity, et cetera). (22)

How can health promotion contribute to the tackling of health inequalities in Trnava? It is our goal to design and plan for a variety of interventions, incorporating the five action areas of health promotion, adopting a settings approach and life-course perspective, whilst developing personal skills and knowledge. 4. Structural Funds Programme in Slovakia (2014-2020)

The purpose of the Structural Funds Programme of the European Commission is to promote and support growth, development and employment in regions and countries across the European Union. The funding programme aims to strengthen economic development in Member States. Connected to economic development as the disciplines of public health and social science recognise is the health of the nation. There can be no full economic prosperity with adequate incomes and employment without a healthy and happy workface, made up of the people currently suffering from the epidemic of chronic disease, most of which are preventable and unnecessary. (23) The role of this action plan is to enable Trnava inhabitants to reach their fullest health potential within the spectrum of activities endorsed by the health promotion approach, whilst connecting explicitly with the priorities for Structural Funds in the country.

Each country has their own priorities for the Structural Funds Programme, which are based on the thematic objectives proposed in Art. 9 of the draft of “Regulation of the European Parliament and of the Council laying down common provisions on the European Regional Development Fund, the European Social Fund, the Cohesion Fund, the European Agricultural Fund for Rural Development and the European Maritime and Fisheries Fund covered by the Common Strategic Framework and laying down general provisions on the European Regional Development Fund, the European Social Fund and the Cohesion Fund and repealing Council Regulation (EC) No 1083/2006.” These thematic objectives at the European level are as follows:

 Strengthening research, technological development and innovation;  Enhancing access to, and use and quality of, information and communication technologies;  enhancing the competitiveness of small and medium-sized enterprises, the agricultural sector (for the EAFRD) and the fisheries and aquaculture sector (for the EMFF);  Supporting the shift towards a low-carbon economy in all sectors;  Promoting climate change adaptation, risk prevention and management;

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 Preserving and protecting the environment and promoting resource efficiency;  Promoting sustainable transport and removing bottlenecks in key network infrastructures;  Promoting sustainable and quality employment and supporting labour mobility;  Promoting social inclusion, combating poverty and any discrimination;  Investing in education, training and vocational training for skills and lifelong learning;  Enhancing institutional capacity of public authorities and stakeholders and an efficient public administration.

The priorities for funding in the next programming period 2014 - 2020 for Slovakia are the following:

 Innovation-friendly business environment;  Infrastructure for economic growth and jobs;  Human capital growth and improved labour market participation;  Sustainable and efficient use of natural resources;  A modern and professional administration.

In all of these priorities public health has a role to play, especially when one takes into account what we know about health determinants and health inequalities. In particular, this action plan can increase and improve human capital growth and by ensuring that the population of Trnava is a healthy and satisfied one, then labour market participation can continue to grow and expand to meet the demands of the market place.

In terms of sustainable and efficient use of natural resources, it is our aim to improve the physical environment of Trnava and thereby Trnava’s inhabitants connection to its natural resources in partnership with various community groups and the municipality. 5. Framework of the Action Plan

The action plan has been developed as part of the DG SANCO funded project entitled ‘Reducing health inequalities: Preparation for action plans and structural funds projects’ (ACTION-FOR-HEALTH) (2012-2014). The goal is that this plan is useful and will be used by all sectors in Trnava town that have an influence on health, from the health sector to the educational, from the local municipality to grassroots community groups. The plan also incorporates in its aims due recognition and connection with the priorities for Slovakia for Structural Funds (SF) for the programme period (2014-2020). In this way, we hope that the plan can enable projects to develop after the lifetime of the project, which can apply for funding from the SF programme. Since the programme period 2014-2020 does not have explicit public health priorities, it is important that connections are made between the priorities and health actions addressing inequalities in Trnava town. 6. Planning method

The Action Plan for Trnava town requires preparation and a process which can inform the plan. A situational analysis was carried out in order to gather evidence and information on the key issues for the health of Trnava’s population: health determinants and inequalities in health for the town’s residents. The following details the process in more detail.

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a) Situational analysis

The initial step in a planning process is to establish the current situation. The Trnava team assessed the health of the Slovak population and then more narrowly the health status of Trnava region population and Trnava town population, whenever data was available. A number of health factors can be attributed to causing health inequalities in the resident population of Trnava town. The team also examined the policy context as is outlined in the following.

In Slovakia there have been two national programmes tackling circulatory system diseases. In recent years in the Slovak Republic a project MOST (One Month about the Heart Topics) took place (24). This could be perceived as a promising practice that increases knowledge of people about the cardiovascular diseases and their prevention. This project was part of the National Programme on Cardiovascular Diseases. From 2009 to 2012 there was a National programme on Cardiovascular diseases as well (25). Besides these two programmes there are objectives within the Slovak National Health Promotion Programme to tackle cardiovascular disease (26). However, there seems to be a gap between political and policy rhetoric and practice. This is one of the reasons why there is a need to address CVD and to plan an intervention to tackle the burden of CVD on society.

The situational analysis was presented to a number of relevant stakeholders at a workshop held in Trnava University on 13.5.2013. A discussion followed this presentation which was helpful and informed the goal and target setting.

b) Methods for goal and target setting

Based on a workshop with representatives of the health, political and educational sectors in Trnava, and on meetings with community groups, strategic issues and target groups were identified and incorporated into the plan. This document recognises the discussion held with abovementioned representatives early on in the drafting process.

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II. Content of the Action Plan

Aim 1 Encourage inter-sectoral partnership for joined-up actions and policies in tackling health inequalities in Trnava town.

It is impossible to make sustainable, long-term and significant changes to the reduction of health inequalities for certain population groups who engage in unhealthy behaviours (which then increases the risk for all chronic diseases) without joined-up action on the level amongst the relevant stakeholders. Without inter-sectoral partnership and working (which would include for instance the local town municipality, health service workers, NGOs and community groups and the education sector), there is a greater likelihood of duplication of work, inefficient use of resources, lack of collective planning in applying for Structural Funds for Trnava town (and region) and an inability of Trnava’s people to maintain healthy behaviours without the appropriate healthy policies, strategies, actions. Nowadays it is clear, that alone, health education and the development of personal skills, without any attention and action on building networks for healthier local policies, is a waste of time and resources. It is wholly unsustainable and in some health promotion schools of thought, unethical. This has been the message since the adoption of the Ottawa Charter for Health Promotion (1986) (18) and continues to be the message for appropriate health promotion planning. This is the first and vital aim of this action plan. There is already much work ongoing in Trnava connected to health promotion and promoting healthy behaviours, however joined-up action, which can be enabled by the creation of a network of interested and relevant stakeholders, can enable such effective action.

Objective 1.1 Increase awareness, knowledge and responsibility of stakeholders for health inequalities in Trnava town.

Activities:

1. Scan the environment for potential network members. 2. Identify common interest in health issues amongst potential network members 3. Provide and disseminate knowledge about health inequalities to stakeholders and interested groups

Indicators: number of stakeholders identified, number of conference presentations made in order to provide and disseminate knowledge about health inequalities to the stakeholders locally and internationally

Objective 1.2 Create a network of relevant partners to enable inter-sectoral partnership and joined-up actions.

Activities: Make closer cooperation with relevant partners such as the Regional Office of Public Health, Healthy City Office Trnava, local schools, NGOs

Indicators: number of stakeholders identified, number of conference presentations made in order to provide and disseminate knowledge about health inequalities to the stakeholders locally and internationally

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Aim 2 Improve behaviours so as to tackle health inequalities of Trnava inhabitants within supportive environments.

A life-course perspective will be used in order to structure the improvement of health behaviours of certain at-risk population groups in Trnava town, within supportive environments. The view is to ensure that personal skills in health and wellbeing can take place within a supportive environment (school, workplace, residence) in a sustainable way.

Objective 2.1 Improve nutritional knowledge and skills in Trnava population

Activities: Provide knowledge and train skills for healthy nutrition

Indicators: number of events, number of people attended on the events, number of examined people (cholesterol et cetera)

Objective 2.2 Encourage more physical activity

Activities:

1. Motivate participants to increase daily moderate physical activity 2. Organise mass physical activities 3. Include physical activity into diverse events (for example in the Symposium and other Congresses e.g. Cardio Run)

Indicators: number of events and mass physical activities; number of people attended the events

Objective 2.3 Support healthy lifestyle behaviours in Trnava population

Activities:

1. Provide knowledge and train skills about healthy lifestyles 2. Promote positive image of a healthy lifestyle behaviour

Indicators: number of events, number of people attended

Objective 2.4 Raise awareness amongst people of the early signs of diseases and encourage people to seek advice and further information

Activities:

1. Provide clear information about early symptoms of chronic non-communicable diseases (CVD, neoplasm et cetera) 2. Encourage people to seek advice at early stage of symptoms

Indicators: number of events, number of people attended

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Aim 3 Improve behaviours so as to tackle health inequalities of Trnava inhabitants within vulnerable groups.

The objectives of this aim will focus on population groups:

Objective 3.1 Children

Activities:

1. Support the implementation of standard of healthy nutrition and physical exercise to schools, kindergartens and other educational institutions in region 2. Implement whole school approach to healthy eating in the school setting 3. Training on healthy nutrition for teachers and food organisers 4. Provide information on noxiousness of smoking and second-hand smoking in childhood.

Indicators: number of schools participated, number of children participated, number of play areas renovated

Objective 3.2 Unemployed people

Activities:

1. Enhance the partnership to implement inter-sectoral programmes for unemployed people (early school leavers, student graduates, long-term employed people) 2. Develop an appropriate training programme to strengthen positive self-image and healthy behaviour 3. Training of social skills building 4. Organise workshops on stress management 5. Support self-help groups for unemployed in order to increase communication and coping skills

Indicators: number of people attended, appropriate training programme, level of self-esteem after training

Objective 3.3 Senior Citizens (elderly population)

Activities:

1. Promote appropriate physical activities 2. Promote healthy nutrition 3. Promote non-abusive behaviour 4. Develop programmes to enable elderly to participate fully in their communities and implement them. 5. Organise training programme on home care for family members 6. Promotion of safe living for the elderly and prevention of injuries at home

Indicators: number of programmes, number of people attended

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Aim 4 Support a clean and healthy physical environment.

Trnava has access to clean water and the town is maintained mostly by the municipality. Parts that are not maintained by the municipality are maintained by local community groups and active citizens and residents. In order for Trnava town to continue to enjoy a pleasing, clean and safe physical environment, this action plans proposes the following objectives:

Objective 4.1 Encourage environmentally friendly policies at the level of Trnava town

Activities: Provide knowledge to and train local stakeholders to make environment-friendly policies. Advocate for environment – friendly policies

Indicators: the number of environment-friendly policies and workshops, number of stakeholders attending the workshops, collaboration with local city advocacy groups

Objective 4.2 Support positive behaviour and ownership of Trnava inhabitants towards their physical environment

Activities:

1. Provide knowledge about healthy environment to increase awareness of population about the influence of environment on people´s lives 2. Develop programmes to discourage pollution creating behaviour by the population 3. Improve the physical environment in Trnava town so that it is more pleasing and encourages healthier lifestyle behaviours 4. Organise activities to encourage people to use the environment-friendly policy measures and make environment-friendly choices 5. Ensure media support of activities

Indicators: range of messages about healthy environment, number of implemented programmes on pollution prevention, number of activities on environment friendly choices, media coverage of activities; number of activities to improve the physical environment

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III. Conclusion

This action plan promotes a range of activities and goals which all aim to improve the health and wellbeing of Trnava’s inhabitants, with due recognition of the connection of the plan to the priorities of the Structural Funds Programme (2014-2020). In particular, the priorities for Slovakia (and therefore Trnava) which envisage greater employment and participation of individuals in the workforce are connected with this action plan since there can be no economic development of any kind without a healthy and fully capable workforce. The action plan adopts a health promotion approach to reducing health inequalities which result in lowered life expectancy and increased morbidity, which thus impacts on quality of life and economic activity. This approach has been taken in addressing the risk factors for chronic disease, in particular the biggest killer for Trnava inhabitants, CVD.

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IV. References (1) Statistical Office of the Slovak Republic. http://portal.statistics.sk/showdoc.do?docid=4 (Accessed May 21st 2010) (2) RegDat, Database of Regional Statistics. http://px-web.statistics.sk/PXWebSlovak/ (Accessed May 20th 2013) (3) World Health Organisation (2013) Glossary of terms, http://www.who.int/hia/about/glos/en/index1.html (Accessed 7th June 2013) (4) Krajnc-Nikolić, T. (2013), Glossary of terms used in the project ACTION-FOR-HEALTH (version 6th June 2013). ACTION-FOR-HEALTH Project. (5) FAO/WHO. Diet, nutrition and the prevention of chronic diseases. Geneva 2003. Geneva: WHO Technical report, Series 916:146. (6) WHO, Regional Office for Europe. CINDI Dietary Guidelines. Copenhagen: WHO 1999 (Document LVNG 020708):33 (7) Avdičová M, Francisciová K, Kamenský G. The occurrence of CVD risk factors - the first national survey results. Cardiology Letters. 2012;Suppl. 2012:8S. (8) Zavod za zdravstveno varstvo Murska Sobota (2005), Health Promotion Strategy and Action Plan for Tackling Health Inequalities in the Pomurje Region. Zavod za zdravstveno varstvo Murska Sobota : Murska Sobota, Slovenija (9) Slovak Investment and Trade Development Agency. http://www.sario.sk/?regionalne- analyzy (Accessed May 22nd 2013) (10) Census 2011. Results of the census 2011.http://www.scitanie2011.sk/en/neprehliadnite/vysledky-sodb-2011 (Accessed May 22nd 2013) (11) Chudikova K, Havelkova B, Michalovicova M, Rovny I. Evaluation of the nutritional condition of the population of the Slovak Republic in relation to cardiovascular risk. Cardiol 2005;14(1):27–36 (12) Gerhardtová, A. 2011. Eurpean Health Interview Survey 2009. Bratislava: Štatistický úrad Slovenskej republiky, 2011. ISBN 987-80-89358-87-8. http://portal.statistics.sk/files/Sekcie/sek_600/Socialne_statistiky/Socialne_statistiky/ EHIS_2009/ehis_2009_verzia_pre_portal-su-sr.pdf (Accessed May 20th 2013) (13) Ministry of Environment. The plan for the development of public water supply in the Slovak Repubic. http://www.minzp.sk/files/sekcia-vod/vlastny-material-verejne- vodovody-pdf-772-kb.pdf. (Accessed May 22nd 2013) (14) Profile of Health of Trnava City. Šťastná V et al (ed.). Trnava: City of Trnava, 2011. (15) Water Research Institute http://www.vuvh.sk/download/VaV/Vystupy/Letak- SK_web.pdf (Accessed May 22nd 2013) (16) Siegrist, J. and Marmot, M. (2006) ‘Introduction,’ in Social Inequalities in Health (ed) Siegrist, J. and Marmot, M. Oxford: Oxford university Press (17) Williams, RB (1998) ‘Lower socio economic status and increased morbidity: early childhood roots and the potential for successful interventions.’ The Journal of the American Medical Association, 279, 1745-1746 (18) European portal for action on Health Inequalities (2013), Health Inequalities, http://www.health- inequalities.eu/HEALTHEQUITY/EN/about_hi/health_inequalities/ accessed on 11.10.2013 (19) World Health Organisation (1986) Ottawa Charter for Health Promotion. Geneva: WHO (20) WHO (1998) Health Promotion Glossary http://whqlibdoc.who.int/hq/1998/WHO_HPR_HEP_98.1.pdf accessed on 11.10.2013

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(21) Naidoo, J. and Wills, J. (2000) Health Promotion- Foundations for Practice, Edinburgh: Bailliere Tindall (22) Power, C. and Kuh, D. (2006) ‘Life course development of unequal health,’ in Social Inequalities in Health (ed) Siegrist, J. and Marmot, M. Oxford: Oxford university Press (23) Siegrist, J. and Teorell, T. (2006) ‘Socio-economic position and health: the role of work and employment,’ in Social Inequalities in Health (ed) Siegrist, J. and Marmot, M. Oxford: Oxford university Press (24) Slovak Heart Foundation. The MOST project http://www.tvojesrdce.sk/index.php?option=com_content&task=blogcategory&id=27 &Itemid=180 (Accessed May 21st 2013) (25) National programme on Cardiovascular diseases. http://www.uvzsr.sk/docs/info/podpora/NPPOC.pdf (Accessed May 21st 2013) (26) Slovak National Health Promotion Programme http://www.uvzsr.sk/docs/info/podpora/narodny_program_en.pdf (Accessed May 20th 2013)

Reduction of health inequalities in Tenerife, Canary Islands, by means of health promotion

Professor Sara Darias Curvo University of La Laguna

This document arises from the project ACTION-FOR-HEALTH which has received funding from European Union, in the framework of the Health Programme .

Unless otherwise stated, the views expressed in this publication do not necessarily reflect the views of the European Commission.

Table of contents

Executive summary 3 Introduction 4 The development of the action plan 4 - Some facts about Canary Islands 4 - Socioeconomic factors 5 - Health and Health Inequalities 6 - Health and Health Inequalities at National and Regional 7 level - Health System in Spain 9 Planning method 10 - Situation analysis 10 - Methods for goal and target setting 11 The content of the action plan 11 • Main goal: Reduction of interregional and intraregional 11 health inequalities in Tenerife - Aim 1: Place health inequalities in the attention of 12 communities and individuals - Aim 2: Increase community capacity and 15 participation/community empowerment - Aim 3: Improve healthy behaviours through health 16 promotion activities - Aim 4: Reduce intraregional health inequalities by 18 supporting vulnerable groups - Aim 5: Support healthy physical environment 22 Resources 23 Conclusions 25 References 26

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EXECUTIVE SUMMARY

Social inequalities in health are unfair and avoidable differences in health between population groups defined socially, economically, demographically or geographically. A growing number of publications have described and analysed social inequalities in health in Spain on the grounds of social class, gender, ethnicity, territory and country of origin. These inequalities have an enormous impact on population health and, therefore, must be a priority for public health policies and a cross‐cutting issue within health policies in our country, following the line traced by the main international organisations and several surrounding countries (Campos Esteban, P. y col., 2010). Scientific evidence also reveals that health inequalities can be reduced if the appropriate public social and health interventions and policies are undertaken (Dahlgren & Whitehead, 2006; Whitehead et al., 2004).

Reducing health inequalities at national level and between regions in Spain has been set as a priority task of the Spanish Government during the Spanish Presidency of the European Union in 2010. Since then many working documents have been published by the Ministry of Health, Social Affair and Equity, in order to raise capacity building in the field of health inequalities.

This document shows a draft proposal of an action plan at regional level to reduce health inequalities by means of health promotion. The main goal is the reduction of intraregional and interregional health inequalities in Canary Islands.

The strategic action plan focuses on the contribution to the reduction of health inequalities. Also it is based on a systematic analysis of the current situation of health status of the Canarian population.

We have identified five main aims which focus on place health inequalities in the attention of communities and individuals, increase community capacity and participation/community empowerment, improve healthy behaviours through health promotion activities, reduce intraregional health inequalities by supporting vulnerable groups and support healthy physical environment.

We believe that the implantation of this action plan will contribute to the general goal of reduce health inequalities in Tenerife.

INTRODUCTION

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Spain has a total population of 47,265,321 (male 23,298,356; female 23,966,965) inhabitants. The Canary Islands, one of 17 autonomous regions of Spain, consists of 7 larger islands and 6 smaller islands. The islands are located off the north-western coast of the mainland of Africa, more or less 100 kilometres west of the coast of southern Morocco. The total population of the Canary Islands in year 2012 was 2,118,344 (male 1,056,240; female 1,062,104). The Canary Islands are located rather far away from the mainland of Spain and are quite isolated. This has an effect on the social and economic position of the islands.

THE DEVELOPMENT OF THE ACTION PLAN

Some facts about Canary Islands

Canary Islands is an archipelago in the Atlantic Ocean which forms one of the seventeen autonomous communities of Spain , recognized as one of the outermost regions of the European Union, which gives them the status of an ultraperiferic region. It has seven main islands: El Hierro , La Gomera , La Palma and Tenerife , which are the province of Santa Cruz de Tenerife , and Fuerteventura , Gran Canaria and Lanzarote , which make up the province of Las Palmas. There are some other islands territories also part of the Canary Islands Archipelago, Chinijo ( La Graciosa , Alegranza , Montaña Clara , Roque del Este and Roque del Oeste) and Isla de Lobos , all belonging to the province of Las Palmas. La Graciosa is the only of these islands which is inhabited.

The archipelago is located in the north of Africa, off the coast of southern Morocco and the Sahara , between latitudes 27 º 37 ' and 29 º 25' north latitude and 13 ° 20 'and 18 º 10 ' west longitude. Because of this situation , Canary Islands used during the winter the Western European Time (WET or UTC ) and during the summer the summer Time Western Europe ( WEST or UTC +1 ). The distance from Canary Islands and the African coast is about 1.400 km. The island of Fuerteventura is the closet to African coast just about 95 km.

The islands are of volcanic origin, are part of the region of Micronesian archipelagos along with Cape Verde, the Azores and Madeira. The climate is subtropical, but varies locally by altitude and the north or south side. This climate variability leads to biological diversity, along with the rich landscape and geology, justifies the existence of four National Parks and several islands are biosphere reserves of UNESCO, and other areas have been declared World Heritage like “Teide National Park”, the most visited park in Spain with the highest mountain of Spain and third largest volcano in the world from its base, the Teide. These natural attractions, good weather and beaches make

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the islands a major tourist destination, being visited each year by about 12 million people, mainly British, Spanish from mainland and Germans.

The total population of the Canary Islands in year 2012 was 2,118,344 (male 1,056,240; female 1,062,104) and a density of 284.46 inhabitants / km ², being the eighth region of Spain in population. The archipelago's population is concentrated mainly in the two main islands, Tenerife and Gran Canaria. The total area of the archipelago is 7,447 km².

Tenerife with an area of 2,034.38 km ² and a population of 898,680 inhabitants (INE, 2012), is the largest island of the Canary Islands.

Socio-economic factors

The average annual income per person in 2011 was 9,321 euros. The annual income per household in 2011 was 24,609 euros according to data from the National Statistics Institute. According to an ADECO report published in 2013, the average salary in Spain per month in 2012 was 1,639 euros while in the Canary Islands, it is less than 1,400 euros. However, the minimum salary is established by the government at 645 euros per month. The gender pay gap was 16.2% in 2011.

The total population with at least an upper secondary education on the mainland was 53.8%. In 2011 the school dropout rate was 26.5%. With respect to education, the total population in Canary Islands with at least an upper secondary education is 34.8% (2011) which is less favourable than the rate on the mainland. In 2011 the school dropout rate was 30.4%.

Spain scores rather high with respect to the rest of Europe with regard to the unemployment rate. The total percentage of unemployed people in Spain increased to 27.1%, which are 6,202,700 people (male 26.8%, female 27.6%) in the first three months of 2013. The unemployment rate increased to 34.27% in the Canary Islands by gender 34.73% for males and 33.72% for females.

The unemployment rate of people under 25 years is even higher, namely 57.2% in the first trimester of 2013. Recent figures for 2013 show the unemployment rate for the population under the age of 25 to be 70% in the Canary Islands.

A total of 21.8% of the population of Spain is at risk of living under the income poverty line in 2012. People under 16 displayed the highest rate of risk of poverty with 25%, followed by the population aged 16-64 with 19.3% and those over 65 8.5%. The percentage of people at risk of living under the poverty line is higher for the Canary Islands: 33.8%.

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In the last five years, the Canary Islands have ranked below Spain in terms of average income per person and per household. An analysis of income per capita shows that 39% of the population earned less than 500 euros per month per person, indicating the deprived situation in the Canary Islands. The data regarding Canary Islands shows the disadvantaged socio-economic position of this region, which together with the on- going economic crisis, had resulted in serious problems for people’s daily lives and consequently, for their health.

Health and health inequalities

Health is strongly influenced by internal and external factors; the environment, how we live, work and enjoy leisure time are influenced by social, cultural, economic or environmental factors. These factors can causes differences in the health status of people. According to WHO, health inequalities can be defined as differences in health status or in the distribution of health determinants between different populations groups (CSDH Employment Conditions Knowledge Network (EMCONET), 2006). Socio-economic inequalities in health pose a major challenge to health policies. Also they can be perceived as systematic and preventable differences in health status between populations, where the poor suffer from poorer health than the rich. Health inequalities exist on the supra-national level (between countries), on the national level (between regions in the same country), and within regions (between different local groups).

Health inequalities are determined by the conditions in which people are born, grow, live, work and age, and the inequities in power, money and resources that give rise to these conditions of daily life {{8399 CSDH 2008;922 Schrecker,T. 2008;}} . Health inequalities are influenced by a variety of factors, education, poverty, employment or public policies. Social and economic differences between groups of people result in health inequalities because their impact on factors that affect health including living and working conditions, health-related behaviours and access to and quality of health care.

There are persisting health inequalities in all levels of society. We need to recognize the importance of addressing health inequalities globally, national, regional and locally. There is clear evidence that health inequalities exist ‐ not just because of the existence of poor health among the worst off but because there is a clear social gradient in health (measured in terms of poor health, disability or mortality) across the whole of society. It has been shown repeatedly that rates of adverse health outcomes raise as one move down {{8399 CSDH 2008}} the social hierarchy {{734 Berkman,L.F. 2000}}

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As the CSDH report showed, the distribution of health and well‐being needs to be understood in relation to a range of factors that interact in complex ways. These factors include material circumstances, social cohesion, psychosocial factors and behaviours. These factors, in turn, are influenced by social position, itself shaped by education, occupation, income, gender, ethnicity and race. All these influences are affected by the socio‐political and cultural and social context in which they sit {{8399 CSDH 2008}}.

In developing strategies to address health inequities, it is important to distinguish between upstream and downstream approaches. Downstream approaches are referred to the individual. These approaches focus on changing behaviour, ensuring access to care, monitoring quality of care, and identifying health risk factors {{8400 Gehler March/April 2008;}} . Upstream approaches build on the understanding that social, economic, and environmental inequity are root causes of health inequity, and that improving social, economic, and environmental conditions will improve health. To achieve health equity, new strategies must move beyond the traditional public health approaches to focus on social, economic, and political change (Barten, Mitlin, Mulholland, Hardoy, & Stern, 2007). Upstream strategies address inequities in education, employment, income, housing, neighbourhood safety, recreational opportunities, environmental hazards, and healthy food access, through policy, systems, and environmental change efforts ("Marmot & "Wilkinson, 2006; Demakakos, Nazroo, Breeze, & Marmot, 2008).

These new approaches that address root causes of health inequities require a long- term commitment to comprehensive multilevel and multisectorial strategies to change the social determinants of health. Broad coalitions of public, private, non-profit, and community stakeholders are required to change community structures. In order to do this work effectively, community engagement is essential; all members of the community should be representing and have voice in the process of decision making and implementing any strategy to improve health status (Wallerstein & Duran, 2010).

Health and health inequalities at national level

Life expectancy at birth in Spain is 82.5 years, 79.4 years for males and 85.4 years for females (Instituto Canario de Estadísitca. ISTAC, 2012). Life expectancy in the Canary Islands is similar to that of Spain (Instituto Canario de Estadísitca. ISTAC, 2012). The score of healthy life years indicator for males is 65.4 years and for female 65.8 years, meaning that women have about 20 unhealthy life years, although their life expectancy is rather high.

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Total life expectancy on the Canary Islands is slightly lower at 81.43 years (78.5 years for males; 84.3 years for females) while the total number of healthy years is 54.5 years (Ministerio de Sanidad, Servicios Sociales e Igualdad, 2008) .

With respect to mortality rates in Spain, according to the National Statistical Institute (2010) the three major health problems are: cardiovascular diseases (31.2%), cancer (28.1%) and respiratory diseases (10.5%) (Instituto Nacional de Estadística. INE, 2010). With respect to cardiovascular diseases, women are more often affected than men, and with respect to cancer men are more affected than women. All these diseases have a higher prevalence on the mainland in the regions of Cataluña, Madrid and Andalucía. The 3 major health problems in the Canary Islands region based on mortality rates are cancer (differing from the mainland where CVD are the first cause of death), (2) cardiovascular diseases and (3) respiratory diseases (Instituto Nacional de Estadística. INE, 2010). Except for heart attacks, women are more affected by cardiovascular diseases then men. Smoking is the leading avoidable risk factor related to cardiovascular diseases in Spain comprising 21.5% of the women and 31.5% of the men over 16 years of age who are daily smokers. But in terms of age groups, this pattern changes and the prevalence of smokers is higher among women in the 16-24 age group: 28.8% of women compared to 25.0% of men.

Alcohol consumption in the last 12 months before the survey was 68.6% (80.2% of males and 57.5% of females).

A total of 37.1% of the population displayed slight obesity and 15.4% signs of serious obesity. Men are more often overweight than woman (45.1% of men versus 30.4% of women) and obesity is more or less comparable in both sexes (10). Almost half the population of Spanish children (45.2%) is overweight, with 26.1% overweight and 19.1% obese. A total of 54.1% of children have a healthy weight and 0.7% are considered thin in relation to their age and size. If the results are analysed by gender, little difference in terms of overweight among children are seen (boys 26.3% and girls 25.9%), while the obesity rate shows a six-point higher frequency rate in boys compared to girls (22% and 16%, respectively) (Ministerio de Sanidad, Servicios Sociales e Igualdad, 2011).

Obesity and severe obesity are a serious health problem in the Canary Islands and the rates of prevalence are higher than in mainland and are still growing.

Smoking and obesity are important risk factor for numerous diseases. Health professionals attempt to discover the reasons for the increasing tendency in

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overweight of 36.8% of the adult population (42.1% of males and 31.7% of females) and obesity (18.5% of the adult population). The percentage of women who are obese (19.24%) is higher than the percentage men (17.92%), in contrast to the percentages of overweight men and women (Instituto Canario de Estadísitca. ISTAC, 2012). Special attention is needed for children as the prevalence of overweight and obese children is higher in the Canary Islands than on mainland Spain.

Being aware of these data and the need for special attention for children with respect to the prevention of obesity, the focus of the action plan in Tenerife will be on this health problem. The prevention of obesity depends significantly on the policy agenda, however, effective evaluation of the existing health promotion programs and interventions is lacking, so the effectiveness of those actions is unknown (S. Darias Curvo, 2008; S. Darias Curvo, 2009).

Gender and socioeconomic status are key social determinants for obesity in Spain and, consequently, need to be addressed when developing preventive activities (Ortiz- Moncada et al., 2011).

Factors influencing obesity in the Canary Islands are education, lifestyle, religion, cultural beliefs and family environment {{8411 Rodríguez Pérez, M.C. 2006}}. Another problem is access to quality food. Food is expensive on the islands as most of it needs to be imported.

Determinants to be tackled first are diet (increased knowledge), physical activity and behaviour & attitudes.

Health System in Spain

The statutory National Health System is universal coverage-wise (including irregular immigrants), funded from taxes and predominantly operates within the public sector. Provision is free of charge at the point of delivery with the exception of the pharmaceuticals prescribed to people under 65 years old, which entail a 40% co- payment with some exceptions. Health competences were totally devolved to the regional level (ACs) as from the end of 2002; this devolution resulted in 17 regional health ministries with primary jurisdiction over the organization and delivery of health services within their territory. The ACs’ financing scheme promotes regional autonomy both in expenditure and in revenue rising. The national Ministry of Health and Social Policy (MSPS) holds authority over certain strategic areas, such as pharmaceuticals’ legislation and as guarantor of the equitable functioning of health services across the country.

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The typical structure of regional health systems consists of a regional ministry (Consejería de Salud) holding health policy and health care regulation and planning responsibilities, and a regional health service performing as provider.

The regional ministry of health is responsible for the territorial organization of health services within its jurisdiction: the design of the health care areas and basic health zones, and the degree of decentralization to the managerial structures in charge of each. The most frequent model consists of two separate executive organizations, one for primary and one for specialist care (ambulatory and hospitals), at the health area level. Nevertheless, regional health services are increasingly creating single-area management structures integrating primary care and specialist care. Basic health zones are the smallest units of the organizational structure of health care. They are usually organized around a single primary care team (PCT) which exercises the gatekeeper function.

Public health responsibilities tend to be centralized in the regional department of health, though functionally following the basic health areas structure. Each health area should cover a population of no less than 200.000 inhabitants and no more than 250. 000 {{8239 García-Armesto 2010;}}.

PLANNING METHOD

In order to effectively reduce inequalities in health, a strategic plan is required, which would identify the key aims and objectives for politicians (on the local, regional and national levels) and other stakeholders to contribute to the reduction of health inequalities as well as strategies for achieving those objectives and indicators to monitor progress.

The process of develop an action plan includes different phases interconnected between them. Each step is necessary to success in the implementation of the action plan. The successive steps in the process were a situation analysis and experts inputs through several meetings.

Situation analysis

The first step in the strategic planning process is to analyse the current situation, including the assessment of the health status of the population. We have used data from the Spanish Statistical Office, Canarian Statistical Office and Ministry of Health, Social Affairs and Equality. A number of health factors have been

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identified as contributors to cause health inequalities in the population of Canary Islands.

The results of the situation analysis are mentioned in the previous sections of this document.

Methods for goal and target setting

Based on the information from the situation analysis, strategic issues and target groups were identified. Using existing information, knowledge and experience, aims and objectives have been identified as well as specific targets and activities to realise the aims.

We have not settle a time line to develop the full action plan as it may continue in a long term and some parts of it needs to be developed intersectorial partnership with other stakeholders.

THE CONTENT OF THE ACTION PLAN

This action plan is based on the analysis of the current situation and on the priorities identified in our region (Tenerife, Canary Islands).

The strategy is divided in three main parts. The first one describes general ideas about health status in the Canary Islands, health inequalities at national and regional level, and characteristics of the National Health System. The second one explains the planning method and the third one describe the content of the action plan.

MAIN GOAL: REDUCTION OF INTRAREGIONAL AND INTERREGIONAL HEALTH INEQUALITIES IN TENERIFE

We have observed interregional and intraregional health inequalities in the Canary Islands.

Interregional health inequalities refer to differences in the health status of the population in different regions. Canary Islands for their characteristic can be considered in general as a poor region together with Extremadura and Andalusia. The health status of our population is less favourable if we compare using socioeconomic data.

Intraregional health inequalities refer to differences in health status within the population of Canary Islands. We find differences if we compare each of the seven

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islands where the smaller ones do not have for example the same access to health care services. Between islands we find great differences among educational status, unemployment rate, income and elderly people.

Our main goal is to improve the health status and reduce health inequalities in the Canary Islands (focus on this first step in Tenerife) by means of health promotion.

AIM 1: Place health inequalities in the attention of communities and individuals

As we have mentioned health inequalities are influenced by a variety of factors. The main determinants of health are shown in figure 1.

Whitehead M and Dahlgren C, in “What can be done about inequities and health? The Lancet, 338, 8774, 26 October 1991, 1059-1063.

A portion of those factors, such as sex, age and genetic factors cannot be influenced. Others, such as life style factors and socio-economic factors (education, poverty, employment) can be influenced, for example, by public policies.

According to the European Health Report 2012, the social determinants of health contribute to 50% of all health inequalities and comprise political, socioeconomic and environmental factors.

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Another influencing determinant on health inequalities is, according to this report, access to effective health services. At least 25% of health inequalities (differences found within a country’s population) are associated with a lack of access to effective health services. This percentage increases if differential access to basic public health interventions such as access to safe water is included.

Health inequalities that can be avoided should be tackled as should interregional health inequalities and differences in the health status of populations in different regions. Not only because inequalities are unjust and unfair, but because they place an economic burden on society. Poor health leads to high health care costs. Additionally, people in poor health are less able to work and learn, affecting the human capital’s ability to contribute to the economy.

To identify health inequalities and health needs we might have a good evidence base database.

Objective 1.1 Increase awareness and responsibility of regional stakeholders about health inequalities in Tenerife.

Activities

- Identify potential network members. - Establish communication with local stakeholders. - Develop knowledge information about health inequalities and implement awareness-raising activities with potential stakeholders.

Indicators

- Number of stakeholders identified. - Communication activities. - Type of information produced: leaflets, courses, presentation, reports, etc.

Objective 1.2 Create a network of partners to enable intersectorial partnership.

Activities

- Establish cooperation with Regional Institute of Public Health, Regional Ministry of Education, local schools, AMPAS (fathers and mother representatives of

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parents with children at school. Currently they have great influences in decision making). - Build alliances and networking.

Indicator - Number of people within those organizations who participate in the network. - Number of networking.

Objective 1.3 Increase the awareness and responsibility of local population regarding their health and give rise to participate in local activities.

Activities

- Organize local health promotion activities within the primary health care centre in each municipality. - To communicate widely local health promotion activities so people can know when and where they will take place. - Give written information through health professional to the population about those activities.

Indicators

- Participation level in local health promotion activities.

Objective 1.4 Support the evidence base on health inequalities and health promotion.

Activities

- Establish health inequality indicators. - Contact with the Canarian Statistical Institute to include indicators of health inequalities in the periodical research. - To promote research projects in the field of health inequalities and health promotion.

Indicators

- Presence of health inequality indicators in the regional health survey. - Establish a regional and national database. - Create a regional database on health promotion interventions. - Number of research projects on health inequalities and health promotion.

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AIM 2: INCREASE COMMUNITY CAPACITY AND PARTICIPATION-COMMUNITY EMPOWERMENT Community can be defined in various ways. Community health literature offers a variety of definitions. Behringer and Richards describe community as a web of people shaped by relationship, interdependence, mutual interest, and patterns of interaction (Behringer & Richards, 1996). It is an open social system that is characterized by people in a place over time that has common goals. To make this happen we need to engage community in common goals and make an open participations community empowerment.

Objective 2.1 Enforce the community to participate in needs assessment and decision making process.

Activities

- Engage community representatives to take part in the task force. - Organize meetings involving community representatives, health professionals, social workers and policy makers to set priorities. - Prepare a draft of an action plan to reduce health inequalities and promote health promotion activities.

Indicators

- Number of representative’s participant in the task force. - Number of meetings. - Document prepared with needs assessment, aims and objectives in first step. - Document prepared with activities, indicators, time frame, resources needed and evaluation activities.

Objective 2.2 Encourage the use of existing resources of the community.

Activities

- Identifications of existing resources in the community. - To establish a guide of resources in the community.

Indicators - Number of people working in all government and sectors to identify existing resources in the community.

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- Guide

Objective 2.3 Promote the knowledge of professionals in health promotion.

Activities

- Provide education and training on health promotion. - Organize a series of theoretical and practical courses to professionals involved in health care (health promotion). - Create a web site with information available on health promotion strategies. - Training on evaluation of interventions in health promotion.

Indicators

- Number of people involved in education. - Number of courses. - Web site. - Number of evaluations taken.

AIM 3: IMPROVE HEALTHY BEHAVIOURS THROUGH HEALTH PROMOTION ACTIVITIES

Investing in prevention and improved control of noncommunicable diseases (NCD) will reduce premature death and preventable morbidity and disability, and improve quality of life and well-being of people and societies {{8413 World 2012;}}. Prevention through life course is effective. It is an investment in health and development.

Objective 3.1 To improve health and well-being by making school and workplace settings more supportive of healthy lifestyles

Target 1: Reduce childhood overweight and obesity-Nutrition

Activities

- Improve nutritional knowledge to children at school. - Improve nutritional knowledge to population level (parents, teachers). - Develop training materials at schools for children, teachers and families. - Organize workshops with children, teacher and families in schools located in deprived areas.

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Indicators

- Number of activities developed at school level. - Number of activities developed at community level related to overweight and obesity. - Number and quality of materials produced. - Number of workshops within children, teachers and families.

Objective 3.2 Promote physical activity

Target 2: Reduce childhood overweight and obesity-Physical activity

Activities

- Motivate children to participate actively in physical activity at school. - Promote sports activities out the school schedule. - Facilitate public and safety spaces to practice physical activity for children and families. - Include physical activities into diverse events.

Indicators

- Number of children involved in activities. - Number of children involved in extra-curricular activities. - Determine how many public places the community have to facilitate exercise. - Number of people attending events.

Objective 3.3 Promote healthy lifestyle behaviours in Tenerife population

Activities

- Promote knowledge and training skills about healthy lifestyles. - Implement existing policies and intervention to promote healthy lifestyles in all settings: work, schools, leisure places, sport training centres. - Engage media to promote healthy habits (produce under supervision of experts).

Indicators

- Number of training courses, seminars, workshops.

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- Evaluation of those activities. - Number of people attended. - Number and quality of advertising on TV and radio.

AIM 4: REDUCE INTRA-REGIONAL HEALTH INEQUALITIES BY SUPPORTING VULNERABLE GROUPS

The literature suggests a strong relation between health and social exclusion, and demonstrate that the health field can play an important role in promoting social inclusion {{8416 Stegeman 2004;}}.

There is limited awareness of the contributions that public health, health promotion and health care sectors can make to tackle social exclusion.

We consider as vulnerable group in our context of Canary Islands, children and youth, singles parents families with young children, people in poverty, unemployment, elderly people, migrants and ethnic minorities. In this action plan we will establish some objectives and actions referred to children and youth, single parents with young children, unemployment, elderly people and migrants.

Objective 4.1 Provide access to quality food for children at school.

The current social and economic situation in the Canary Islands is complicated. About 6,160 children do not have access to quality food. Last summer 2103, 162 schools opened their canteens to give at least one food to children of disadvantage groups. The total poverty risk in Canary Islands for the year 2011 was 33,8% (INE). That is the highest level of all Spain. The population at risk of poverty under 16 is 25.9% (INE). The risk of poverty rate differs depending on the level of training of the individual. Thus the 28.9% of the population that has attained an educational level equivalent to education primary or less is at risk of poverty. When the education level is reached higher, the rate stands at 10.0%.

Activities

- Sign an agreement with the local authorities to provide food at school for children under 12 (primary schools). - Implement whole school approach to healthy eating in the school setting.

Indicators

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- Number of signed agreements with local town council. - Number of produced activities to implement whole approach to healthy eating.

Objective 4.2 Provide information about drugs consumption and their effects in health.

Activities

- Provide information at primary and secondary schools about the effects of drug consumption. - Select a person who has been drug consumer to participate in the talks.

Indicators

- Number of school participating in the talks. - Number of events. - Evaluation from the children and adolescents of all the activities that will be implemented.

Objective 4.3 Encourage smoke-free environment for children at home.

Activities

- Supporting smoking cessation programmes for families. - Provide information on noxiousness of smoking and second hand smoking in childhood.

Indicators

- Range of smoking cessation programmes. - Level of awareness on noxiousness of smoking by filling a questionnaire during the sessions.

Objective 4.4 Encourage self-esteem and healthy behaviours of school drop-outs {{8417 Belovic, B. 2005;}}.

Activities

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- Enhance the partnership to implement intersectorial programmes for drop- outs. - Develop appropriate training programme to strengthen positive self-image and healthy behaviour. - Implement a training programme.

Indicators

- Appropriate training programme. - Numbers of participants in the training sessions. - Level of self-esteem after training.

Objective 4.5 Encourage single parents to take part at school and community activities.

Activities

- Provide information on available resources for them and their children at the community. - To establish relationships among members of the community.

Indicators

- Report from social workers about how many single parents have consulted them. - Number of social activities developed at community level and number of participants (single parents).

Objective 4.6 Increase social and coping skills of unemployed.

Research has shown that unemployed people are more likely to have poor health habits, characterized by excess drinking, smoking, lack of exercise, and a sedentary lifestyle (Benach, J.,Muntaner, O., Solar, I., Santana, V., Quinlan, M.and the Emconet Network., 2010). Unemployment is associated with a range of increased health problems (Dooley, Fielding, & Levi, 1996). A widespread conviction in psychology is that the response to stressful events, such as unemployment, takes the form of a progression through stages. Shock tends to characterize the initial phase, during which the individual is still optimistic and unbroken. As unemployment advances, the individual becomes pessimistic and suffers

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active distress, and ultimately becomes fatalistic about their situation and adapts unenthusiastically to their new state. Thus, the unemployed are expected to exhibit poorer mental health due to elevated levels of anxiety, frustration, disappointment, alienation and depression. Moreover, these feelings are likely to be more pronounced among those who shoulder greater financial responsibilities and persons with a greater sense of self efficacy fostered by prior success in a host of domains including school and work. Thus, the highly educated and parents are particularly vulnerable to the debilitating emotional consequences of unemployment. A host of factors may buffer the adverse psychological impact of involuntary joblessness including an understanding spouse, parents, siblings, adult children and friends {{8417 Belovic, B. 2005; 8418 Goldsmith 2012;}}.

Activities

- Training of social skills. - Increase knowledge and skills on healthy lifestyles. - Increase stress management capacity through workshops. - Give information on existing resources in the community to job search.

Indicators

- Number of participants in training and workshops. - Number of people using resources at community level.

Objective 4.7 Support healthy lifestyles and social contact to elderly people.

Activities

- Promote appropriate physical activity. - Promote healthy nutrition. - Involve elderly people in different activities at community level. - Promote safe environments at home, care centres and streets.

Indicators

- Number of activities to promote physical activity. - Number of people attending activities. - Number of activities developed at community level to engage elderly people. - Research on the current state of safety at home, care centres and streets.

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Objective 4.8 Encourage healthy behaviours of migrants and ethnical groups.

In Canary Islands, migrant population come mainly from South America and we speak the same language. In this case this is not a barrier. Another group of migrant are people from England or Germany but they have better socioeconomic status than the people from the Canaries. A small group of Indian people also live in Tenerife and Gran Canaria. They have their own business and also a good socioeconomic position. A small number of people came from Africa and they keep in an irregular legal situation. This group is really difficult to reach. Some NGO´s work with all of them.

Activities

- Get in contact with migrants and ethnical minorities groups. - Establish a way of communication and dissemination of information. - Promote healthy activities taking into account their expressed needs. - Enable accessibility to health care system. - Empowerment of different groups.

Indicators

- List organizations, locals, places where migrants meet. - Find an “entrance” person to their community. - Use churches, health care centre, bars, public places to spread information on activities. - Facilitate their integration into the health care system. - Level of partnership within groups.

AIM 5: SUPPORT HEALTHY PHYSICAL ENVIRONMENT

The physical environment has a huge impact on health. This includes not only the study of the direct pathological effects of various chemical, physical, and biological agents, but also the effects on health of the broad physical and social environment, which includes housing, urban development, land-use and transportation, industry, and agriculture {{8414 Kranic-Nikolic, T. 2013;}}.

Objective 5.1 Encourage positive behaviour of people towards the physical environment.

Activities

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- Provide knowledge about healthy environment to increase awareness of population about influence of environment on people’s lives. - Develop programmes and interventions focus on how to improve the environment. - Involve media in those activities. - Encourage people to use public transport. - Encourage people to keep the environment clean.

Indicators

- Range of messages about healthy environment. - Number of programmes and intervention. - Evaluation of those programmes and activities. - Media coverage of activities and information. - Report on environment cleanness.

RESOURCES

In this action plan we will implement objective 3.1. We have established collaboration with the Regional Institute of Public Health (which depend on The Health Government Department) and the Education Government Department. The preparation of this implementation has been a long negotiation process. Some steps needs to be decided and an effective assessment of all the activities. Health promotion implies a long term outcomes. The focus group will be children from 6 to 12 years old at primary school.

Rationale

Primary education consists of six grades, from 6 to 12 years, and is mandatory. It is divided into three cycles of two years each: an initial cycle (for 6-8 years), medium cycle (from 8-10 years) and an upper (10 to 12 years). This is the first stage of compulsory education system so all children of 6 years old should be incorporated into the education system regardless of whether or not they conducted Childhood Education in nurseries. It's a free and compulsory education stage. Its purpose is to promote the socialization of children, promote their incorporation into the culture and contribute to the progressive autonomy of action in their environment.

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Objective 3.1 To improve health and well-being by making school and workplace settings more supportive of healthy lifestyles

Target 1: Reduce childhood overweight and obesity-Nutrition

Activities

- Improve nutritional knowledge to children at school. - Improve nutritional knowledge to population level (parents, teachers). - Develop training materials at schools for children, teachers and families. - Organize workshops with children, teacher and families in schools located in deprived areas.

Indicators

- Number of activities developed at school level. - Number of activities developed at community level related to overweight and obesity. - Number and quality of materials produced. - Number of workshops within children, teachers and families.

Objective 3.2 Promote physical activity

Target 2: Reduce childhood overweight and obesity-Physical activity Activities

- Motivate children at school to participate actively in physical activity at school. - Promote sports activities out the school schedule. - Facilitate public and safety spaces to practice physical activity for children and families. - Include physical activities into diverse events.

Indicators

- Number of children involved in activities. - Number of children involved in extra-curricular activities. - Determine how many public places the community have to facilitate exercise. - Number of people attending events.

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Human resources

Regarding to the economic situation we need to be realistic in the human resources we can use. The action plan should be developed in six schools in Tenerife and after that in Gran Canaria. We will evaluate the activities and then make them extensive to other islands (La Gomera, El Hierro, La Palma, Fuerteventura, Lanzarote). First step in Tenerife we need a team of eight people. Two professional trained in nutrition, two professionals trained in physical activities, two stagiares, and two teachers. The estimated cost of the intervention is 15,000 euros. We need to fit the program into this budget for one year. That is the amount of money that the Government will put into the implementation of this objective.

CONCLUSION

The preparation of this action plan is an indicator of the increase capacity to tackle health inequalities in Tenerife. This is a draft proposal of an action plan. One of the important issues about an action plan is the need of continuous assessment in any phase of it. The content of the action plan is based on the regional context.

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REFERENCES

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Barten, F., Mitlin, D., Mulholland, C., Hardoy, A., & Stern, R. (2007). Integrated approaches to address the social determinants of helath for reducing health inequity. Journal of Urban Health, 84(Suplement, May), 164-173.

Behringer, B., & Richards, R. W. (1996). The nature of communities. In R. W. Richards (Ed.), Building partnerships: Educating health professionals fro the communities they serve. (pp. 82-101). San Francisco: Jossey-Boss.

Benach, J.,Muntaner, O., Solar, I., Santana, V., Quinlan, M.and the Emconet Network. (2010). In Benach J., Muntaner O. :., I., Santana V. and Quinlan, M.and the Emconet Network. (Eds.), - Employment, work, and health inequalities: A global perspective. Barcelona: Icaria.

Campos Esteban, P. y col. (2010). Hacia la equidad en salud: Monitorización de los determinantes sociales de la salud y reducción de las desigualdades en salud. Madrid: Ministerio de Sanidad y Política Social.

CSDH Employment Conditions Knowledge Network (EMCONET). (2006). A glossary of key concepts. Geneva: WHO.

Dahlgren, G., & Whitehead, M. (2006). Levelling up (part 1): A discussion paper on european strategies for tacling social inequities in health. EURO: WHO.

Darias Curvo, S. (2008). Análisis de las desigualdades económicas en la prevalencia de diabetes y obesidad en Canarias. Revista ENE, 4, 51-60.

Darias Curvo, S. (2009). Determinaciones socioeconómicas y factores de riesgo cardiovascular: Un estudio en canarias

Demakakos, P., Nazroo, J., Breeze, E., & Marmot, M. (2008). Socioeconomic status and health: The role of subjective social status. Social Science & Medicine, 67(2), 330- 340.

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Dooley, D., Fielding, J., & Levi, L. (1996). Health and unemployment. Annual Review of Public Health, 17, 449-465.

Instituto Canario de Estadísitca. ISTAC. (2012). Retrieved May, 2013, from http://www.gobiernodecanarias.org/istac/

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Ministerio de Sanidad, Servicios Sociales e Igualdad. (2011). Proyecto ALADINO. Retrieved May, 2013, from www.naos.aesan.msssi.gob.es/naos/ficheros/investigacion/aladino_final.pdf

Ortiz-Moncada, R., Álvarez-Dardet, C., Miralles-Bueno, J. J., Ruíz-Cantero, M. T., Dal Re- Saavedra, M. A., Villar-Villalba, C., et al. (2011). Determinantes sociales de sobrepeso y obesidad en españa 2006. Medicina Clínica, 137(15), 678-684.

Wallerstein, N., & Duran, B. (2010). Community based participatory research contributions to intervention research: The intersection of science and practice to improve health equity. American Journal of Public Health, 100(1), 40-46.

Whitehead, M., Petticrew, M., Graham, H., Macintyre, S. J., Bambra, C., & Egan, M. (2004). Evidence for public health policy on inequalities: 2: Assembling the evidence jigsaw. Journal of Epidemiology and Community Health, 58(10), 817-821.

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The Strategic Plan for Tackling Health Inequalities in Međimurje County through Health Promotion 2014-2020

ISBN 978-953-57941-1-0 (EPUB) ISBN 978-953-57941-4-1 (CD-ROM)

The Strategic Plan for Tackling Health Inequalities in Međimurje County through Health Promotion 2014-2020

This document arises from the project ACTION-FOR-HEALTH which has received funding from the European Union in the Framework of Health Programme.

Unless otherwise stated, the views expressed in this publication do not necessarily reflect the views of the European Commission.

ISBN 978-953-57941-1-0 (EPUB) ISBN 978-953-57941-4-1 (CD-ROM)

Title: The Strategic Plan for Tackling Health Inequalities in Međimurje County through Health Promotion 2014-2020

Title of the translation: Strateški plan za unapređenje zdravlja i smanjivanje nejednakosti u zdravlju u Međimurskoj županiji od 2014.-2020.

Publisher: INSTITUTE OF PUBLIC HEALTH OF MEĐIMURJE COUNTY Ivana Gorana Kovačića 1e, 40000 ČAKOVEC

Editors: Renata Kutnjak Kiš (main editor), Marina Payerl-Pal, Diana Uvodić Đurić, Berta Bacinger Klobučarić, Elizabeta Najman Hižman

Authors: Renata Kutnjak Kiš, Diana Uvodić–Đurić, Berta Bacinger Klobučarić, Marina Payerl-Pal, Elizabeta Najman Hižman, Renata Tisaj, Marko Klemenčić, Marija Prekupec, Hrvoje Barić

Translator: Didasko d.o.o. jezično edukativni centar Čakovec - Aleksandra Trupković

Čakovec, December 2013

ISBN 978-953-57941-1-0 (EPUB) ISBN 978-953-57941-4-1 (CD-ROM)

The Strategic Plan for Tackling Health Inequalities in Međimurje County through Health Promotion 2014-2020

Publisher: INSTITUTE OF PUBLIC HEALTH OF MEĐIMURJE COUNTY

When using the data from this publication please specify the source.

Čakovec, 2013

Table of Contents

1. Introduction ...... 1 1.1. The framework of the Strategic Plan for Tackling Health Inequalities in Međimurje County through Health Promotion and its methodology ...... 2 2. A need for the Strategic Plan for Tackling Health Inequalities in Međimurje County through Health Promotion ...... 4 2.1. Income, unemployment and education ...... 4 2.2. Geographical distribution of the leading causes of death in the Republic of Croatia . 6 3. Health inequalities in Međimurje County ...... 11 3.1. Basic information ...... 11 3.2. Socio-economic data ...... 12 3.3. Health and health inequalities ...... 15 3.4. Health inequalities and cardiovascular diseases ...... 15 3.5. Geographical distribution of cardiovascular diseases in Međimurje County ...... 15 3.6. Socio-economic and environmental factors which can influence health inequalities in connection with cardiovascular diseases in Međimurje County ...... 18 3.7. Possible obstacles and solutions available ...... 22 4. Aims and objectives ...... 25 4.1. Aim 1: Promote different aspects of health of the Međimurje County population based on health promotion methods within various sectors ...... 27 4.1.1. Objective 1: Promote mental health and well-being ...... 28 4.1.2. Objective 2: Promote a healthy lifestyle ...... 38 4.1.3. Objective 3: Improve prevention, early detection, monitoring and treatment for chronic non-communicable diseases ...... 49 4.2. Aim 2: Reduce health inequalities in the county through programmes of health promotion for the groups in a socially unfavourable position...... 57 4.2.1. Objective 1: Improve the health of marginalised groups and groups at risk of social exclusion ...... 58 4.2.2. Objective 2: Improve the health and well-being of the old and the infirm ...... 63 4.2.3. Objective 3: Improve the health of children with developmental disabilities and youth leaving the social care system ...... 68 4.2.4. Objective 4: Improve the health of people with disabilities ...... 71 4.2.5. Objective 5: Improve the position of high risk families ...... 75 4.3. Aim 3: Place health inequalities at the centre of attention of both the community and the individual ...... 78

4.3.1. Objective 1: Set up a surveillance system for health inequalities and compose an evidence-based database that would include indicators and interventions for the reduction of health inequalities through health promotion ...... 80 4.3.2. Objective 2: Raise the awareness and knowledge of experts belonging to different sectors about health inequalities, as well as the possibilities for their reduction, and encourage them to cooperate ...... 82 4.3.3. Objective 3: Raise the awareness of local population about health inequalities and the possibilities of their reduction ...... 85 4.3.4. Objective 4 Raise the awareness of regional and local decision-makers and stakeholders about the importance of health for community and individual well-being, and stress their responsibility in the process of reducing health inequalities ...... 87 4.4. Aim 4: Lobby for clean, healthy and sustainable environment ...... 91 4.4.1. Objective 1: Raise awareness about the importance of environmental conservation, sustainable agriculture and development in general ...... 92 4.4.2. Objective 2: Encourage choices that support clean, healthy and sustainable environment ...... 92 5. Communication strategy and partners in the implementation of the Strategic Plan for Tackling Health Inequalities in Međimurje County through Health Promotion ...... 93 6. Funding of the Strategic Plan ...... 96 7. References ...... 98 8. Partners in the ACTION-FOR-HEALTH Needs Assessment and other important steps in the creation of the Strategic Plan ...... 104

1. Introduction

According to the definition of the World Health Organisation, health is the state of complete physical, mental and social well-being, and not merely the abscence of illness or infirmity (1). A somewhat similar definition is offered by Breslow, who sees health as a dynamic equilibrium between an individual (group, community) and their surroundings. For an individual, a group or community to reach a state of complete physical, mental and social well-being, they should have the possibility to identify and recognise their aspirations, fulfill their needs and either change the environment or cope with it (2).

The classic Dahlgren-Whitehead model of health determinants speaks of various levels of influence of certain determinants on the health potential of an individual. Whitehead has described the following factors as being unchangeable: age, gender and hereditary factors. However, she also sees them as a combination of potentially changeable risk factors, expressed through a number of influence layers, including life habits, physical and social surroundings and the general socio-economic, cultural and environmental conditions (3).

Figure 1. The Dahlgren-Whitehead model (Dahlgren and Whitehead’s rainbow: social determinants of health). Source: Whitehead, M. and Dahlgren, C. ‘’what can be done about inequities and health?’’, The Lancet, 338, 8774, 26 October 1991, 1059-1063.

According to the Ottawa Charter for Health Promotion 1986, the basic conditions for health are peace, adequate housing, education, food, income, stable ecosystem, sustainable exploitation of resources, social justice and health equity. That is to say that one's life and health are not merely influenced by one's biological, hereditary and bihevioural attributes; in fact, the characteristics of the social group to which one belongs have a considerably

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stronger impact on human health. In this sense, health inequalities can actually be regarded as a consequence of unequal opportunities in life (4).

Health inequalities can be defined as the differences in health status or in the distribution of health determinants among different population groups. It is important to distinguish between the inequality and the inequity of health. Some health inequalities are attributable to biological variations or free choice and others to the external environment and conditions mainly outside the control of individuals concerned (WHO definitions). Health inequalities exist on the supra-national level (between countries), on the national level (between regions in the same country) and within regions (between different local groups). Socio-economic inequalities in health are a major challenge for health policies worldwide (5).

Therefore, the World Health Organisation, in its document “Health-for-All Policy for the 21st century”, places equity and solidarity at the centre of concern, and together with the civilian and political rights equally important are the economic, social and cultural rights which include the right to work and to be educated, social security, adequate housing and food as well as the highest possible health standard and the benefits of scientific progress.

The World Health Organisation emphasises that better health is possible to ensure through healthy lifestyle promotion and by reducing the risk factors of health that arise from environmental, social or bihevioural characteristics of one's surroundings. It is equally important to develop a health system that would be financially sustainable and just in its promotion of health incomes, would be based on the policy and practice of “non-exclusion” (available, accessible, efficient), and whose services would meet the needs of its user. Apart from that, it is important to develop a health policy within the health system and in general to create one that would take into account the social, economic and environmental facets of health (6). These settings will be our guidelines in the design and implementation of the Strategic Plan for Tackling Health Inequalities in Međimurje County through Health Promotion.

1.1. The framework of the Strategic Plan for Tackling Health Inequalities in Međimurje County through Health Promotion and its methodology

The Strategic Plan for Tackling Health Inequalities in Međimurje County has been developed as part of the ACTION-FOR-HEALTH project, partly funded by the EU. Its primary objective is to reduce health inequalities by using methods of health promotion and the EU Structural Funds. The first step in developing the plan was to carry out the situation analysis for health inequalities at national and county level. The project team of experts at the Institute of Public Health of Međimurje County, in collaboration with other experts from the Institute and elsewhere, conducted a detailed analysis of health determinants. This was based on the

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data provided by EUROSTAT, National Bureau of Statistics, Croatian Institute of Public Health and other international, national and regional databases and various other sources (expert and scientific publications). Some data were also provided by the Institute of Public Health of Međimurje County (both published and not). Indicators were gathered via online questionnaire prepared by a team of experts at the Dutch Institute for Health Improvement – CBO, in charge of the ACTION-FOR-HEALTH project (Work package 4 - Situation overview, needs assessment and examples of good practice in the field of health inequalities). Having completed the situation analysis, our team of experts focused on carrying out the needs assessment. For that reason, a few focus groups were organised for a number of partners, where the project objectives and the current situation with regard to health inequalities at national and county level were in short presented. This was followed by a discussion to estimate strengths, weaknesses, opportunities and possibilities in the context of reducing health inequalities in the county. In addition, all partners were asked to fill out an open- ended questionnaire so that an insight into the available knowledge, time, good will, financial, human and other resources could be gained. The existing networks and their way of functioning, as well as their policies, objectives and management, were then assessed. More than 35 people from various county sectors took part in focus groups, and the open- ended questionnaire was filled out by more than 60 people (contacted via email, telephone or in person). The needs assessment also entailed an online questionnaire prepared by experts at the Dutch Institute for Health Improvement, based on the Dutch Framework for Health Promotion. Situation analysis and needs assessment are essential steps in creating the Strategic Plan for Tackling Health Inequalities in Međimurje County.

Most significant results of situation analyses and needs assessments, and the methodology with good practice examples in tackling health inequalities from seven European countries, have been presented in the joint project publication ''ACTION-FOR-HEALTH Situation Analysis and Needs Assessment in Seven EU-Countries and Regions, Reducing Inequalities in Health).

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2. A need for the Strategic Plan for Tackling Health Inequalities in Međimurje County through Health Promotion

The problem of health inequality is of great interest to all transitional countries, including Croatia, which has experienced great changes in all aspects of health care system. Countries in transition are being faced with ever higher health care costs due to demographic changes, the rising expectations with regard to health care right and the general constraints in health care funding (5).

Health inequalities, as in all other European countries, are also evident in the Republic of Croatia. In fact, according to the research conducted by Šućur, the self-estimated inequalities concerning health status and access to health care of different population groups, based on income differences, urbanisation level and regional distribution, are more conspicuous in Croatia than in other EU countries.

Significant differences have been determined between different regions in Croatia. People of Central Croatia (Karlovac, Sisak-Moslavina and Bjelovar-Bilogora counties) report experiencing most difficulties when it comes to health and access to health services. Eastern Croatia (Virovitica-Podravina, Požega-Slavonija, Brod-Posavina, Osijek-Baranja, Vukovar- Srijem counties) follows Central Croatia in terms of the negative perception of health and the access to health services. The most favourable situation is in the Zagreb region (the City of Zagreb, Zagreb County) and North Adriatic (Primorje-Gorski kotar, Lika-Senj, Istria)(7).

2.1. Income, unemployment and education

Notable differences between Croatian counties are evident in GDP, employment and education, which is reflected in the differences between health indicators. Figure 2 shows considerable regional disproportions concerning the level of development. The most underdeveloped counties are those of Central and Eastern Croatia, and by far the highest GDP per capita is noted in the City of Zagreb. Primorje-Gorski kotar and Istria also show GDPs per capita above the Croatian average. The City of Zagreb has more than one third of the GDP reached, followed by Split-Dalmatia (9%) and Primorje-Gorski kotar (8%), as well as Istria, Osijek-Baranja and Zagreb County (6% each). The lowest value of 1% (for each) in the total GDP is found in the counties of Lika-Senj, Virovitica-Podravina and Požega-Slavonija(8).

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Figure 2. Gross domestic product (GDP) per capita (EUR) across counties (EUR) 2009. Source: the Croatian Central Bureau of Statistics (2012); the Report of 14 March 2012. No. 12.1.2. Source: National Strategy of Health Care Development 2012-2020, Government of the Republic of Croatia, 2012.

Furthermore, regional disproportions are present in Croatia with regard to unemployment rate (Figure 3). In 2010, most counties had higher unemployment rates than the Croatian average. For the City of Zagreb the registered unemployment rate was the lowest, whereas it appeared highest for Brod-Posavina, Vukovar-Srijem, Virovitica-Podravina and Sisak- Moslavina(8).

Figure 3. The registered unemployment rates across counties 2010 (%). Sources: Croatian Central Bureau of Statistics (2012), Monthly Statistical Report 2; Croatian Employment Service (2010), Analytical Bulletin No. 4. Source: National Strategy of Health Care Development (Nacionalna strategija razvoja zdravstva) 2012-2020, Government of the Republic of Croatia, 2012.

The Republic of Croatia is characterised by striking differences in the educational structure of its counties. According to the most recent data from the Population Census of 2011, most highly educated people older than 15 were found in the City of Zagreb (29%), followed by 5

Primorje-Gorski kotar (20.1%), Dubrovnik-Neretva (18.7%), Split-Dalmatia (18%) and Istria (16.6%); the Croatian average was 16.4%. The lowest shares of highly educated population were found in Virovitica-Podravina (8.2%), Krapina-Zagorje (9.2%), Bjelovar-Bilogora (9.3%), and finally Vukovar-Srijem and Brod-Posavina (10% each). In Međimurje County the share of highly educated people was 10.1%(9). Differences in the educational structure have a strong impact on health inequalities in a number of factors. Well-documented is the statistical fact that life-expectancy in the case of higher educational status is longer than in the case of lower educational status. Individuals of lower educational status also show a tendency towards lower health literacy, which is reflected in poor health incomes (more chronic diseases, bad compliance in the application of recommended treatments, higher mortality etc.), poor lifestyle, and higher health care costs(10). All this has a negative influence on the development of Croatia, not just at health level but also at social and economic levels.

The share of people above the age of 15 having attained high and higher education in Croatian counties, Population Census 2011,

County of Virovitica-Podravina 8,2 County of Krapina-Zagorje 9,2 County of Vukovar-Srijem 9,3 County of Vukovar-Srijem 9,5 County of Slavonski Brod-Posavina 9,5 County of Požega-Slavonija 10,0 County of Međimurje 10,1 County of Lika-Senj 10,5 County of Sisak-Moslavina 10,5 County of Koprivnica-Križevci 10,7 County of Varaždin 11,9 County of Zagreb 12,4 County of Osijek-Baranja 12,7 County of Karlovac 12,8 County of Šibenik-Knin 13,2 County of Zadar 14,8 Republic of Croatia 16,4 County of Istria 16,6 County of Split-Dalmatia 18,0 Dubrovačko-neretvanska 18,7 County of Primorje-Gorski kotar 20,1 The city of Zagreb 29,0 0,0 5,0 10,0 15,0 20,0 25,0 30,0 35,0

Figure 4. The share of people above the age of 15 with high education in Croatian counties. Source: Croatian Bureau of Statistics, Population Census 2011; the chart was created at the Institute of Public Health, County of Međimurje(9)

2.2. Geographical distribution of the leading causes of death in the Republic of Croatia

The leading causes of death in Međimurje County as well as Croatia in 2010 were cardiovascular diseases (with the share of 46% in the total number of deaths in Međimurje,

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and 49% in Croatia), malignant diseases (28.8%:26.3%), followed by injuries, poisoning and other consequences of external causes (6.1%:5.7%)(11).

In 2010 the standardised mortality rate for cardiovascular diseases was for all ages in Croatia 370.88/100,000. The highest mortality rate was found in Virovitica-Podravina (555.06/100,000) and the lowest in Split-Dalmatia (283.28/100,000). Mortality rates are mostly higher in the continental part of Croatia and lower in the coastal region, with the exception of Međimurje County (341.2), Zagreb County (362.4) and the City of Zagreb (320.84), which also showed lower mortality rates than the Croatian average. Of 1,235 people (609 men and 626 women) who died in Međimurje County in 2010, 568 people (232 men and 336 women) died of cardiovascular diseases, with the share of 46% in the total number of deaths (12).

Age-standardized mortality rates of diseases of circulatory system (ICD10-I00-I99), all ages, per 100,000 people in Croatian counties, 2010

County of Split-Dalmatia 283,28 County of Zadar 301,19 County of Dubrovnik-Neretva 313,17 County of Primorje-Gorski kotar 316,35 The city of Zagreb 320,84 County of Istria 337,16 County of Međimurje 341,20 County of Šibenik-Knin 358,63 County of Zagreb 362,40 Croatia 370,88 County Slavonski Brod-Posavina 378,75 County of Karlovac 415,44 County of Vukovar- Sirmium 418,22 County of Varaždin 427,27 County of Lika-Senj 443,11 County of Krapina-Zagorje 453,55 County of Koprivnica-Križevci 455,05 County of Požega - Slavonia 461,58 County of Osijek-Baranja 463,27 County of Sisak-Moslavina 468,78 County of Bjelovar-Bilogora 478,82 County of Virovitica-Podravina 555,06 0,00 100,00 200,00 300,00 400,00 500,00 600,00 DSR/100.000 (EU stand.pop.)

Figure 5. Age-standardised mortality rates for circulatory system diseases (ICD 10, I00-I99), all ages, per 100,000 population, 2010, Croatian counties. Source of data: Croatian Institute of Public Health, National Bureau of Statistics, standardised mortality rates have been calculated at the Institute of Public Health County of Međimurje (age-specific rates have been calculated on the basis of the estimated population number of the

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Republic of Croatia in mid 2010, followed by the standardisation by direct method per European standard population)(12)

In 2010, age-standardised mortality rate for cancer (ICD 10-C00-C97) was for all ages in Croatia 210.9/100,000 people. The highest mortality rate was recorded in Sisak-Moslavina (261.33) and the lowest in Dubrovnik-Neretva (167.44). Međimurje County was also above the Croatian average in terms of mortality rate for cancer (225.09). In 2010, 356 people in Međimurje County died from malignant diseases (213 men and 143 women), and their share in the total number of deaths was 28.8%(12).

Age-standardized mortality rates of malignant neoplasm (ICD10-C00-C97), all ages, per 100,000 people in Croatian counties, 2010

County of Dubrovnik-Neretva 167,44 County of Zadar 181,61 County of Split-Dalmatia 187,96 County of Šibenik-Knin 195,95 County of Bjelovar-Bilogora 198,56 County of Istria 201,32 County of Vukovar- Sirmium 201,8 Croatia 210,9 The city of Zagreb 210,91 County of Zagreb 212,62 County of Primorje-Gorski kotar 213,97 County of Koprivnica-Križevci 214,92 County of Krapina-Zagorje 215,06 County of Osijek-Baranja 219,11 County of Karlovac 221,4 County of Međimurje 225,09 County of Varaždin 225,39 County of Virovitica-Podravina 228,28 County of Lika-Senj 228,63 County of Požega-Slavonia 233 County of Slavonski Brod-Posavina 235,58 County of Sisak-Moslavina 261,33 0 50 100 150 200 250 300 DSR/100,000 (stand.EU popul.)

Figure 6. Age-standardised mortality rates of malignant diseases (ICD 10-C00-C97), all ages, per 100,000 people, 2010, Croatian counties. Source of data: Croatian Institute of Public Health, National Bureau of Statistics, standardised mortality rates have been calculated at the Institute of Public Health County of Međimurje (age-specific rates have been calculated on the basis of the estimated population number of the

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Republic of Croatia in mid 2010, followed by the standardisation by direct method per European standard population)(12)

In 2010, age-standardised mortality rate for injuries, poisoning and other consequences of external causes (ICD 10 S00-T98) was in Croatia 52.67/100,000. The lowest mortality rates were recorded in Split-Dalmatia (39.95/100,000) and the City of Zagreb (41.18/100,000), whereas the highest mortality rates were found in Krapina-Zagorje (84.01/100,000) and Virovitica-Podravina (74.21/100,000). Međimurje County has a slightly lower mortality rate (52.54/100,000) compared with the average for Croatia. In 2010, injuries were in Međimurje County the third leading cause of death, with 75 deaths (36 men and 39 women), and their share in the total number of deaths was 6.1% (12).

Age-standardized mortality rates of external cause injury and poison, all ages, per 100,000 (ICD10-S00-T98), all ages, per 100,000 people in Croatian counties, 2010

County of Split-Dalmatia 39,95 The city of Zagreb 41,18 County of Dubrovnik-Neretva 45,15 County of Istria 46,73 County of Primorje-Gorski kotar 48,85 County of Zadar 52,35 County of Međimurje 52,54 Croatia 52,67 County of Slavonski Brod-Posavina 53,32 County of Požega-Slavonia 53,37 County of Koprivnica-Križevci 55 County of Zagreb 55,94 County of Vukovar- Sirmium 56,08 County of Šibenik-Knin 56,91 County of Karlovac 57,19 County of Osijek-Baranja 60,28 County of Sisak-Moslavina 61,57 County of Bjelovar-Bilogora 69,46 County of Varaždin 69,53 County of Lika-Senj 73,09 County of Virovitica-Podravina 74,21 County of Krapina-Zagorje 84,01 0 20 40 60 80 100 DSR/100,000 (stand EU popul.)

Figure 7. Age-standardised mortality rates of injuries, poisoning and consequences of other external causes (ICD 10 S00-T98) all ages, 2010, Croatian counties. Source of data: Croatian Institute of Public Health, National Bureau of Statistics, standardised mortality rates have been calculated at the Institute of Public Health County of Međimurje (age-specific rates have been calculated on the basis of the estimated population number of the

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Republic of Croatia in mid 2010, followed by the standardisation by direct method per European standard population)(12)

In 2007, the Republic of Croatia, in accordance with the regulations of the Treaty of Accession to the European Union, signed the Joint Inclusion Memorandum-JIM with the aim of fighting poverty and social exclusion (13), and in 2011 the Development Strategy of Social Care System in the Republic of Croatia 2011-2016 was adopted (14). Two very important documents, whose main objective is also to reduce health inequalities in the Republic of Croatia (besides having other important goals), have been adopted recently: the National Strategy of Health Care Development 2012-2020 and the Strategic Plan of Public Health Development 2011-2015 (8,15). To carry out the objectives of the Strategy of regional development in the Republic of Croatia 2011-2013 is also extremely important for improving the well-being of all Croatian regions and reducing the lagging behind the EU average. The goals of the strategy focus on the socio-economic development of Croatia, the reduction of regional inequalities and strengthening the development potential of those parts of Croatia that lag behind the rest (16). What is more, a new Law on Regional Development of Croatia is currently being drafted.

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3. Health inequalities in Međimurje County

3.1. Basic information

Međimurje County is the smallest county in the Republic of Croatia covering 730 sq km. It is bordered by the Mur river to the north and east, and the Drava river to the south. With its 156.11 population per square km it is the most densely populated county in Croatia. According to the Population Census of 2011, in Međimurje County live 113,804 people (55,601 men and 58,203 women). People aged 0-14 take the share of 16.9% population in Međimurje, or 15.2% in Croatia. The percentage of people older than 65 is in Croatia 15.6%, whereas the Croatian average is 17.7%.

The average population age in Međimurje is 40 years, and in Croatia 41.7. The City of Čakovec is the administrative, cultural and political centre of the county. Administratively and politically speaking, the county comprises two more towns and 22 municipalities. The predominant national minority in Međimurje are the Roma people. According to the Population Census of 2011, in Međimurje live 5,107 Roma people and their share in the total number of population is 4.49%. The same source states that 16,975 Roma people were registered in Croatia, of which a registered 30% live in Međimurje (9).

There were 11,738 people with disabilities recorded in Međimurje on 17th January 2013, of which 6,363 men (54%) and 5,375 women (46%). People with disabilities thus take the share of 10.3% of county's population total. The greatest share of people with disabilities, 5,761 (49%), is of economically active age, while 16% of them (1,831) is aged 0-19. In Međimurje County, the total prevalence of people with disabilities as well as the prevalence of economically active age and the age group above 65, are below average. At the same time, the prevalence of children age (0-19) is above the average and the highest recorded in Croatia. According to the available data on education, 76% of people with disabilities did not finish primary education or only have primary education, 17% have secondary education, whereas 1% of people with disabilities have higher or highest level education, and 6% of them finished special needs education. As found in the database of employed people with disabilities, in Međimurje County 273 people are employed (both the currently employed and those temporarily unable to work), of which 67% are men and 33% are women. Around 55% of people, who are users of social care services, are in constant need of assistance and care. In Međimurje County also live 399 veterans with disabilities and 102 people who were left with consequences of war operations from World War II, or are civilian invalids of war and postwar (17). People with disabilities are, therefore, an especially vulnerable population group who are in need of special attention in the efforts to reduce health inequalities.

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3.2. Socio-economic data

In 2010, the average monthly net salary per employee in legal entities in Međimurje County, according to the Central Bureau of Statistics, was 4,251 HRK or 584 EUR (4,495 HRK/617.45 for employed men and 3,941 HRK/541.34 EUR for employed women), this being the lowest paid net wage in all counties. In 2010, the highest paid net wage per employee, on average, was found in the City of Zagreb, with 6,245 HRK total (5,871 for women and 6,580 for men), whereas the Croatian average was 5,329 HRK or 737 EUR (5,575 HRK for men and 5,026 HRK for women) (18).

According to the National Bureau of Statistics, in 2011 the poverty risk rate was in the Republic of Croatia 21.1% (20.0% for men and 22.1% for women). It was found highest for people aged 65 and more (27.3%). This group also showed the biggest discrepancy gender- wise (21.5% for men and 31.3% for women) (19). Another source (Ivica Rubil, Accounting for regional poverty differences in Croatia, the Institute of Economics, Zagreb, January, 2013) states that, in 2010, the poverty risk rate for Croatia was 17.7%, and 12% for Međimurje County. A lower poverty risk rate compared with Croatian average according to the same source was, apart from Međimurje County, found in seven other counties – Istria 3.9%, the City of Zagreb 7.9%, Dubrovnik-Neretva 9.3%, Primorje-Gorski kotar 9.5%, Krapina-Zagorje 9.6%, Split-Dalmatia 16.3% and Zagreb 16.7%. The highest poverty risk rate was found in Virovitica-Podravina County, 47.5% (20).

According to the Croatian Employment Bureau, Regional Office Čakovec, on 30th September 2012, 7,564 unemployed people were registered in Međimurje County, of which 1,750 (23.1%) were the unemployed below the age of 25. There were 38,578 employed people and 46,142 people of active population registered. Thus, the overall unemployment rate in Međimurje County was 16.4% - the unemployment rate of men being 14% and of women 19.3% (21). In Međimurje County, the unemployment rate appears to be very high among the Roma national minority. According to the aforementioned research of Šlezak, Sociologija i prostor, 51 (2013), in the Roma settlement of Kuršanec, as shown by a study from 2009, the employment rate was no higher than 3.78%. Of 15 employed people, there were 14 men and only one woman (22).

According to the National Bureau of Statistics, the unemployment rate for the year 2012 was in Croatia higher than in Međimurje County, 18.3% (16.4% for men and 20.5% for women), whereas in the total number of the unemployed, those aged 25 or less had the share of 20.5% in the total number of unemployed people (23).

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In Međimurje County an extremely unfavourable situation has been recorded in terms of education compared with the overall situation in Croatia. The share of population older than 15 who had completed at least secondary education in Međimurje County, according to the Population Census for 2011, amounted to 51.8% (63.1% for men and 41.3% for women), while the average for Croatia was 52.6% (60% for men and 45.9% for women). Apart from the above stated, the share of people with high level education was in Croatia 16.4% (16.7% for women and 16% for men), and no higher than 10.1% in Međimurje County (10.9% for women and 9.2% for men). The share of people who had finished less than eight grades of primary school in Croatia was 9.6% (13.1% for women and 6.2% for men), and in Međimurje County the percentage is as high as 15.3% (20.2% for women and 10.1 for men). An exceptionally low level of education is evident among the Roma population in Međimurje County. In the context of education, notable descrepancies are found in the county. The greatest share of highly educated people is recorded in the towns and in Šenkovec and Strahoninec municipalities, whereas the lowest share of highly educated people is found in Orehovica, Domašinec and Vratišinec (Figure 8)(9). The research of Šlezak, Sociologija i prostor, 51 (2013), who analysed the structure of Roma population on the basis of the second largest Roma settlement of Kuršanec, with 960 people in 2009 (around 18% of total Roma population in Međimurje), has been of great help in this respect. According to this research, almost one fourth of people older than 15 never attended school (23.5%), 56.5% left primary school, 15.9% finished only primary school, and 4.2% of them finished secondary school. An extremely low educational status of Roma population leads to the lack of capacity to engage in any qualified work, which gives way to a high unemployment rate of Roma people (22).

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The share of people above the age of 15 having attained high and higher education in the towns and municipalities of Međimurje County, Population Census 2011

Čakovec 18,9 Šenkovec 16,3 Strahoninec 10,2 Međimurska županija 10,1 Mursko Središće 9,2 Prelog 9,1 Nedelišće 8,8 Donji Kraljevec 8,7 Sveti Juraj na Bregu 7,4 Donja Dubrava 7,1 Pribislavec 6,7 Kotoriba 6,7 Sveta Marija 6,6 Sveti Martin na Muri 6,3 Donji Vidovec 6,1 Mala Subotica 5,8 Dekanovec 5,7 Goričan 5,4 Štrigova 5,2 Selnica 5,1 Belica 5 Vratišinec 4,7 Domašinec 4,6 Orehovica 3,7

Figure 8. The share of people above the age of 15 having attained high or higher education in Međimurje County. Source: Croatian Bureau of Statistics, Population Census 2011; the chart was created at the Institute of Public Health, County of Međimurje(9)

The average annual age-standardised mortality rate for ages 25-64 based on the educational status of people having died in Međimurje County, for the period 2006-2010

350 300 250 200 150 100 50 0 high and secondary primary school higher primary school school not finished mortality rate/100 000 people rate/100 mortality education total mortality 73,98 172,68 287,19 234,09 mortality of circulatory system 20,22 39,48 64,8 63,5 diseases ICD10-IOO-I99

Figure 9. The average annual age-standardised mortality rate based on the educational status of people having died in Međimurje County. Source: Croatian Bureau of Statistics, Population Census 2011, DEM 2(2006-2010); the chart was created at the Institute of Public Health, County of Međimurje.

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3.3. Health and health inequalities

The life expectancy in Croatia, according to EUROSTAT, was for 2010 76.1 years (72.9 years for men and 79.2 years for women) (24). According to the National Bureau of Statistics, life expectancy in Međimurje County is close to the Croatian average and was in 2008/2009 72.14 years for men and 79.8 years for women – 7.7 years longer for women than men. The longest life expectancy is on average in Adriatic Croatia, especially in the coastal region, whereas the lowest life expectancy is in Pannonian Croatia. The lowest life expectancy is estimated for men of Krapina-Zagorje County (68.8 years), and the longest of Dubrovnik- Neretva (75.23 years). For women the number is again highest in Dubrovnik-Neretva (81.96 years) and lowest in Bjelovar-Bilogora (77.5 years) (25). The leading cause of death in Međimurje County as well as Croatia are cardiovascular diseases (with the share of 46% in the total number of deaths in Međimurje in 2010, and 49% in Croatia), malignant diseases (28.8%:26.3%), and finally injuries, poisoning and other consequences of external causes (6.1%:5.7%)(11).

3.4. Health inequalities and cardiovascular diseases

In the span of 15 years, a considerable decrease in mortality due to cardiovascular diseases occurred in Međimurje County. Since 2004, they have been one of five county public health priorities. In spite of that, however, their burden remains as evident as ever, and it is essential to invest more effort to continue with the trend of reducing mortality and morbidity from cardiovascular diseases, as well as to reduce health inequalities in connection with these diseases. Cardiovascular diseases are the leading cause of death and hospitalisation in Međimurje County. The standardised mortality rate for cardiovascular diseases in Međimurje County was in 2012 lower than the Croatian average (341.2/100,000 for Međimurje County and 370.75/100,000 for Croatia), as well as the mortality for ischemic heart disease (156.34/100,000:164.21/100,000). Mortality for cerebrovascular diseases was in Međimurje County only slightly higher than the average for Croatia (108.28/100,000 for Međimurje County and 106.77/100,000 for Croatia). However, mortality rates for cardiovascular diseases are in Međimurje County higher than in 27 countries of the EU, and higher than in Slovenia and Austria (12).

3.5. Geographical distribution of cardiovascular diseases in Međimurje County

To analyse the geographical distribution of cardiovascular diseases in Međimurje County, we have used the data on death causes for Međimurje County in the period 2006-2010,

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registered with the Institute of Public Health County of Međimurje. In the five-year period, 2,822 people died of cardiovascular diseases (81,196 men and 1,626 women), the annual average being 564 people (239 men and 325 women). This is the share of 47.3% in the total number of deaths during that time. The share of deaths of cardiovascular diseases was considerably higher for women than men. In the five-year period altogether 5,969 people died of all causes. Among them were 3,082 men and the share of those who had died of cardiovascular diseases in the total number of deaths was 39%. In the same period altogether 2,887 women died and the share of female deaths due to cardiovascular diseases was 56%.

In order to compare the data for cities and municipalities of Međimurje County, annual average age-standardised rates have been calculated (per European standard population). The annual average standardised mortality rate for cardiovascular diseases for the period 2006 – 2010 in Međimurje County was for all ages 457.15/100,000; and it was higher for men (561.38/100,000) than women (389.41/100,000). For the ages 0-64 years it was 54.4/100,000; and also considerably higher for men (83.56/100,000) than women (27.11/100,000). The highest mortality rate was noted in the smallest municipality, territorially and population-wise (with only 832 citizens), the municipality of Dekanovec, where the mortality for all ages was 1025.98/100,000, and for the age group 0-64 it was 139.33/100,000. In the period 1006-2010 altogether 91 people died in the municipality, 42 of them of cardiovascular diseases, with the share of 46% in the total number of deaths.

The lowest mortality rate for all ages was noted in the municipality of Strahoninec (248.02/100,000), with 67 deaths during the five-year period, of which 21 were the result of cardiovascular diseases, with the share of 31.4%. The lowest mortality rate for the age group 0-64 was recorded in Gornji Mihaljevec (17.31/100,000 st).

With regard to gender, for all age groups, the mortality rates for men are again highest in the municipality of Dekanovec (1,536.48/100,000), and lowest in the municipality of Strahoninec (288.82/100,000), whereas for the age group 0-64, Donja Dubrava shows the highest mortality rate for men (226.85/100,000) and Gornji Mihaljevec the lowest (32.82/100,000). Mortality rates are lower for women than men in general. The mortality of women of all age groups is again highest in the municipality of Dekanovec (904.81/100,000), and lowest in the municipality of Šenkovec (214.65/100,000). For the age group 0-64 mortality rate remains highest in Dekanovec, with 151.32/100,000, and it is lowest in Selnica (10.16/100,000). However, during that period, for the ages 0-64, in four other municipalities not one female death of cardiovascular diseases was recorded (Strahoninec, Kotoriba, Gornji Mihaljevec and Goričan).

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As already mentioned, the highest mortality rates of cardiovascular diseases, total and for both genders, were found in Dekanovec. However, mortality rates (total and for both genders) are also higher than the county average in Donja Dubrava, a municipality farthest from the county centre (the City of Čakovec), followed by Nedelišće, the biggest municipality in the county, as well as in three other municipalities and a city situated in the Upper Međimurje – municipalities of Sveti Martin na Muri, Sveti Juraj na Bregu, Vratišinec and the town of Mursko Središće(26).

Age-standardised mortality rates of circulatory system diseases (ICD10-I00-I99), all ages, per 100,000 people, in the municipalites of Međimurje County, 2006-2010

Municipality Strahoninec 248,02 Municipality Senkovec 272,54 Municipality Gornji Mihaljevec 340,66 Municipality Orehovica 341,63 Municipality Kotoriba 363,14 Municipality Donji Kraljevec 364,41 Municipality Gorican 389,47 Municipality Donji Vidovec 402,08 Municipality Sveta Marija 432,63 Municipality Domasinec 444,05 Municipality Belica 444,65 Municipality Selnica 446,87 Municipality Podturen 453,58 County of Medimurje 457,15 Town of Cakovec 460,4 Town of Prelog 474,89 Municipality Strigova 477,33 Municipality Mala Subotica 486,7 Municipality Nedelisce 512,74 Municipality Vratisinec 588,41 Municipality Sveta Martin na Muri 593,29 Town of Mursko Sredisce 596,1 Municipality Sveti Juraj na bregu 598,14 Municipality Donja Dubrava 662,28 Municipality Dekanovec 1025,98 0 200 400 600 800 1000 1200 DSR/100,000 (stand.EU popul.)

Figure 10. The average annual age-standardised mortality rate for cardiovascular diseases, all age groups, 2006- 2010, Međimurje County. Source of data: Croatian Institute of Public Health, National Bureau of Statistics; age- specific mortality rates have been calculated at the Institute of Public Health County of Međimurje on the basis of the estimated population number in Međimurje in mid 2010(26)

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Age-standardised mortality rates of circulatory system diseases (ICD10-I00-I99), ages 0-64, per 100,000 people, in the municipalites of Međimurje County, 2006-2010

Municipality Gornji Mihaljevec 17,31 Municipality Strahoninec 19,59 Municipality Senkovec 21,83 Municipality Selnica 24,24 Municipality Podturen 40,98 Municipality Sveta Marija 41,14 Municipality Orehovica 44,47 Municipality Kotoriba 45,32 Town of Cakovec 48,81 Municipality Gorican 49,88 Municipality Strigova 50,92 Municipality Nedelisce 52,99 Municipality Vratisinec 53,02 County of Medimurje 54,4 Municipality Sveta Martin na Muri 56,64 Municipality Sveti Juraj na bregu 59,37 Municipality Donji Kraljevec 61,45 Municipality Belica 65,72 Municipality Mala Subotica 65,91 Town of Mursko Sredisce 65,97 Town of Prelog 68,44 Municipality Domasinec 68,67 Municipality Donji Vidovec 80,93 Municipality Donja Dubrava 126,74 Municipality Dekanovec 139,33 0 20 40 60 80 100 120 140 DSR/100,000 (stand.EU popul.)

Figure 11. The average annual age-standardised mortality rate for cardiovascular diseases, ages 0-64, 2006- 2010, Međimurje County. Source of data: Croatian Institute of Public Health, National Bureau of Statistics; age- specific mortality rates have been calculated at the Institute of Public Health County of Međimurje on the basis of the estimated population number in Međimurje in mid 2010(26)

3.6. Socio-economic and environmental factors which can influence health inequalities in connection with cardiovascular diseases in Međimurje County

Age and gender are extremely important personal factors that influence mortality of cardiovascular diseases, and notable differences with regard to them can be observed. In Međimurje County in 2010, 568 people died of cardiovascular diseases, of which 336 were men and 232 women. Among the total number of deaths that year from cardiovascular diseases, 12.2% (69 people) were aged 64 or less, with a considerably higher share of men dying at the age of 64 and less (53 deaths, the share of 26.1%). The share of women who died at the age of 64 or less was 4.8% (16 female deaths). Age-specific mortality rates for cardiovascular diseases grow with age and are higher for men than women of all age groups, except for ages 45-49 and above 85 years, when the rate is higher for women. A more notable mortality increase begins above the age of 50 (12). Mortality for cardiovascular diseases, but also the different data for men and women, certainly could have been influenced by gender differences in the prevalence of harmful risk factors such as dietary

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habits, physical avtivity, smoking, alcohol consumption, the use of medical services, health literacy, education, income and beliefs and opinions of individuals.

Lifestyle factors. According to Croatian Health Survey 2003, the prevalence of unhealthy dietary habits was higher for men in all regions. The respondents in Međimurje County belonged to the Northern Region, where convincingly the highest burden of overweight, obesity and central obesity cases was found. Among men who belonged to the Northern Region in the same survey, the highest prevalence of high blood pressure was noted (47.06%), followed by the high prevalence of insufficient physical activity (37.7%, it was only higher in the City of Zagreb) and a very high prevalence of alcohol overconsumption (13.12% for men, it was only higher in Eastern and Adriatic regions). The highest prevalence of alcohol overconsumption was found among women in the Northern Region, 1.45%. Only the prevalence of smoking was for both genders lowest in the Northern Region (10.54% of women and 24.07% of men).

According to Croatian Health Survey 2003, the highest synthetic regional cardiovascular burden defined by incidents (heart attack, stroke), blood pressure, overweight/obesity (BMI, waist circumference) and risky behaviours (smoking, physical inactivity, high alcohol consumption, inadequate nutrition) was recorded in the Northern Region – 53.1% for men and 54.2% for women. It was highest for women of Central Region with 56.5%, and Eastern Region with 55% (27,28,29,30,31,32,33).

Conclusions on the influence of certain health risk factors for our population can be made on the basis of the qualitative research regarding the health needs of Međimurje County, conducted as part of the programme A Healthy County, with 174 respondents from the community and a group of observers taking part, including interviews, focus groups and surveys. One of the questions in the research was: ''What harms your health and your family’s health?'' The most common answer categories (5) for the community included stress, existential insecurity, bad dietary habits, pollution and different kinds of addiction (smoking, alcohol, drugs). In the observer group the answer categories were almost identical - stress, the state of being overworked, poor dietary habits, pollution and material insecurity (34).

On studying the determinants pertaining to personal factors as well as income and the level of education, which could affect mortality due to cardiovascular diseases in Međimurje County in the period 2006-2010 statistically relevant differences between men and women were noted. For instance, statistically less men had been treated for the diseases from which they died – 87.8%:92.3% (OR is 0.60, and 95% CI – 0.47-0.78), the share of men not having finished primary education compared with women is considerably lower – 35.2%:55.4% (OR

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is 0.44, and 95% CI – 0.37-0.51), considerably more men than women die in the hospital – 40.1 %:34.3% (OR is 1.28, and 95% CI – 1.10-1.50), and the share of men who are financially independent is notably higher than that of women of the same group– 88.9%:73.8% (OR is 2.84, and 95% CI 2.84 – 3.51) (35).

Occupation, income and education are very important socio-economic determinants of health. Considering the fact that the population of Međimurje County is less educated, insufficient knowledge and awareness about the most notable risk factors for cardiovascular diseases as well as the symptoms could have affected the level of morbidity and mortality for cardiovascular diseases. What is more, Međimurje County had the lowest paid average monthly net wage compared with all other counties in 2010 (9,18).

Prospective studies have shown that stress in general as well as the stress at work is related to increased morbidity and mortality risk for cardiovascular diseases, which is in no connection with smoking or other risk factors. In the doctoral dissertation by Šikić Vagić J., (Psihosocijalne karakteristike kao čimbenici rizika u hospitaliziranih koronarnih bolesnika u Hrvatskoj, the School of Medicine, University of Zagreb, Zagreb, 2010), professional stress as a possible risk factor for cardiovascular diseases is found in 12.2% of patients; 15% of men in Continental Croatia suffers from professional stress in terms of professional failure or the losing of a job, whereas in Mediterranean Croatia the percentage is 8.7%. According to the same research, the lowest incomes were reported by women respondents in Continental Croatia (19.3% of them had the income of less than 2000 HRK) (36).

In the qualitative study of the population’s health needs conducted in Međimurje County, stress is marked as a very important factor, and it is mostly caused by economic as well as social conditions. Most commonly this is reflected in the existential concern (unemployment, fear of losing a job, insufficient income, the housing problem), stress caused by various other obstacles (in civil engineering, administration, in obtaining health care), stress due to overwork, stress due to fear of death or social isolation, poor family relations, the lack of understanding for the needs of those who are ill, etc. (34).

Social determinants related to cultural and environmental factors. According to a qualitative study regarding the health needs of Međimurje County, the awareness about the importance of activity for the health improvement and preservation, is still insufficient, especially in the smaller rural regions. Apart from the lack of knowledge, this is also influenced by the cultural norms; e.g. people who take walks or ride bicycles for recreation are generally perceived as not having anything better to do (or are not interested in spending their time more ‘’usefully’’), and the situation is aggravating enough for women due to overwork and family-related obligations (the inequalities pertaining to female roles

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and tasks), who then lack time for physical activity (even if they show interest). The same research showed the lack of sporting and recreational facilities, halls, clubs (both places and programmes), as well as bike trails (34). According to the research by Šikić Vagić, the more educated men and women with ischemic heart disease are statistically more physically active. Also, men tend to be notably more physically active than women (36).

In Međimurje County, which is, because of a specific geographical position, a wine-bearing region, alcohol consumption has got a positive connotation and is socially acceptable, even expected on many occasions. The whole community contributes to this idea by promoting wine-related tourism, examples of which are the ''wine roads,'' ''new wine christening'', ''St Urban wine days'' (Dani vina uz Sv. Urbana), etc. The local media marketing is quite influential here as well, especially when it comes to young people, by promoting various kinds of ''parties'' (e.g. vodka party, bambus party, etc.), the law that prohibits the selling of alcohol and cigarettes to those under 18 is ignored. Especially problematic is the beer and wine advertising, which is allowed by law, because both are considered to be food products and not merely alcoholic beverages (this applies to Croatia in general) (37). . Tradition also affects the dietary habits of the Međimurje County population, even though the latest studies point to a growing trend of abandoning the traditional diet, which abounds in saturated fat of animal origin, red meat and salt-cured products and is characterised by the insufficient amount of fruit and vegetables (38).

A number of studies conducted in Croatia have confirmed the assumption that the burden of cardiovascular diseases is more prominent in continental and rural parts of Croatia. Therefore, we investigated the situation in Međimurje County as well (39,40). During the research of some determinants that might have influenced mortality for cardiovascular diseases (was the person treated or not for the disease that led to death, the share of people dying without having finished primary school, had the person been hospitalised when death occurred, was the person financially dependent), regardless of gender, a statistically relevant difference between people who died in municipalities and cities of Međimurje County has been observed only in the case of personal income. A considerably lower number of deaths of people who had not been financially dependent was determined in municipalities of Međimurje, as opposed to deaths in the cities of Međimurje – 77.5%:84.7% (OR is 0.62, and 95% CI – 0.51-0.76). Among the men who died of cardiovascular diseases no statistically relevant differences were found in the aforementioned research on determinants with regard to cities and municipalities. For women, differences in education were observed; in municipalities of Međimurje County there is a statistically less prominent share of women who did not finish primary school than in the cities - 53.65%;59.3% (OR is 0.79, and 95% CI – 0.65-0.97), whereas in municipalities there is a smaller share of women who are not

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financially dependent compared with the share of those in the towns of Međimurje - 70%;80.6% (OR is 0.56, and 95% CI – 0.44-0.72) (35).

The differences in mortality for cardiovascular diseases in cities and municipalities of Međimurje County could have been influenced by the differences in public transport, cultural norms and the predominant attitudes of the community on health and health- related behaviour, the community's social networks and the accessibility of health care (41). Public transport is not developed enough, and it is worse in Upper Međimurje than in Lower Međimurje, and public transport fares from the remote places in Međimurje could also have influenced the delay in seeking medical assistance. Given that the Emergency Medical Service was by 2012 located only in the City of Čakovec, as well as the specialist services (which will remain in current location), greater spatial distance of medical care and high public transport fares, could have had an impact on the differences in mortality of cardiovascular diseases.

3.7. Possible obstacles and solutions available

After the situation analysis, we started with the process of needs assessment. The needs assessment was carried out by means of a questionnaire prepared by the experts from the Dutch Institute for Health Improvement, which is based on the Dutch Framework for Health Promotion. In order to assess the needs and possible solutions, we organised several focus groups with a number of partners, introducing them briefly to the project objectives and the current situation with regard to health inequalities both at national and county level. This was followed by a discussion with the aim of assessing the strengths, weaknesses, opportunities and possibilities when it comes to reducing health inequalities associated with circulatory system diseases. In addition, all partners were asked to complete a semi- structured questionnaire with open-ended questions all partners were asked to fill out an open-ended questionnaire so that an insight into the available knowledge, time, good will, financial, human and other resources could be gained. The existing networks and their way of functioning, as well as their policies, objectives and management, were then assessed. Based on the results of the needs assessment, we would like to highlight strengths and possibilities, obstacles and challenges and the main development needs.

Strengths and possibilities (factors that can contribute to easier realisation of the Strategic Plan). In Međimurje County highly competent multidisciplinary teams of experts have been formed (the Team for Health and Implementation of the Health Plan for Međimurje County, whose members have finished two phases of education as part of the programme “A Healthy County”, and the Health Council together with the Council of Social Welfare, Međimurje County). These teams of experts are experienced in drafting strategic documents

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addressing health, which are selected through participatory method and in agreement with the policy-makers, profession and direct beneficiaries – the community itself. In Međimurje County there is a number of different strategies and action plans (adopted on the basis of the bottom-up approach) in which health promotion and prevention as well as early detection of chronic non-communicable diseases are considered a priority, in the same way as strategies for the promotion of regional development and fight against poverty and social exclusion. In the Long-Term County Health Plan 2008-2012 (adopted as part of the programme Health – Plan for It – County Public Health Capacity Building Programme, or ''A Healthy County''), coronary heart disease, cerebrovascular diseases, insufficient physical activity, smoking and overconsumption of alcohol among children and the younger population are health problems of high priority. In County Health Care Plan, adopted in 2010, health promotion and the prevention as well as control of both communicable and non-communicable chronic diseases, injuries and disabilities, and the protection of vulnerable and socially deprived groups are the development areas of great importance. In the Development Strategy of Međimurje County 2011-2013, as part of the secondary goal - To foster human resources and improve the quality of life, one of the development needs is to enhance health care in terms of prevention and strengthen the “healthy lifestyle trend.” There are two more county documents important in the context of reducing health inequalities – the Social Map of Međimurje County, adopted in 2012, and the Rural Development Strategy of Međimurje County adopted in 2009. In Međimurje County a Europen Union project is being carried out (IPA Component IV – Human Resources Development) – ''Support for the social welfare system in the process of further deinstitutionalisation of social services,'' under whose wing the Council for Social Welfare of Međimurje County is working on the Plans of Social Services in an expanded team. Through training as part of the Healthy Counties programme, through the creation of strategic documents addressing health in the county and other documents, and finally through the implementation of a number of projects and activities as part of the Health Plan for Međimurje County, the communication and cooperation within and between different sectors of regional and local self-governments, decision-makers, health and social sector, education, NGOs and the media have been improved. Additional effort is needed to create the network's infrastructure and to more clearly define the protocols when it comes to the functioning of and each member's contribution to the network.

Despite the availability of a number of strategies that might contribute to the reduction of health inequalities as well as a few highly competent multidisciplinary teams of experts, experience and cooperation, certain obstacles need to be overcome in the forthcoming period for the efficient application of strategies and plans (42,43,44,45,46).

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Possible obstacles and challenges: insufficient funding for plan implementation, the lack of awareness about the prevailing public health problems (and health inequalities) and the population’s lack of interest therefor, the lack of motivation and contribution of stakeholders, the lack of experts’ time where motivation exists, the lack of motivation and support of the local and regional self-governments, the lack of support at national level (whereas the local self-government has little authority and low funds), the gap between legislation and scientific achievements, poor economic situation, the lack of cooperation of all stakeholders, the risk of discontinuity because of the lack of funds or human resources, non-compliance with laws and regulations, the attitudes and insufficient motivation of people, tradition, the lack of qualified staff, insufficient motivation of professionals to work on projects due to no or little financial compensation, older age – a barrier to becoming involved in activities and the problem of health care insufficiently addressing the needs of older population, poor literacy of the Roma population, the lack of experts’ understanding for the needs of individual target groups, insufficient funding for education.

The main development needs. It is necessary to additionally influence the level of awareness of county leaders about the importance of continuity in carrying out the aforementioned plans and strategies as much as the importance of investing in health (not only in the segment of health care) for the development of the county (it is important to think of ''Health in all Policies''). It is also important that certain decisions are made in accordance with adopted plans. Apart from that, it is necessary to clearly develop the system of funding the programmes and actions of health promotion, in state and county budgets. What is more, there is an objective lack of experts who deal with health promotion. There is no estimation whatsoever as to the sufficient number of experts in the public health service nor the Institutes of Public Health. Also, field nurses within healthcare centres are focused on secondary and tertiary prevention to a greater extent than on primary prevention and health promotion, and family doctors also mostly deal with curative medicine. To this we add the fact that the general public, experts and politicians are not convinced that the methods of health promotion are effective, partly due to the lack of attention paid to the dissemination of results and programme evaluation, and partly because it takes a long time to see any results. The AIR project of EU (Addressing Inequalities Interventions in Regions) recommends that the intervention to reduce health inequalities should be shielded from rash expectations and too short political programme plans (47). Especially prominent is the need for an interdisciplinary approach and the cooperation of the public, business and civil sectors as well as cooperation with the media (at the same time justly including all stakeholders). For the implementation of the plan it is necessary to have at our disposal a sufficient number of partners and make obligatory the cooperation of the target population for which the plan is intended, with actions being long-term. Moreover, the need for a more consistent application of existing laws and the adoption of more efficient legislation is evident as well as

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the need to improve the quality of work of all state institutions. Finally, the importance of strengthening the social responsibility of business organisations in order to promote the health of their employees has also been highlighted.

In the context of economic crisis, the cutting-downs in health budgets and the ever growing health care needs, it is required that the opportunity given to Croatia (with all its counties) as the 28th member of EU be used to the fullest. This can be accomplished by using the financial resources as part of EU Structural Funds, thereby reducing health inequalities and raising capacities, or the competence of public health experts in the field of health inequality. Different EU programmes are also available in Croatia. The Community Programme 2014-2020, for example, highlights health promotion (including the reduction of health inequalities) and the creation and spreading of information and knowledge on health as its main goals.

4. Aims and objectives

One of the goals of the ACTION-FOR-HEALTH project is tackling health inequalites through methods of health promotion. The situation analysis of Croatian counties has shown conspicuous differences in life expectancy, mortality rates, self-evaluation of health status, health care accessibility, socio-economic factors, lifestyle and other health determinants. Numerous inequalities have been observed among counties as well as within Međimurje County itself. Therefore, the main goal of the strategic plan is:

TACKLING HEALTH INEQUALITIES IN MEĐIMURJE COUNTY THROUGH HEALTH PROMOTION METHODS – FIRSTLY, BY COMPARING MEĐIMURJE COUNTY WITH OTHER COUNTIES IN CROATIA; SECONDLY, BY COMPARING TOWNS AND MUNICIPALITIES WITHIN MEĐIMURJE COUNTY; AND THIRDLY, BY COMPARING DIFFERENT POPULATION GROUPS OF MEĐIMURJE COUNTY.

There is an abundance of reasons to focus the efforts of the state, regional and local governments, public health sector and many others on the reduction of health inequalities. Firstly, health inequalities are not ethically acceptable, being unjust and possible to prevent. Apart from that, poor health often leads to poverty and social exclusion. Therefore it is essential to keep improving health of the most vulnerable population groups, who are most prone to illness. If we succeed in achieving that, public health would be far more effective, making it possible to reduce the increased trend of health service needs that are becoming harder to meet. In other words, by reducing health inequalities, we are reducing health care

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costs and increasing employment rate, which contributes to the economic progress at personal, regional and national level (48).

Based on the analysis presented by the Commission on Social Determinants of Health, World Health Organisation, there are three basic principles for achieving health equality: 1) improve everyday life, i.e. the circumstances in which people are born, grow, live, work and age; 2) deal with the unjust distribution of power, money and resources – the driving force in accomplishing acceptable conditions for everyday life – globally, nationally and locally; 3) assess the magnitude of the problem and anticipate efficiency of the action, gather workforce with knowledge and skills with respect to social determinants of health, spread knowledge and raise awareness about social determinants of health (49).

Apart from the aforementioned basic principles that are to be met, the main methods in the efforts to reduce health inequalities are the methods of health promotion that will focus on creating acceptable social health policies and a health-supporting environment. Acting as the cornerstone of the plan's actions, these methods will also focus on strengthening the community actions, personal skill development and a reorientation of health care.

THE VISION

MEĐIMURJE, A COUNTY WHERE ALL PEOPLE HAVE EQUAL OPPORTUNITIES TO REACH THEIR HIGHEST HEALTH POTENTIAL

MAIN GOAL

TACKLING HEALTH INEQUALITIES IN MEĐIMURJE COUNTY THROUGH HEALTH PROMOTION

AIM 1 AIM 2 AIM 3 AIM 4

P romote different Reduce health Place health aspects of health of inequalities within Lobby for clean, the Međimurje inequalities at the county through health healthy and County population promotion centre of attention of sustainable based on health programmes for both the individual promotion methods environment groups in socially and the community within various sectors unfavourable position

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4.1. Aim 1: Promote different aspects of health of the Međimurje County population based on health promotion methods within various sectors

Health promotion is ''the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realise aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy lifestyles to well-being'' (4).

In reducing health inequalities between the populations of Međimurje County and the City of Zagreb or the North Adriatic, different strategies, that should rely on multisectoral cooperation, are at our disposal. According to the Ottawa Charter, interventions can focus on the individual (education, informing, personal skill development, risk factor assessment, early disease detection) or the entire community based on population approach. The latter entails community actions by creating social and material environment that supports health and facilitates healthy choices of behaviour, and by adopting and implementing public policies (4).

Aim 1 Promote different aspects of health of Međimurje County population based on health promotion methods within various sectors

Objective 1 Objective 2 Objective3 Improve prevention, early Promote mental health and Promote a healthy lifestyle detection, monitoring and well-being treatment for chronic non-communicable diseases

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4.1.1. Objective 1: Promote mental health and well-being

According to the WHO, mental health is part of our general health and not merely the abscence of a mental illness. The same source states that mental health is the state of well- being in which an individual realises their potential, is able to cope with normal levels of stress, productive and able to contribute to the community. Mental health also includes a sense of satisfaction, tranquility, success and optimism. In 2008, the European Pact for Mental Health and Well-Being defined a number of priority areas of action: prevention of depression and suicide, promotion of mental health and well-being of children and adolescents, promoting mental health and well-being in workplaces, older people's mental health and well-being, and promoting social inclusion and combating stigma. The Republic of Croatia has adopted the National Mental Health Strategy for the period 2011-2016 which revolves around the treatment and rehabilitation of patients with mental illnesses, relying on the proactive approach (mental health promotion, preservation and prevention). This will serve as our guideline in this strategy (50).

Lifestyle today presents a growing threat for our mental health. It is therefore necessary to support the protective factors through a number of activities, i.e. to adopt healthy life attitudes, skills and habits that would contribute to our mental health. The importance of proactive approach is illustrated by research results showing that 1 in 5 women and 1 in 10 men will at some point in their life suffer from depression (51). What is more, the share of mental disorders in hospitalised patients is for Croatia quite high – 7.4% in 2010. Most common are the disorders as a consequence of alcohol consumption and schizophrenia, which were the leading diagnostic subcategory. The Situation Analysis has shown that Northern and Eastern Regions of Croatia (Croatian Health Survey, 2003) have a very high prevalence of alcohol consumption. In fact, standardised mortality rate (per 100,000 people) of diseases connected with the overconsumption of alcohol (ICD 10, the codes K70, 73, 74, F10 and T51) was in 2010 highest in the counties of Krapina-Zagorje (54.1), Koprivnica- Križevci (36.8), Bjelovar-Bilogora (25.7), Virovitica-Podravina (24.9), Međimurje (23.5) and Varaždin (21.8), with the Croatian average of 16.5 (26).

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Objective 1

Promote mental health and well-being

Target 1 Target 2 Target 3 Target 4

Strengthen Raise awareness Encourage skill Reduce the impact of and inform about development in the stress on the social networks occurrence of chronic in the the importance of general population for the non-communicable mental health diseases through community improvement of creation and mental health implementation of antistress programmes

Target 5 Target 6 Target 7

Encourage Promote the Ensure a timely

mental health importance of mental identification of change in protective programmes in health in the and risk factors of nurseries and workplace schools mental health within different sectors

4.1.1.1. Target 1: Strengthen social networks in the community

The community is a social identity that entails a limited social and spatial mobility and represents a population whose members are consciously identified with one another. It is manifested by the formal and informal relations among its members and the existence of cohesion based on the sense of belonging. Because they live within the same space, they take part in common activities. The WHO and European project for mental health promotion have described the Ottawa Charter for Health Promotion conceptual framework for prevention strategies, which suggests community interventions by creating public health policies (taking care of health, diet, environment etc.) and a supporting environment, by strengthening activities of the community (strengthening social networks, actions of the community pertaining to drug abuse etc.) and similar (WHO, 1986) (51).

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Activities: 1) Encourage partnership development in the local community between institutions of the health and social care system, the local self-government and business units – based on the mutual investment and improvement of the quality of life in the community 2) Strengthen the protective factors in terms of giving support to personal growth and development, to healthy family development, and to networking, cooperation and project partnership within the community in order to achieve a healthy environment that would support one's safety, improvement of the quality of life as well as health 3) Participate in the development, implementation and improvement of general health care programmes for vulnerable population groups: children with disabilities and developmental risks, the elderly, victims of violence, mentally ill, the unemployed, socially excluded etc. 4) Take part in programmes of capacity development for providing services in the community by educating volunteers within the support network 5) Encourage the activity organisation processes of the community by initiating intergroup situations, new types of communication and interaction, by the encouragement of the sense of belonging to a group, making its resources available and creating a sense of shared responsibility.

Indicators: 1) Number of meetings, symposiums and conferences held for the community stakeholders with the aim of common investment in improvement of the quality of life in the community 2) Number of volunteers partaking in the activities of the promotion of health care for the vulnerable population groups 3) Number of activities that involve community members and are focused on strengthening cohesion.

4.1.1.2. Target 2: Raise awareness and inform about the importance of mental health

Mental health promotion is a process that helps improve the quality of life and increase personal control, so as to achieve personal responsibility for one's mental health. Under the patronage of WHO, the European Pact for Mental Health and Well-Being was adopted on a high-level conference in 2008, the aim of which was to promote the importance of mental

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health in the domain of public health, productive learning and social cohesion in the EU (52,53).

Activities: 1) Inform the public (timely and in an affordable way) about the factors relevant to their lives and health by distributing clear and simple information; this should encourage community members' personal engagement and at the same time abide by the rules of efficient communication – primarily by simplifying texts and making the use of all available media and means of informing more flexible (brochures, media appearances and public hearings, television, internet, radio, newsletters, etc.) 2) Inform the population about the importance and relationship of mental and general health, and provide them with knowledge that would facilitate their reading, assessing and understanding of information pertaining to mental health 3) Given that the media are prompt and comprehensive in spreading information, it is essential to create media campaigns about the importance of mental health care and include media representatives in the multidiciplinary work of expert teams 4) Provide education for segmented population groups in order to raise awareness and knowledge about the importance of mental health, early detection of behavioural difficulties and changes in mental health in self and others, and actions taken in case of problem detection.

Indicators: 1) Articles published for the general public informing about healthy lifestyles 2) Number of media statements informing the public about the importance of health 3) Number of educational lectures and public hearings on the importance of mental health and the early detection of problems in mental health, organised to raise awareness and knowledge of community members.

4.1.1.3. Target 3: Encourage skill development in the general population for the improvement of mental health

Mental ability is reflected in all aspects of human behaviour. To be mentally functional is to use one's 'gifts' and resources, from intelligence to physical disposition, in the optimal and well-balanced way by satisfying one's personal and community needs. The body can be healthy in every aspect, genetic disposition may be unburdened and intelligence immaculate. However, a person may still behave in a completely inefficient, even harmful

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way, presenting a threat for themself or the community. Unhappiness of such a person may lead them to the verge of suicidal behaviour, even in the case of quite favourable life circumstances.

For the shaping and structuring of one's personality, its morality, strength, stability and capacity to adapt to adverse circumstances, or tenacity and skill to solve problems or change reality (not at the expense of others), it is crucial to apply measures for the improvement and preservation of one's mental health (50,52,54).

Activities: 1) Improve community programmes of efficient free time management for all age groups, especially children, adolescents, families, the elderly, persons with disabilities, the long-term unemployed 2) Take part in improving the social and health-related conditions of life in the community, thus offering to its members, especially children and adolescents, the possibility of a healthy and fulfilled life, at the same time helping them develop interest in socially valuable key objectives in the process of mental health promotion 3) Provide psychoeducation on psychological aspects of existing problems (for example, the connection between physical pain and trauma), on anxiety and other symptoms, inform about efficient strategies for coping with stress, changing dysfunctional attitudes, overcoming fear 4) Develop competencies for changing the situation of the long-term unemployed threatened by social exclusion.

Indicators: 1) Reports on cooperation with the Croatian Employment Service, Regional Office Čakovec and activities for improved employability of the long-term unemployed 2) Number of activities and events organised in local communities for the improvement of social and health-related conditions of life 3) Reports on the cooperation with local community leaders and the number of meetings held to discuss the possibility of offering more community-level content for constructive and creative ways to spend free time 4) Nmber of public discussions held for the promotion of mental health and well- being.

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4.1.1.4. Target 4: Reduce the impact of stress on the occurrence of chronic non-communicable diseases through creation and implementation of antistress programmes

The social changes witnessed by the past decade have compelled modern man to acquire skills for finding meaning and achieving balance in his surroundings. Overbudened and stressed, experiencing lack of satisfaction in personal life and workplace, we are trying to cope with the quick pace imposed on us by the modern life. Negative psychological states can lead to disorders and imbalance of physical functions. Strong and persisting negative feelings that are a result of accumulated stress can with time evolve into an illness – the body's typical response. People have a hard time adapting to stressful situations so they look for other solutions (52,55).

Activities: 1) Create, implement and improve stress-management interventions to achieve general effectiveness in the workplace, especially for those professions that are psychologically demanding and therefore more stress-prone (health workers, teachers, social workers, police officers, those working in shifts, etc.) 2) Create and organise training programmes for stress management focusing on the individual level of protection by strengthening the personal capacity for stress management. This may be done by learning social and communicational skills that facilitate integration in the working environment and increase the general satisfaction with life (of individuals and families) 3) Organise and conduct training on stress management for individuals experiencing work-family conflict.

Indicators: 1) Number of workshops for professions most prone to stress with the aim of improving strategies for stress management and the number of workshop participants 2) Number of lectures organised for the working population on stress-related topics and the number of lecture attendants 3) An overview of research results for ways of coping with stress in helping professions.

4.1.1.5. Target 5: Encourage mental health programmes in nurseries and schools

Children are an especially vulnerable group and are therefore given special attention and care. One analysis shows that the field of children's status and rights has shown in the

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Republic of Croatia considerable progress in recent years. However, some challenges remain unfaced, especially for the most vulnerable children, e.g. those without parental care, children whose parents are in prison or are for some reason unable to care for them, children whose families are living in difficult conditions, and younger children with developmental delays. Finally, experts should pay special attention to the promotion and protection of children's mental health. The aforementioned analysis shows that, in spite of Croatia's signing numerous treaties on children's rights and adopting countless national documents, ''there is the obvious need for coordination, stronger implementation of measures and cooperation of the responsible institutions'' (58,59,60).

Activities: 1) Develop, implement and cotinuously evaluate the efficiency of interventions for improving the communicational skills of children, adolescents and families in general, making them a tool for better self-advocacy and healthier life choices 2) Stress the importance of creating a safe environment for children (playgrounds, nursery and school yards) 3) Promote and explain the importance of teaching children about self-protective behaviour, to make them feel more powerful in protecting themselves in certain situations (e.g. a stranger's offer, alcohol, drugs and tobacco, risky behaviour, games of chance, etc.) 4) Promote and justify the importance of child-parent relationship and affectionate behaviour for the child's mental health and adjusted behaviour; the importance of the upringing style adopted by parents for the preservation and improvement of their child's mental health; the importance of quality parental care. In other words, it is essential to address the devastating consequences of poor parental skills and child neglect, and other parent-child topics of relevance. 5) Promote storytelling to children as a factor of strengthening the prosocial behaviour in children, through education in nurseries, training organised for parents, in cooperation with local libraries 6) Organise children's workshops for developing good personal and social skills, which can boost children's capacities for the successful affirmation of their own strengths, making them more inclined to healthy life choices 7) Contribute to the improvement of approach and capacities of expert services in the educational system, so as to help all participants (children, teachers and educators, parents), by assisting, developing, preventing, planning and evaluating, in the following aspects of everyday life: 1 playing, learning and teaching, 2 culture, upbringing and discipline, 3 physical, personal (cognitive and emotional) and social development, 4 a child's enrollment into nursery school

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and their transition to primary school, 5 education and professional guidance, 6 social and/or financial problems.

Indicators: 1) Number of workshops and lectures in educational institutions, targeted at the improvement of children's mental health 2) Number of meetings of educational experts 3) Number of conferences, conventions and workshops promoting storytelling to children 4) Number of children's workshops for the improvement of their mental health 5) Reports from the meetings of local community representatives and health experts with regard to the improvement of health in children and adolescents.

4.1.1.6. Target 6: Promote the importance of mental health in the workplace

A workplace can have a strong impact on mental health, good or bad. Given that today more time is spent at work than anywhere else, it is extremely important for the workplace to make one feel productive and able to fullfil one's expectations. A stressful working environment, on the other hand, can lead to depression, anxiety and other mental disorders or states. In Croatia's continental region the situation analysis has shown a high occurrence of hospitalisations (especially of men) for the coronary heart disease due to professional stress. This type of stress is a powerful risk factor and should therefore be given special attention, especially since the qualitative analysis of health needs in Međimurje County has revealed stress as one of the most negative factors affecting the life quality of its population (53).

Activities: 1) Conduct research on the ways of dealing with stress in helping professions so as to widen the range of effective ways of dealing with stress in the workplace 2) Carry out activities for the early detection of problems and a timely intervention for the workers whose mental health is endangered by working conditions 3) Raise awareness and educate family doctors about the early detection of mental health problems pertaining to work and working conditions, and encourage them to cooperate in the early detection when it comes to such individuals 4) Inform and educate employers and managers about employing people with mental health problems by providing adequate support and refraining from social labeling, 35

which is to offer psychosocial aid to individuals with mental health problems in adjusting to the conditions and requirements of their workplace.

Indicators: 1) Number of workshops for professions that are most prone to stress, with the aim of improving strategies for coping with stress and the number of workshop participants 2) Number of lectures for the working population with the aim of educating about stress-related topics and the number of lecture participants 3) Level of cooperation of public health representatives and family doctors 4) Number of conferences and meetings held to raise the awareness of managers/employers about the effects of workers' good mental health on working efficiency.

4.1.1.7. Target 7: Ensure a timely identification of change in protective and risk factors of mental health within different sectors

A local community displays a number of protective and risk factors, which determine the residents' quality of life and their children's development. Thus, certain aspects of the community can improve the well-being of people. Finally, their identification, use and strengthening can contribute to good mental health (53,56,60).

Protective factors: I. The awareness of people holding key positions in the community about the importance of supporting children, adolescents and other population groups in need, and the importance of investing in the accessibility and quality of health care services. II. The capability of a local community to offer its members socialisation incentives (a community that instills norms and values, eg. tradition and education) and social cooperation (to widen the social support network). III. Feeling safe in the community: zero tolerance for criminal activities and leaving school; respecting the prohibition of selling alcohol to underaged persons (under 18); the existence of social control, messages against delinquency. IV. Raising awareness among people that it is everyone's responsibility to carry out and promote activities for the protection of vulnerable groups by actively contributing to the community, different associations and institutions. V. Creating conditions for stable families – supporting parents who are devoted to their role.

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VI. The network of services promoting mental health protection by sustaining a supporting environment and conditions in which individuals fulfill their potential and the positive context of their everyday life is emphasised.

Risk factors: NEGATIVE SOCIAL AND FAMILY ENVIRONMENT: I. Marginalised families living in poor conditions, socially excluded, people outside the health care system and the unemployed II. Parents of poor mental health: mental patients and drug addicts

III. High level of family stress, e.g. a difficult illness or death in the family, negative family atmosphere, separation or divorce IV. Irresponsible parenting: neglected or molested children V. Negative parent-child interaction, domestic violence and manipulation during divorce VI. Negative family models – parents prone to antisocial or asocial behaviour.

NON-FAMILY ENVIRONMENT: I. Interpersonal influence: belonging to groups that show deviant behaviour, social isolation (lack of close relationships), molesting and violence II. Cultural factors: environment prone to criminal activities, weapon and drug accessibility III. Belonging to a subculture with a tendency to fear, violence and bad parenting IV. Poverty and economic deprivation, high level of unemployment, poor accessibility of health services, lack of useful programmes for children and adolescents outside the school system, media presentment and tolerance of violence, easy access to alcohol, liberal attitudes to drug abuse and other criminal activities (53,56,60).

Activities: 1) Identify risk factors within the community in order to remove or alleviate their influence or identify protective factors in order to strengthen them, through different programmes as a result of multisectoral cooperation 2) Promote and explain the role and importance of protective factors with regard to healthy and safe behaviour and the ways of implementing them in everyday life.

Indicators: 1) Level of participation of all included in the activities of health promotion (from community representatives to residents)

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2) Number of activities intended to improve the quality of community life 3) Number of projects and programmes intended to improve the quality of community life 4) Local reports on the activities carried out in the community.

4.1.2. Objective 2: Promote a healthy lifestyle

Health is the basic requirement to improve the quality of life and help the development of the society as a whole. Each individual is responsible for their own health. However, the state shares that responsibility in that it has the power to act directly or through different sectors to create conditions for a healthy lifestyle.

The most significant factors of an unhealthy lifestyle are insufficient physical activity, unhealthy diets, smoking, drug abuse and overconsumption of alcohol. It has been scientifically proven that the above listed risk factors have a great impact on the development, progression and arising complications of the leading chronic non- communicable diseases: cardiovascular diseases, diabetes, certain cancer sites, some forms of chronic lung diseases, obesity, osteoporosis and diseases of the musculoskeletal system. Moreover, insufficient physical activity and unhealthy dietary habits are associated with the development and persistence of high blood pressure, as well as high levels of cholesterol and blood sugar (61,62).

According to the Croatian Health Survey of 2003, the highest synthetic cardiovascular burden defined by attacks (heart attack, stroke), blood pressure, overweight, abdominal obesity and risky behaviour (excessive drinking, unhealthy diets, physical inactivity, smoking) was noted for men in the Northern Region - 53.1% - to which belonged the respondents of Međimurje County. For women of the Northern Region it was even higher, 54.2% (although it was still higher for women of the Central Region – 56.5%, and Eastern Region – 55%) (33). Therefore, the promotion of a healthy lifestyle is one of the most important targets in the process of reducing health inequalities in Međimurje County.

During needs assessement, one of the priorities highlighted (as stated by a number of partners) was the importance of providing the spatial, financial and human resources for the continuity in carrying out the project of health promotion that have already proven their efficiency as part of the programme ''A Healthy County'' conducted in Međimurje County. Also, the partners stressed the importance of providing financial resources from the state and local community budgets for health improvement and protection. Finally, special emphasis was placed on the importance of networking and better cooperation of different institutions for the successful health promotion.

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4.1.2.1. Target 1: Promote health-enhancing physical activity

For the health and personal development of all individuals, it is essential to have the opportunity to lead an active life and engage in sports and recreational activities regardless of gender, age, social and economic status, functional abilities or ethnocultural background. A number of scientific studies have confirmed that regular physical activity reduces the risk of coronary heart disease and stroke, diabetes, high blood pressure, depression, colon and breast cancers. What is more, regular physical activity is essential in maintaining adequate body weight and keeping the musculoskeletal system healthy. Apart from the numerous studies on the health benefits of physical activity, an increasing number of recent studies also point to other benefits – psychological, social, economic and ecological.

Special attention needs to be directed toward promoting physical activity from the earliest age, given that the benefits of physical activity in childhood and youth are immense and extend to adulthood. These benefits entail physical and mental health, as well as socialisation in childhood, and may guarantee good health in adulthood, extending the habit of regular physical activity acquired in childhood to adulthood.

Even though the benefits of physical activity in childhood and youth are being increasingly addressed and a lot is known about them, the prevalence of inadequate physical activity is among children and adults as high as ever. A number of studies have shown that the level of physical activity decreases with age and is lower in female population. Moreover, the tendency toward physical activity is less common in people of lower education and socio- economic status and vulnerable groups. Therefore, to reduce health inequalities, it is necessary to encourage the overall population, and not only the socially disadvantaged groups, to lead an active life. In order to achieve success, it is important to know and understand attitudes, beliefs, expectations, needs, capabilities and behaviours of certain population groups.

This area is in great need of social marketing so as to be accepted by the overall population. Once accepted, it may be modified and certain ideas, views, practices or behaviours may be abandoned. Moreover, it is important to stress that the units of local self-government, through spatial planning, construction and public utility, have a big role in health-friendly landscaping and creating conditions for the promotion of physical activity and active lifestyle.

If we care to acquire better understanding of the reasons why some people are more active than other, it is essential to understand the major determinants of physical activity that can

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be divided into several categories – personal characteristics, social environment, physical environment (residential and natural environment), family influence and other types of social support.

In order to succeed in raising the number of people who are physically active, we should resort to the multi-sectoral cooperation and successful partnerships. The key sectors that should be in collaboration are: local community and non-governmental organisations, nurseries, schools and universities, health sector, working environment, transport and city planning (63,64,65). As published in the Lancet in 2012, effective evidence-based interventions that can increase the population’s level of physical activity regardless of age include, for example, the initiatives based on successful partnerships, i.e. activity coordination of the health sector in cooperation with a number of other sectors and organisations. Similarly, they include different informational approaches to the promotion of physical activity by organising campaigns at community level, mass media campaigns, campaigns for the use of staircases instead of elevators and escalators, etc. The Lancet also suggests initiatives to increase social support for physical activity in the community, neighbourhood or workplace. The level of physical activity in children and youth can be increased by comprehensive strategies for the promotion of physical activity in schools as part of physical education (PE), classroom activity, after-school sports and recreation, and active transport. Furthermore, approaches based on active policies and interventions can ensure access to facilities and services for sports and recreation, while at the same time the adjustment of infrastructure through planned construction of towns, neighbourhoods and streets, as well as active transport policy can be efficient. In order to support initiatives for the promotion of physical activity in an acceptable way, those in charge should undergo training regarding the interconnection of physical activity and health or the basics of public health and ways of cooperating with different sectors. Even though it is important to inform people about physical activity so as to offer motivation therefor, the main priority of public health sector should entail making sure that the environment is safe and supportive of healthy choices (66).

Activities: 1) Organise educational workshops with the purpose of raising awareness and knowledge about the interconnection of physical activity, health and well-being, and improve knowledge on effective interventions in the promotion of physical activity and the importance of interesectoral cooperation (for health and educational experts, members of non-governmental organisations, mayors and prefects and other groups of interest) 2) Organise programmes for different population groups with the common goal of informing about the benefits of physical activity and teaching the skills for achieving regular physical activity

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3) Lobby for landscaping that would support physical activity and active lifestyle (construction, improvement and maintenance of pedestrian paths and cycling tracks, health paths, trim trails, parks, sports and recreational halls and centres, public transport 4) Include representatives of children, adolescents and people with disabilities as well as their organisations in the process of needs assessment, planning, phases of construction development and improvement of buildings or surfaces to support an active lifestyle 5) Broaden the range of sports and recreational programmes for different age groups 6) ensure free or subsidised access to sports and recreational programmes and facilities for socially disadvantaged groups and elderly people through different programmes and projects 7) Use services of public informing for the promotion of active lifestyle of elderly people and people with disabilities so as to remove stereotypes, which appear as an obstacle to physical activity of these population groups 8) Organise comprehensive campaigns for the promotion of physical activity that include different sectors of society and activities for all social groups 9) Develop intersectoral cooperation and coordination for the successful setup of campaigns promoting physical activity 10) Support programmes focusing on social cohesion – encourage units of local self- government to organise different events in the community, including sports and recreational activities 11) Promote social and cultural norms that encourage physical activity 12) Encourage individuals, families and the whole community to overcome obstacles to physical activity 13) Lobby for more PE lessons in primary and secondary schools, as well as universities 14) Ensure funds and conduct research on a regular basis with regard to the level of physical activity of different population groups 15) Create healthy lifestyle conditions for people with developmental disabilities; adjust the existing capacities and build new ones 16) Strengthen the social responsibility of businesses for them to partake in promoting physical activity and health among their employees 17) Encourage active transport and physical activity in the workplace.

Indicators: 1) Number of educational workshops and programmes held, the level of participants' knowledge and positive reactions for having joined the programme

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2) Number of campaigns for the promotion of physical activity carried out, number of participants, media announcements and reports, and the number of educational and promotional materials distributed 3) Number of research activities on the the level of physical activity of different age groups 4) Share of physically active population based on different age groups 5) Political support through projects for the promotion of physical activity – funds provided 6) Number of programmes for the promotion of physical activity in the workplace 7) number of designed, printed and distributed educational materials (handbooks, brochures, leaflets) 8) Number of educated staff in the field of sports and recreation 9) Meters of walking and cycling tracks created 10) Trim trails, sports halls and sports and recreation centres built.

4.1.2.2. Target 2: Promote a healthy diet

In the last few decades, the county's situation with regard to nutrition has changed as a consequence of significant technological, social and economic changes that have influenced our lifestyle, especially in terms of intensity and types of physical activity, dietary habits and the structure and ways of family functioning. The contemporary way of life is also characterised by the constant lack of time, greater exposure to stress due to time pressure, increased competitiveness and availability of fast, tasty, cheap and high-calorie food, which is consumed in great amounts. All this results in the growing number of overweight and obese people. Obesity is an important risk factor when it comes to the leading causes of morbidity and mortality today – cardiovascular diseases, stroke, diabetes, high blood pressure, certain cancer sites and many other diseases, states and disorders. Adult obesity of Croatian population is in both genders associated with old age, rural environment and frequent intake of the 'hidden' fats of animal origin, and the lower education in women. The connection of obesity and old age is the strongest, and healthy behaviour in both genders is socially conditioned. The prevalence of obesity, according to the Croatian Health Survey of 2003, is largest in the Northern Region to which belonged the respondents from Međimurje County (28). Therefore, the implementation of this plan should focus on improving our population's dietary habits so as to reduce the prevalence of obesity.

In the context of disease prevention, i.e. maintaining health by means of a healthy diet, it is important to talk about the quality of food that is consumed. Being aware of the importance of a balanced diet with plenty of fresh fruits and vegetables, and limited intake of simple

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sugars and saturated fat, should go hand in hand with being aware of the origin of food that is consumed as well as its place and way of production. The best and healthiest fresh fruits and vegetables come from local organic farming, where they are grown without adding harmful chemicals, at the same time preserving nature and the balance of the local ecosystem. Organic farming ensures the production of high quality and safe food rich in nutritional value as well as in vitamins, minerals and antioxidants. Given that this way of production prohibits the use of easily soluble fertilizers, chemically synthesized plant protection products (pesticides), genetically modified organisms and products derived from these organisms and various growth regulators, there should be no residues of these substances found in food products or the consumer. Fruits and vegetables grown locally and freshly picked are delivered to the end user in the shortest time possible, which guarantees the food's freshness and quality. Also, fuel consumption in transportation is minimal, thus reducing pollution. Međimurje County is by tradition an agricultural area, abundant in small farms that grow and produce fresh fruits and vegetables in an environmentally sound manner. However, contact with end users is difficult or even denied because of the inability of small farms to penetrate the market due to unfair competition (large retail chains) that import cheap food products sold in different classes of quality, which are often as questionable as their actual nutritional value.

The United Nations have declared 2014 as the year of family farms, with the aim of calling people's attention to the importance and preservation of the system of local food supply and food sovereignty in the local communities.

To encourage people in Međimurje to produce organic food, but also consume this locally and ecologically produced food, we should introduce a certain percentage of such foods in schools, homes for the elderly, hospitals and elsewhere. Similarly, by encouraging social facilities to purchase organic and local (produced in the county) food products, we raise awareness about the importance of consuming high quality food from local farms. The economic effect of the process is an added value, given that the economic entities involved in the production and delivery of foods are guaranteed at least partial economic stability, thus ensuring the stability of the county's economy as a whole(89,90,91).

Activities: 1) Increase accessibility of safe and healthy food for all population groups by:

I. monitoring the eating conditions in public places - epidemiological surveillance of hygienic and sanitary, as well as technical conditions in public (restaurants and other catering establishments) and community facilities (companies, nurseries, schools, recreation centres, student restaurants, soup kitchens, hospitals, etc.)

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II. increasing availability of healthy food in community and public facilities by educating the staff planning and preparing meals and training the management personnel III. lobbying local and regional governments for the improvement of community eating conditions (through higher costs of subsidising community eating) IV. supervision of facilities for the production and distribution of food through epidemiological surveillance of hygienic-sanitary and technical conditions in these facilities and their maintenance and improvement V. monitoring the implementation of measures of HACCP in objects and persons involved in the production of food and water for human consumption VI. lobbying local food manufacterers for the production of food with reduced amounts of salt, fats of animal origin, etc. VII. conditioning and, if necessary, subsidising the procurement of food from local organic farming (10-20%) in public facilities

Indicators: I. Number of epidemiological surveillance processes and the supervision of HACCP system conducted II. Monitoring of the registration of infectious diseases and epidemics III. Number of educational seminars conducted IV. Height of the approved grants for community eating V. Number of local food manufacturers VI. Number of local food manufacturers who produce food with reduced amounts of salt, fats, sugar, etc. VII. Number of local organic farmers involved in the distribution of food to public facilities VIII. Percentage of organic food from local farms included in the menus of public facilities.

2) Improve the dietary habits of Međimurje County residents by:

I. promoting the importance of proper nutrition for pregnant women, infants and young children through Counseling Centre of Primary Gynecologists, family doctors, field nurses, courses for pregnant women, breastfeeding support groups, enforcement of programmes Children-Friendly Maternity Wards, etc. II. improving knowledge and skills for the healthy nutrition of pregnant women and parents by organising training courses and workshops – choose several key messages that need to be adopted – exclusive breastfeeding until a child is at least six months old, increase the intake of fruits and vegetables, reduce the use

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of energy-rich food and beverages (especially the food with 'empty' calories, rich in calories but poor in nutrients) III. improving knowledge and skills for the healthy nutrition of health professionals, particularly in primary health care, the staff of educational institutions, social workers, members of NGOs and others by organising educational seminars and practical workshops IV. improving knowledge and skills of school children and university students about the principles of proper nutrition through the implementation of various projects, courses, workshops, and through the work of Counseling for Healthy Nutrition as part of the Department of School Medicine (Public Health Institute of Međimurje County) V. organising media campaigns to raise awareness about the importance of proper nutrition in health promotion and disease prevention, using methods of social marketing (in connection with or regardless of the Breastfeeding Week, World Food Day, European Obesity Day, World Heart Day, World Health Day) VI. promoting healthy diets and healthy lifestyles in the media and on web portals VII. creating informative and educational materials on the principles of healthy nutrition for various age groups VIII. ensuring continuous work of the Counseling for the Prevention of Overweight and Obesity at the Department of Public Health, Međimurje County and continuous work of educational and supportive groups focusing primarily on weight control, and health in general IX. organising and conducting field analyses of body weight composition and other indicators of nutritional status of the general population, in combination with the doctor's consultations regarding healthy diets and adequate physical activity X. establishing a local model of intersectoral cooperation in order to promote healthy nutrition in different sectors of society.

Indicators: I. Number of breastfeeding support groups operating in Međimurje County and the number of their members II. Share of children exclusively breastfed until six months of age III. Number of attendants of courses for pregnant women IV. Number of seminars and workshops held with the aim of vocational training V. Number of media campaigns and public health actions organised and the number of published media reports VI. Number of designed, printed and distributed educational materials

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VII. Number of field analyses conducted with regard to body weight composition and other indicators of nutritional status and the number of participants in field operations VIII. Monitoring of eating habits - for example, the share of people meeting the recommendations of proper fruit and vegetable intake and other indicators (in 2014 the European Health Survey (EHIS2) is to be conducted).

4.1.2.3. Target 3: Reduce the use and harmful effects of tobacco, alcohol and other addictive substances

Smoking is considered to be the most important avoidable risk factor for a number of diseases that cause premature death. The World Health Organisation (WHO) warns that every year over 6 mil. people die from the consequences of smoking, and among them are around 600,000 second-hand smokers. Given that the developed countries show a trend of the reduction in the number of smokers, the tobacco industry is more prone to choosing adolescents as its target population, and it is therefore necessary to focus on their protection when applying different prevention activities. In this sense, extremely important is the adoption and implementation of positive legislative measures that would prohibit smoking in indoor public places, increase the price of cigarettes and prohibit cigarette distribution among adolescents. Advertising tobacco products is another issue, and we find that it is necessary to include both children and adolescents in prevention programmes as well as education related with tobacco use and its risks for health (68).

Harmful alcohol consumption has serious consequences for the health of society – for individual and family development and thereby the development of the society as a whole. People of lower socioeconomic status experience more serious consequences of harmful alcohol consumption even in case of smaller amounts of alcohol, which is probably due to differences in the way of drinking and the quality of alcoholic drinks. According to the World Health Organisation, around 2.5 mil. people die of the consequences of alcohol consumption. The same source states that drinking is the third leading risk factor when it comes to premature death and disability, given that the harmful use of alcohol is a risk factor for more than 60 types of diseases and injuries. This problem represents a serious threat to men; it is the leading mortality risk factor for men aged 15 – 59, mostly on account of causing injuries, physical violence, cardiovascular diseases and digestive system diseases. The consequences of alcohol are especially harmful for younger age groups. For example, 9% of all deaths for ages 15 – 29 can be attributed to the harmful effects of alcohol (68,69). In the Northern and Eastern Regions of Croatia, the situation analysis has shown a high prevalence of alcohol consumption (Croatian Health Survey, 2003). Accordingly, the standardised mortality rate (per 100,000 people) of diseases related with the overconsumption of alcohol

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(ICD 10, codes K70, 73, 74, F10 and T51) in 2010 was highest in those counties. In Međimurje County the standardised mortality rate of this type of diseases was also higher than Croatian average (23.5:16.5). Today, there exist numerous evidence on the effectiveness and profitability of different interventions and policies aiming at the reduction of harmful alcohol consumption, and they will be our guidelines in this strategy. Unfortunately, efficient interventions for the reduction of health inequalities and the negative consequences of alcohol abuse among the poor are scarce.

Drug supply, which has become more diverse, has increased in Croatia in the recent years. At the same time, availability of drugs has also increased and influenced the growing trend of drug abuse, especially among adolescents. Some of the most common reasons for the abuse of drugs and other addicive substances among children and adolescents include social affirmation among peers, the pursuit of pleasure, curiosity, personal and family problems, difficult life conditions and ignorance (70).

Activities: 1) Raise general awareness and inform the public about the harmful effects of the use of addictive substances through media campaigns, round tables, educational seminars, exhibitions, etc. 2) Increase the visibility of different county associations, organisations and intiatives that offer quality free-time activities for children, adolescents and adults 3) Develop a positive atttude toward a life without smoking, drinking and addictive substances, and ensure a schooling environment that would put less pressure on students and offer more educational content 4) Raise awareness of our population, especially children and adolescents, when it comes to positive effects of healthy lifestyles that contribute to good mental health (activities related with sports and recreation, healthy social life, volunteer work in the community, etc.), and warn on the negative effects of drug abuse 5) Control and monitor the application of regulations associated with the reduction of cigarette and alcohol accessibility to adolescents 6) Periodically conduct research on attitudes, habits and drug abuse in children and youth of Međimurje County 7) Conduct independently created prevention programmes: Aggressive child, Early detection of problems associated with growing-up, Procvjetajmo.

Indicators: 1) Number of lectures and conferences for the prevention of addiction 2) Number of children’s workshops for the prevention of addiction

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3) Number of public discussions targeted at raising awareness about the harmful effects of the use of addictive substances 4) Number of publications on the topic of the prevention of addiction, (independent) articles in professional and popular journals, magazines and other publications 5) User assessment of the work of Counseling Centre for Alcohol-Related Problems and Alcoholism 6) Number of new users in the programme of the resocialisation of addicts 7) Continuity in carrying out the programmes of prevention – Aggressive child, Early detection of problems while growing-up, Procvjetajmo 8) Published results of the research ‘’Attitudes, habits and use in connection with addictive substances among adolescents of Međimurje County'' (‘’Stavovi, navike i korištenje sredstava ovisnosti kod mladih Međimurske županije“)

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4.1.3. Objective 3: Improve prevention, early detection, monitoring and treatment for chronic non-communicable diseases

Chronic non-communicable diseases are the leading cause of death in global terms, with 36 millions deaths in 2008. The most fatal are cardiovascular diseases, malignant diseases, diabetes and chronic lung diseases, and one fourth of deaths occurs in people under 60 (61). The leading causes of death in Međimurje County are also the chronic non-communicable diseases, whose share in the total mortality is rising, while at the same time the share of deaths for people under 60 is decreasing. In 1995 the share of people who died of chronic non-communicable diseases in Međimurje County was 83%, of which 16% were below the age of 60. Fifteen years later, in 2010, chronic non-communicable diseases were the cause of death for as many as 94% of people, whereas the share of people dying before the age of 60 was reduced to 12.7% (71). According to the situation analysis conducted as part of this project, the leading causes of death in both Međimurje County and Croatia were in 2010 the cardiovascular diseases (with the share of 46% in the total number of deaths in Međimurje and 49% in Croatia), malignant diseases (28.8%:26.3%), and injuries, poisoning and other consequences of external causes (6.1%:5.7%). The standardised mortality rate for cardiovascular diseases per 100,000 people was in the same year in Međimurje somewhat lower than Croatian average (341.2:370.88), for malignant diseases somewhat higher (225.09:210.9) and for injuries, poisoning and other consequences of external causes it was slightly lower in Međimurje compared with Croatia (52.54:52.67). Number of people dying of diabetes is almost three times as high than 15 years ago in Međimurje (18 deaths in 1995 and 50 in 2010). In 2010, the standardised mortality rate in Međimurje County (28.93/100,000 people) was considerably higher than Croatian average (20.22/100,000 people) and was among highest of all counties (only in the County of Vukovar-Srijem was it higher with 33.39/100,000 people). In the same year, mortality of chronic lung disease was in Međimurje County considerably lower than Croatian average (16.49/100,000 : 21.07/100,000) and among lowest of all counties (as many as 15 counties showed higher mortality rates) (26).

Given that cardiovascular diseases are the leading cause of death in Međimurje County, we would like to address the causes of health inequalities with regard to them. Even though they usually appear in middle age, they are diseases with a long period of incubation. Thus the socio-economic determinants of health can have life-long effect on cardiovascular health. Unfavourable life conditions in childhood as well as parents' belonging to a certain social class, strongly affect cardiovascular health. Smoking, insufficient physical activity, unhealthy diets, high blood pressure, obesity, high cholesterol levels and diabetes increase the risk of cardiovascular diseases in middle age . The prevalence of these factors is higher among people of lower social status. In old age the accessibility of health care, family support and other types of social support, as well as a sense of control over one's life and health have a strong

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impact on cardiovascular health. The impact of the aforementioned health determinants is also very different with regard to socio-economic factors. The health outcomes in case of cardiovascular diseases are also much worse in people of lower socio-economic status, which needs to be taken into consideration when planning measures for the reduction of health inequalities (68). Health promotion, therefore, asks for a life-long approach, i.e. a comprehensive prevention strategy that advocates the implementing of measures of health promotion at the same time at population level and through active approach when it comes to groups and individuals who are healthy, or at risk of becoming ill / already ill, in order to prevent any complications and ensure a longer life of better quality. It is equally important to ensure availability and maximum management of patients by effective treatment and health care (72,73).

Individual approach Population approach Procjena čimbenika rizika Rano otkrivanje bolesti -skrining

Risk factor Acquisition Social Community actions Environment

assessment, of new skills marketing for the creation of and public health-supporting policies which early disease and and health detection - social and material support healthy knowledge information environment choices screening

To ensure successful implementation of quality programmes of health promotion it is necessary to apply a capacity development strategy that would include:

Development of Skill and expertise development Resource provision institutes / organisations and allocation

Figure 12. Intereventions of health promotion and strategies of capacity development. Based on source: Working in Health Promoting Ways. A strategic framework for DHHS 2009.-2012., Tasmanian Government, 2010.

Through different activities as part of this objective there will be an attempt to prevent or delay occurrences, causes, complications or relapse of chronic non-communicable diseases and improve the patients' quality of life. We will be focusing on the leading causes of death – cardiovascular and cerebrovascular diseases, malignant diseases, injuries, poisoning and other consequences of external causes and diabetes. Over 80% cases of cardiovascular and cerebrovascular diseases and diabetes type 2, and over 30% cases of malignant diseases are possible to prevent by eliminating the key risk factors – smoking, unhealthy diet, insufficient physical activity and harmful alcohol consumption, while additional reduction is possible to achieve by methods of early detection, timely treatment and successful rehabilitation and resocialisation.

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We will be focusing on the leading causes of death – cardiovascular and cerebrovascular diseases, malignant diseases, injuries, poisoning and other external causes of death, as well as diabetes. Over 80% of cardiovascular and cerebrovascular diseases, together with diabetes type II, and over 30% of malignant diseases are possible to prevent by eliminating the main risk factors – smoking, inadequate diet, insufficient physical activity and the harmful alcohol consumption. Additionally, they can be prevented by applying methods of early detection, timely treatment as well as successful rehabilitation and resocialisation.

Through measures of healthy lifestyle promotion directed at the whole population through lifelong approach (and which have been addressed as part of other objectives), there is an attempt to reduce the risk of the healthy population turning ill (primary prevention). Measures of secondary prevention and early detection of illnesses are an attempt to identify risks for becoming ill and support the population in changing its behaviour and in better disease control. In other words, it is an attempt to detect a disease in its early phases and thereby prevent progression and hospitalisation. With persons who have already been diagnosed with a disease, early and adequate treatment is an attempt to postpone the occurrence of complications and relapse. People are also encouraged to change behaviour and to be in better control of diseases, by strengthening the community ties and offering mutual assistance (disease control and tertiary prevention) (61,74).

Objective 3

Improve prevention, early detection, monitoring and treatment for chronic non-communicable diseases

Target 4 Target 1 Target 2 Target 3 Improve early Improve prevention, Improve Improve early early detection, detection, monitoring prevention, early detection, monitoring and and control of detection, monitoring and control of disorders as a result of control of malignant cardiovascular and monitoring and addictive behaviour, diseases cerebrovascular control of diabetes and addictions diseases (primarily alcoholism)

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4.1.3.1. Target 1: Improve prevention, early detection, monitoring and control of cardiovascular and cerebrovascular diseases

Activities within this target will be carried out at county level, but primarily in towns and municipalities with the highest noted mortality rates for cardiovascular diseases – in the municipalities of Dekanovec, Donja Dubrava, Nedelišće, Sveti Martin na Muri, Sveti Juraj na Bregu, Vratišinec and the town of Mursko Središće.

Activities: 1) Lobby for the implementation of a programme for systematic prevention of cardiovascular diseases in family medicine 2) Lobby at national, regional and local levels for balanced investment, i.e. fair allocation of resources in preventive and curative health care 3) Organise several-week, weekly or monthly campaigns for raising awareness of the public on the importance of prevention, early detection and timely treatment of cardiovascular diseases 4) Design, organise and conduct programmes for informing and educating the population about risk factors for cardiovascular diseases and development of personal skills to encourage the necessary change of behaviour 5) Conduct public health actions for the early detection of risk factors, i.e. states that increase the risk of cardiovascular diseases (blood glucose level, cholesterol level, triglycerides level, blood pressure, body mass index, waist circumference, waist-to- hip ratio, smoking, alcohol consumption, family and personal history) 6) Educate population about signs of heart attack and stroke, as well as the importance of early calling of emergency medical services for percutaneous coronary intervention and thrombolytic therapy in earliest possible phase (in case of indication) 7) Keep ensuring (through lobbying for continuous financial and human resources) for the unobstructed implementation of the project of care for acute heart attack patients through the network of primary percutaneous coronary intervention 8) Organise and carry out workshops for acquiring skills and knowledge in the field of reanimation with the use of automatic external defibrillator – as part of the programme for public access defibrillation ''RESTART A HEART – RESTART A LIFE'' (''POKRENI SRCE – SPASI ŽIVOT'') 9) Design, print, publish and distribute informative and educational materials for prevention, early detection, treatment, rehabilitation and resocialisation of patients 10) Modernise the equipment for acute treatment of cardiovascular diseases

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11) Form a counseling clinic, as part of the secondary prevention programme for cardiovascular disease patients that would be open once a week at Čakovec County Hospital 12) Lobby for the regionalisation of invasive cardiology development in Međimurje that would cover three counties - Varaždin, Koprivnica-Križevci and Međimurje 13) Form a team of experts – all interested persons who would come together in an attempt of a more successful cooperation, information dissemination, planning, conducting and evaluation of regular activities, i.e. activities as part of special programmes and projects for prevention, early detection, monitoring and control of cardiovascular and cerebrovascular diseases 14) Reafirm the work of associations of cardiovascular disease patients for better control of the disease.

Indicators: 1) Increased resource allocation for preventive health care 2) Systematic prevention of cardiovascular diseases is carried out as part of family medicine programmes 3) Number of media campaigns conducted 4) Number of designed and implemented programmes to inform and educate the population about the risk factors and the number of participants 5) Number of carried out public health actions of early risk factor detection 6) Improved knowledge of the population about the signs of cardiac arrest and stroke, reduced time from the onset of symptoms to the arrival of emergency medical service 7) The project of emergency PCI is being carried out 8) Number of workshops and their participants – the project ''RESTART A HEART – RESTART A LIFE'' 9) Designed, printed and distributed educational materials and their number 10) A founded Medical counseling clinic for cardiovascular disease patients as part of Čakovec County Hospital, open once a week 11) Methods of invasive cardiology made more available 12) A formed group of experts working on the improvement of prevention, early detection, monitoring and control of cardiovascular and cerebrovascular diseases 13) Associations of cardiovascular disease patients having been formed

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4.1.3.2. Target 2: Improve prevention, early detection, monitoring and control of diabetes

Activities: 1) Raise awareness and knowledge of the general public about diabetes risk factors and motivate them to change behaviour – through media campaigns, public health actions, workshops, lectures 2) Lobby primary health care doctors for a national health care programme of diabetes patients, and in this way help the early detection and better control of the disease, as well as prevent any complications and the enhancement of patients' quality of life 3) Carry out field actions of early detection of diabetes by carrying out public health actions 4) Stress the importance of early detection of diabetes in pregnant women (especially in those at high risk) 5) Prepare professional material for printing and other media - production and distribution of educational materials on websites, TV, through radio broadcasts, etc. 6) Encourage new patients to join the Association of Diabetics 7) educate members of diabetes associations for secondary and tertiary prevention 8) Lobby for units of local self-government to support the work of diabetes associations and the forming of new ones where needed.

Indicators: 1) Number of media campaigns, public health actions, workshops, lectures and participants 2) Number of field actions of early diabetes detection carried out, number of people included in the early detection programme 3) Increase in the number of preventive check-ups in primary health care 4) Increase in the number of new patients who regulate diabetes by adopting healthy habits 5) Increase in the number of new diabetes patients with no complications 6) Number of designed and disseminated printed and other materials in the media 7) Regular and precise filling in of the registry of persons with diabetes (CroDiab).

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4.1.3.3. Target 3: Improve early detection, monitoring and control of malignant diseases

Activities: 1) Raise awareness and knowledge of the general public about malignant disease risk factors and motivate them to change behaviour – through media campaigns, public health actions, workshops, lectures 2) Organise public health actions, lectures, workshops and media campaigns for the promotion of national programmes for the early detection of breast cancer, colon cancer and cervical cancer in order to enhance knowledge, perceptions, self-help skills and encourage people to change their behaviour accordingly (especially in the context of programme response) 3) Conduct research on the reasons for poor response to national programmes of early cancer detection (especially colon cancer) 4) Support the work of the County Cancer League Čakovec and associated clubs of cancer patients for the better rehabilitation and resocialisation of cancer patients 5) Promote the importance of a healthy lifestyle in secondary and tertiary cancer prevention – support programmes of psychosocial support, sports and recreation programmes, workshops on healthy eating, etc. 6) Lobby for the active inclusion of primary health care in the promotion and implementation of national programmes for the early detection of cancer 7) Organise educational workshops for non-governmental organisations (pensioners', women's, sports and recreational associations, etc.) to improve response to programmes for early cancer detection 8) Organise lectures, seminars and other forms of education for medical secondary school and university students, as well as for health experts as part of professional training.

Indicators: 1) Number of media campaigns, public health actions, workshops, lectures, as well as the number of participants and the positive reactions of users 2) Number of promotional and educational materials disseminated 3) Activity of the County Cancer League, Čakovec, and its clubs 4) A survey carried out in order to ascertain the reasons for not taking part in the programme of early detection of the colon cancer 5) Response to programmes for early cancer detection and share of FOB (fecal occult blood) tests carried out 6) Share of cancers detected in early stages.

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4.1.3.4. Target 4: Improve early detection, monitoring and control of disorders as a result of addictive behaviour, and addictions (primarily alcoholism)

Activities: 1) Early detection of persons at risk of developing addictive behaviour through collaboration of school and medical staff 2) Provide accessible forms of addiction treatments 3) Enhance cooperation with non-institutional forms of treatment 4) Strengthen the possibility of early detection, treatment and rehabilitation in case of mental disorders and disorders as a result of the use of addictive substances for the whole population of our county and in this way reduce the number of such disorders 5) Early detection, monitoring and registration of experimentors and addicts, individual and family counseling, group therapy 6) Test urine for the presence of drugs in groups or individuals showing risky behavior and drug addicts in the process of quitting 7) Implement programmes for the resocialisation of addicts 8) Continue with the work of the Counseling centre for alcohol-related problems and alcoholism, thereby offering professional and logistic support to clubs of treated alcoholics as a proven effective method of non-institutional treatment and rehabilitation of alcoholics 9) Through the work of the Counseling Centre for Alcohol-Related Problems and Alcoholism, formalise and enhance the cooperation of all subjects involved in treating and caring for people having problems with excessive drinking (Centre for Social Welfare, hospital, Institute of Public Health, police, primary health care – field nurses and family doctors).

Indicators: 1) A well-established cooperation between the school and the health care system for persons at risk for developing addictive behaviour 2) Number of public discussions held for adults aimed at raising awareness about the harmful effects of addictive substances and the opportunities for early detection, treatment and rehabilitation, and the number of participants 3) Evaluation of counseling for alcohol-related problems and alcoholism by the users 4) Number of new users in addict resocialisation programme 5) Number of people who attend at clubs of treated alcoholics and good cooperation established between the clubs and other institutions 6) Better cooperation established between the subjects involved in treating and caring for people having problems with excessive drinking.

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4.2. Aim 2: Reduce health inequalities in the county through programmes of health promotion for the groups in a socially unfavourable position

Socially disadvantaged position is associated with socio-economic characteristics such as income, employment, education and socio-economic status; socio-cultural features such as gender, ethnic origin and backgroud, religion / religious affiliation, culture, migration status and social capital; socio-geographic features such as the life in a deprived environment; age. Groups in a socially disadvantaged position can actually be affected by more than just one group of features (75) .

Since cardiovascular diseases are the leading cause of death and hospitalisations in Međimurje County, we will draw special attention to the connection between cardiovascular diseases and socially disadvantaged position. Social status affects behavioural risk factors, the development of cardiovascular diseases and their outcomes. Other psychosocial and material factors are also important when it comes to the problem of cardiovascular diseases, for example: lack of social support, inability to cope with stress in the workplace, reduced seeking of medical assistance, poor access to health care and high comorbidity. For this reason it is necessary to achieve balance of strategies and interventions, focusing on total population on the one hand and on population groups in the socially disadvantaged position on the other (68).

As part of the EU project (IPA IV) "Support for the social welfare system in the process of further deinstitutionalisation of social services" and the chapter on Assessment and Planning of Social Services, which has been implemented in Međimurje County since April this year, the Council for Social Welfare of Međimurje County in extended membership has reached a consensus on the definition of five groups that are in a socially disadvantaged position in Međimurje County. In this segment of the Strategic Plan for Tackling Health Inequalities we will try to combine the situation analysis and needs assessment from the aforementioned IPA and the ACTION-FOR-HEALTH project.

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AIM 2 Reduce health inequalities in the county through programmes of health promotion for

the groups in a socially unfavourable position

OBJECTIVE 1 OBJECTIVE 2 OBJECTIVE 3 OBJECTIVE 4 OBJECTIVE 5

Improve the Improve the

health of Improve the health of Improve the Improve the marginalised health and well- children with health of position of groups and being of the old developmental people with high risk groups at risk of and infirm disabilities and disabilities families social exclusion youth leaving

the social care

system

4.2.1. Objective 1: Improve the health of marginalised groups and groups at risk of social exclusion

Even though the notion of social exclusion is becoming commonplace among experts as well as the general public, it remains theoretically unsubstantiated and empirically unproven. Certain countries have their own definitions of social exclusion. In 2001, in an attempt to transform the concept of social exclusion into a measurable tool, the EU adopted a set of indicators to monitor social exclusion, i.e. 18 statistical indicators covering four aspects of social exclusion: financial poverty (income), employment (labour market), health and education. The risk of marginalisation and poverty is in Croatia connected with exclusion from the labour market. In other words, employment is not only the most significant determinant of position in the society, but is also very important for one's income, social stability and health, finally providing a sense of meaning to one's life and making one an active member of the society (76).

In December 2012, the Croatian Employment Service, Regional Office Čakovec, recorded 8,040 unemployed people, as part of the EU project (IPA IV) ''Support for the social welfare system in the process of further deinstitutionalisation of social services,'' conducted in Međimurje. If we carefully observe the situation in Međimurje County, we will find that it is quite unfavourable, especially in terms of the disparity of supply and demand in the labour market, as well as the indicators based on gender, age, level of education, waiting time and other limiting factors connected with the possibilities of employment (77). By the end of

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2012, the situation with the unemployed who had been registered, as based on negative circumstances in the labour market, was as follows: the share of women was 52.3% (4,204) and the share of people with lower educational levels or deficits (no school or only primary school) was 2,760 or 34.3%. Furthermore, there were 1,831 or 22.8% young people under 24 and similarly 1,985 or 24.7% of people above 50 registered as unemployed. The share of people that were registered as long-term unemployed (more than 12 months) was 2,291 or 36.5%, and of people having no working experience 1,682 or 20.9%. When it comes to people with disabilities, the share was 177 or 2.2%, and of people with reduced employability 1,085 or 13.5%. The situation for the members of Roma community was only estimated at 1,100 or 14.0%, and finally, the share of war veterans was 389 or 4.8% (77).

Unemployment is often based on the merging of a number of factors of reduced employment (e.g. education deficit, disability, old age, long-term unemployment, etc.), and it can actually be estimated that a significant number of unemployed people recorded can be considered difficult to employ or marginalised in the labour market i.e. socially excluded, which is estimated at more than 4,000 unemployed, with the share of 50% in the total number of the unemployed.

Long-term unemployment has special impact on health. Meta-analyses in a number of studies have shown that the long-term unemployed people are at risk of mental illness and anxiety disorders that is twice as high compared with the employed. Total mortality is 60% higher for the unemployed than the overall population. Additionally, alcohol can both lead to loss of a job on the one hand or be its consequence on the other. Apart from that, unemployment increases the risk of heart attack and stroke, whereas malignant diseases often lead to loss of a job. All the facts point to the vicious circle of unemployment and illness which can only be broken by a combination of different interventions – health care accessibiliy, social intervention and measures to promote health for the unemployed (78).

People without the primary education are at highest risk of social exclusion. Given that Međimurje County, as based on Population Census of 2011, showed a considerably higher share of people above 15 not having finished primary education (15.3%) compared with the whole country (9.6%), it is important to place special emphasis on regular education and lifelong learning. According to the Department of School Medicine, Institute of Public Health County of Međimurje, of 1,458 children who enrolled in the first grade of primary school in 2004, 195 children (13.37%) never finished primary school. In most cases they are children of the Romani population. The same source states that 4.5% of secondary vocational school students (3-year programmes) and 1.24% of secondary school students attending 4-year programmes did not finish secondary education. Therefore it is essential to persist in finding

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cause for leaving primary and secondary school, so that guidelines and an action plan to tackle the problem might be created (26) .

Croatia and Međimurje County take special notice of education when it comes to socially disadvantaged groups. In Zagreb, on 21st August 2013 the Ministry of Science, Education and Sport signed an EU Grant as part of IPA IV tender titled ''The integration of disadvantaged groups into the regular education system'', which meant 984,363 EUR of financial aid to Međimurje County. The main objective of the grant is to promote equal opportunities in education accessibility for socially disadvantaged groups. This is to fund implementation of the project that will contribute to the inclusion of disadvantaged youth in the educational system. The funds were granted to Međimurje County, Association of the Blind and Visually Impaired of Međimurje County, Primary School of Mursko Središće, Nursery School of Čakovec, Primary School of Orehovica and Primary School of Podturen. Apart from the mentioned funds, additional funds will be granted to other institutions and associations from Međimurje who are partners of beneficiaries from other counties: Association of Educators ''Krijesnica'' and the Primary School of Tomaš Goričanec Mala Subotica.

OBJECTIVE 1 Improve the health of marginalised groups and groups at risk of social exclusion

Target 1 Target 2 Target 3 Design and carry out Ensure the sustainability Prepare vulnerable programmes of health of civil society groups for the labour organisations (CSO) that promotion for market by working marginalised groups and actively support with civil society groups at risk of social employment of marginalised groups and exclusion organisations encourage social entrepreneurship

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4.2.1.1. Target 1: Design and carry out programmes of health promotion for marginalised groups and groups at risk of social exclusion

Activities: 1) Improve support programmes for the long-term unemployed to arrange free time activities in the community 2) Create and organise stress education programmes focusing on the individual level of protection by strengthening personal capacity to cope with stress, overcome stress in different situations (e.g. unemployment) and manage stress by adopting social and communicational skills that facilitate the integration of individuals in the future working environment, as well as the skills that increase the quality of and overall satisfaction with life 3) Identify and analyse the reasons for abandoning primary and secondary education – it is necessary to come up with guidelines and an action plan to reduce the problem 4) Offer psychological support to the long-term unemployed 5) Develop and carry out several-week programmes of healthy lifestyle promotion for marginalised groups and groups at risk of social exclusion 6) Develop and conduct a survey on the lifestyle of the Roma community and encourage its members in participatory assessment of their health needs 7) Develop health promotion programmes for the Roma community, respecting their culture and traditions 8) Work on further improvement of the partnership with the Roma community in order to increase their participation in health promotion programmes, and to encourage them to have better control over their health 9) Raise the level of health literacy of marginalised groups and groups at risk of social exclusion.

Indicators: 1) Number of implemented programmes for health promotion, number of participants and their reactions 2) A conducted study on the reasons for leaving the primary and secondary education, 3) A conducted study on the lifestyle of the Roma community, 4) Improved partnership with the Roma community, 5) Improved health literacy of people at risk of social exclusion.

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4.2.1.2. Target 2: Ensure the sustainability of civil society organisations (CSO) that actively support employment of marginalised groups and encourage social entrepreneurship

Activities: 1) Support civil initiatives that increase integration and networking of vulnerable groups 2) Organise radio and TV programmes on the phenomenon of social exclusion with the aim of raising public awareness and encouraging social solidarity and philanthropy 3) Design community programmes through cooperation with civil society organisations that would include vulnerable groups, so as to improve their capacity to cope with unfavourable everyday life and enhance their skills of practical self-help.

Indicators: 1) Number of reports in the media, on TV and the radio 2) Number of civilian intiatives increasing the level of inclusion and networking of vulnerable groups 3) Number of designed and conducted community programmes, number of participants and their reactions.

4.2.1.3. Target 3: Prepare vulnerable groups for the labour market by working with civil society organisations

Activities: 1) Implement programmes and projects for the improvement of competencies for better employment of the long-term unemployed at risk of social exclusion 2) Create and subsidise programmes of additional educational activities for the children of socially excluded families 3) Sistematically encourage and invest more into lifelong learning.

Indicators: 1) Number of programmes and projects implemented with the purpose of competency development for improved employment 2) Number of subsidised programmes of educational activities for the children of socially excluded families 3) Number of programmes and people having finished courses or programmes of lifelong learning.

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4.2.2. Objective 2: Improve the health and well-being of the old and the infirm

According to the Population Census of 2001, the share of people older than 65 in Međimurje County was then 13.7%, which rose to 15.6% in 2011. Given that life expectancy is on the rise, there is an evident need for better comprehensiveness of both institutional and non- insititutional aid for the elderly.

The data gathered as part of the EU project (IPA IV) the Support for the social welfare system in the process of further deinstitutionalisation of social services, currently being implemented in Međimurje County (2013), show that there are 50 centres for providing accomodation to the elderly outside their family home currently active in the same county (7 centres for the old and infirm, 7 family homes, 2 centres for mentally ill adults and 34 foster families). The total capacity of these centres is 1,074 people, which is concerningly less than necessary. Apart from the mentioned centres, there are also non-institutional forms of elderly care: the Day Centre as part of the Retirement Home Čakovec, which provides accomodation for people suffering from Alzheimer's disease, with the capacity of 10-15 people, and was founded in 2007. Furthermore, there is the Centre for Home Assistance and Care ''3D Centre'' Čakovec, which was founded in the spring of 2013. Similarly, the Autonomous Centre-ACT Čakovec is about to found a centre for home assistance and care that will start with its work at the beginning of 2014 and will soon organise the training of geronto-housewives. While working on the project, the following problems have been identified: weak multisectoral coordination of different institutions and associations, lack of problem prevention related with old age, isolation of the elderly, the problem of elderly care in the terminal phase, lack of empathy for problems related with old age, insufficiently developed services of home assistance and care, poor use of volunteers' services (77).

OBJECTIVE 2 Improve the health and well-being of the old and the infirm

Target 1 Target 2 Target 3 Target 4 Target 5

Encourage volunteer Strengthen the Raise standards Support the Establish and work for the further development in the non- develop improvement of of palliative care in health and well- Međimurje County institutional institutional intersectoral being of the elderly to improve the life care forms of care coordination and and the quality of the cooperation development of terminally ill and intergenerational their families solidarity

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4.2.2.1. Target 1 Raise standards in the institutional care

Activities: 1) Take necessary measures for the equal standards of state and private homes/centres 2) Lobby for the reconstruction of the existing capacities in terms of ensuring higher share of capacities for immobile and partially immobile persons 3) Standardise the quality of institutitional service 4) Educate institutional workers in terms of user needs, offering support and enrichment of everyday life 5) Educate both institutional workers and users about the prevention of falls.

Indicators: 1) Increased capacities of institutional care for the immobile and the partially immobile individuals 2) Adopted quality standards of institutional services 3) Number of educational programmes carried out and the number of participants.

4.2.2.2. Target 2. Support the non-institutional forms of care

Activities: 1) Broaden the work of social and health services to non-institutional forms of work in which special teams will work with associations and units of local self-government to carry out preventive and other programmes focused on improving the quality of life and health of the elderly 2) Carry out programmes of healthy lifestyle promotion for elderly people (especially in terms of a healthy diet, physical activity and reduced alcohol consumption), i.e. facilitate choices for healthy behaviour: - create age-appropriate environments - organise hiking groups for the elderly together with other interesting content - inform the elderly about the meaning and benefit of physical activity and a healthy diet so as to create positive opinions and raise their knowledge - support physical activity for the elderly at all levels (especially in their family, neighbourhood and local church, but also with the assistance of health and kinesiology experts)

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- ensure a wider range of programmes in accordance with age and physical capabilities in order to make physical activity fun, and not tiresom and 'dangerous' - offer free or subsidised access to sports and recreational programmes and venues - organise courses on healthy eating based on tradition for the elderly and their caregivers - increase the accessibility of healthy diets for the elderly - draw attention to the harmful effects of smoking, especially the overconsumption of alcohol among the elderly 3) Support the work of counseling centres for alcoholism and clubs of treated alcoholics in order to offer expert guidance in easy access to treatment and maintenance of apstinency 4) Conduct educational programmes and workshops to reduce the risk of falls 5) Encourage the founding of home assistance and care services and ensure their accessibility in the whole county 6) Continue supporting the work of free rentals of orthotics 7) Found and support SOS telephone service in terms of the nonstop assistance and support with the help of an alarm device for the elderly who are alone full-time or most of the day.

Indicators: 1) Programmes designed and implemented for raising the quality of life and improving health, and the number of participants 2) Elderly people empowered for better control over their own health 3) Number of subsidised sports and recreational programmes and number of participants 4) Improved availability of services for home care and assistance.

4.2.2.3. Target 3: Establish and develop intersectoral coordination and cooperation

Activities: 1) On account of the multidimensional character of the programme and the need to rationalise resources, when making a plan of the social politics the interdiciplinary and intersectoral approach is indispensible (politics, professions, institutions and civil society) and it is necessary to set up successful cooperation and coordination

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2) Merge programmes and funds that would enable the implementation of activities planned 3) Organise courses on the importance and possibilities of raising health literacy of the elderly for health care experts, social workers, volunteers, people included in the institutional and non-institutional elderly care and private providers of elderly care.

Indicators: 1) Channels of successful cooperation and coordination established 2) Number of educational courses and number of participants 3) Improved health literacy of elderly people.

4.2.2.4. Target 4: Encourage volunteer work for the improvement of health and well-being of the elderly and the development of intergenerational solidarity

Activities: 1) Include volunteers in the above mentioned activities and organise education for them 2) Create empathy in adolescents for the elderly through continuous education, raise awareness about the importance of empathy and offering help to the elderly 3) Make the civil associations partners in defining needs and priorities in the community 4) Promote the importance of an active approach towards everyday life for the elderly and the importance of active free-time management, recreation, entertainment and socialising.

Indicators: 1) Number of volunteers 2) Bottom-up approach used in defining needs and priorities in the community 3) Inhanced intergenerational solidarity.

4.2.2.5. Target 5: Strengthen the further development of palliative care in Međimurje County to improve the life quality of the terminally ill and their families

Unfortunately, the mortality of malignant diseases is on the rise, both in Croatia and Međimurje County, thus the need for palliative care is increasing. In 1995 in Međimurje County 254 people died of group II of diseases in ICD (International Classification of Diseases 10), with 19% in the total number of deaths, whereas in 2010 the number of deaths rose to 356 and the share of deaths from neoplasms was 29% (71). As part of the Healthcare Centre Čakovec, a mobile team of palliative care has been active since 1 March 2013. The team

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includes a physician and a nurse, who treat 4-5 people outside healthcare centre daily. They are joint by another physician and a nurse from the Intensive Care Unit, County Hospital Čakovec as volunteers. The organisation ''Pomoć neizlječivima'' (''Helping the incurable''), founded by Renata Marđetko, master of palliative care, is also active in the county. Assistance and visitation by the palliative team focuses mainly on patients suffering from an incurable disease and family doctors (secondary health care), home nursing service or social service, and entails finding a solution and offering possible options to alleviate the symptoms and improve the quality of life of the terminally ill.

Activities: 1) Work on strengthening the team for palliative care – include social workers, psychologists, priests and experts from different fields as equal team members 2) Organise education for health experts (from different sectors of health care) 3) Found a county centre for the coordination of palliative care 4) Lobby for the forming of a hospital team of palliative care as part of Čakovec County Hospital and a clinic for palliative care 5) Install palliative beds for the terminally ill in the County Hospital 6) Initiate the process of opening hospices in Međimurje County 7) Offer a wide range of orthopedic aids products for rent and inform the public about the availability of orthopedic aids 8) Set up a clinic for pain relief as part of palliative care service 9) Educate other, non-health experts and volunteers 10) Promote palliative care service by means of leaflets, the media, lectures and workshops.

Indicators: 1) Defined structure of the basic and extended palliative care team within primary health care 2) Founded county centre for the coordination of palliative care 3) Formed hospital team for palliative care 4) Good cooperation established between different sectors within the health system and between the health and social care systems 5) Improved offer of orthopedic aids 6) Number of educational seminars, workshops and counseling services held, and number of people informed 7) Number of promotional and educational materials produced and distributed.

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4.2.3. Objective 3: Improve the health of children with developmental disabilities and youth leaving the social care system

In Međimurje County there are 30 primary schools with 10,000 students, the Centre for Education with 174 students and 7 secondary schools with 4,400 students. In the school year of 2012/2013, Međimurje County together with the units of local self-government financed 23, and the City of Čakovec together with the Employment Service 21 personal teaching assistants. The employment of personal teaching assistants has lasted for the past three yers. The County has taken on itself the task of organisation, but there are still no regulations on who is qualified, how to finance and who is responsible for the management of the personal assistance service. The financing is conducted by various means – through the so-called public works for the unemployed organised by the Croatian Employment Service by means of training, etc. The problem lies in the fact that public work tenders are limited to 6 months, whereas the need for assistants lasts for the whole year.

For next year, schools have expressed the need for 68 assistants in 30 different primary schools and 3 assistants in 3 secondary schools – for all these students there are written resolutions proposed by the Office of State Administration that recommend the enrollment in regular school programs with the help of a personal assistant (71).

OBJECTIVE 3 Improve the health of children with developmental disabilities and youth leaving the social care system

Target 1 Target 2 Target 3

Identify environmental Enhance treatment Enhance intersectoral and personal risks for programmes for the cooperation so as to the health of children children and youth improve the and youth and improve who display acceptance efficiency the discrete actions of early detection of deviations in of young people physical and mental adapting to society leaving the social care health problems in system children

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4.2.3.1. Target 1: Identify environmental and personal risks for the health of children and youth and improve the discrete actions of early detection of physical and mental health problems in children

Activities: 1) Conduct screening for the detection of behavioural disorders and emotional sensitivity in children in secondary schools (especially vocational) 2) Periodically conduct research on the attitudes, habits and use of addictive substances of children and adolescents in Međimurje County 3) A research conducted with regard to juvenile delinquency in Međimurje County - criminal activities, offenses, educational measures proscribed therefor

Indicators: 1) Number of classes covered by the screening 2) Number of children and adolescents in which risks were recorded 3) A conducted study on the attitudes, habits and use of addictive substances and the interpretation of results 4) Conducted research and monitoring of juvenile delinquency.

4.2.3.2. Target 2: Enhance treatment programmes for the children and youth who display deviations in adapting to society

Activities: 1) Learn communicational and socialisation skills in small socialisation groups 2) Provide assistance in learning 3) Enhance programmes for supporting good free time management 4) Organise excursions for children and adolescents subjected to labeling ('untalented', 'lacking in interest', 'clumsy'; recidivists, hyperactive children, children with mental disorders) 5) Ensure the availability of experts dealing with the treatment of children with disabilities and in this way strengthen the non-institutional forms of treatment 6) Support associations of parents and children with disabilities professionally and otherwise, so as to equip parents with the knowledge necessary to become active participants in helping such children 7) Health education and counseling work, as well as constant monitoring as part of the Department of School Medicine at the Institute of Public Health, Međimurje County in cooperation with pediatric services 8) Constant efforts with children at the Department of Mental Health of the Institute of Public Health, Međimurje County

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9) Extend projects of primary prevention carried out by the Instute of Public Health to all nurseries and schools (the programmes ''Pričaonica'', ''Procvjetajmo'', etc.)

Indicators: 1) Number of small socialisation groups in treatment and the number of participants 2) Number of implemented programmes for assistance in learning 3) Number of schools and nurseries covered by the programmes ''Pričaonica'' and ''Procvjetajmo'' 4) Provided maximum professional support through organisations and activities within the Department of School Medicine and the Department of Mental Health of the Institute of Public Health to children and young people showing discrepancies in adapting to society and their parents.

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4.2.3.3. Target 3: Enhance intersectoral cooperation so as to improve the acceptance efficiency of young people leaving the social care system

Activities: 1) Health education and counseling, as part of the Department of School Medicine at the Institute of Public Health, Međimurje County 2) Constant efforts with children at the Department of Mental Health of the Institute of Public Health, Međimurje County.

Indicators: 1) Number of children included in health education and counseling, as part of the Department of School Medicine and the Department of Mental Health at our Institute

4.2.4. Objective 4: Improve the health of people with disabilities

Social Welfare Centre Čakovec, which takes care of children with developmental difficulties and people with disabilities, offers the following forms of rights and services: 794 people receive disability benefit, 2,261 people are users of home care allowance, while 393 people (of which 100 children) show intelectual difficulties (this category does not include people with intelectual difficulties who also demonstrate other difficulties and therefore belong to the category of people with a number of difficulties). Most of these people lives with their families, while 118 adults and 34 children with development disorders live outside their families. The status of a nursing parent is approved to 99 people.

Based on restrictions by the social welfare system, children with development disorders (vision impairment, hearing damage, voice and speech damage, physical impairment, intelectual difficulties, development disorder, multifold development disoder) are all people from the age of birth to 21 years, by which time they may use training programmes for independent life and work.

Social Welfare Centre of Čakovec has under its wing 715 children with development disabilities that are according to age stratification divided into six categories: 95 children are aged 0-3, 109 children are aged 3-7, 240 children are aged 7-14, 73 children are aged 14-16, 66 people are aged 16-18, and 132 children are aged 18-21.

Adults with mental disorders in Međimurje County are accomodated in three different institutions: Centre for Adults with Mental Disorders Orehovica (state institution), Centre for

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People with Mental Disorders Kotoriba (private institution), Centre 'Ščavničar' in Selnica (a private institution) and a foster family in Štrigova.

In the local community, apart from the above listed institutions taking care of people with mental difficulties, as well as their families, who also take care of them, there are no other forms of organised support and care. Most of people with mental difficulties are deprived of working obligation and are under constant care (custody), which makes their integration in the society difficult. According to the data of the Social Welfare Centre Čakovec, accomodation services by right are used by 130 people, of which 13 are accomodated in other counties.

Four secondary schools in Međimurje County offer training to people with mental difficulties for the following assisting jobs: florist, seamster, cook, car painter, tinsmith, floor layer and painter. Some classes are small (three people in a single class), and apart from education, socialisation is ensured in accordance with their individual and group age, which is very important. On a more negative note, an estimated one third of those attending training for assisting jobs are not able to apply the acquired knowledge and skills in real life, and are therefore deprived of the chance to find work.

According to the data from the Croatian Employment Service, Regional Office Čakovec, on 31 December 2012 there were registered 177 people with disabilities, of which 85 have mental disabilities and 6 have mental illnesses. In 2012 altogether 68 people with disabilities were employed, of which 43 have mental disabilities.

In the Centre of Education, as ordered by the Social Welfare Centre of Čakovec, there are 20 adults included in production activities as part of half-day stay with the financial support of the Ministry responsible therefor. Children with development disorders have since 1989 systematically been integrated in regular nursery school programmes.

The most comprehensive support to people with disabilities are provided in different associations that have been founded with this goal (71).

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OBJECTIVE 4 Improve the health of people with disabilities

Target 1 Target 2

Deinstitutionalisation Integration of and prevention of people with institutionalisation; disabilities into the promotion of a working sector healthy lifestyle

4.2.4.1. Target 1: Deinstitutionalisation and prevention of institutionalisation; promotion of a healthy lifestyle

Activities: 1) Establish a systematic financial support for the work of associations and the carrying out of activities at local level 2) Develop and carry out several-week programmes to promote a healthy lifestyle for people with disabilities 3) Improve health literacy of people with disabilities as well as family members who take care of them 4) For the mentally ill it is necessary to define support teams based on the war veteran model of support 5) Establish new channels of cooperation between County Hospital Čakovec and field nurses of the Healthcare Centre Čakovec for the improvement of care for mentally ill after being discharged from the hospital (control of treatment, easier return to everyday life, help in finding other forms of support) 6) Define the needs of people with mental disabilities by supporting their own and foster families 7) Question the possibility of partial or complete return of working capacity in people with mental difficulties 8) Aid deinstitutionalisation programmes by creating support services and the integration into local community, by forming residential communities and different forms of employment in accordance with individual capabilities

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9) Establish cooperation of the Centre for Adults with Mental Illnesses Orehovica and the Association for Persons with Mental Retardation of Međimurje in order to situate people with intellectual disabilities in residential communities 10) In the forthcoming years, provide maximum support to non-institutional care for people with intellectual disabilities, including care in the day centre, through a day- long, half-day, and occasional stay), organised housing, the clubs Mura and Duga and the forming of mobile service provider for people with mental difficulties and their families in Međimurje.

Indicators: 1) Established systematic financial support for associations' activities 2) Number of implemented training programmes and number of participants 3) Improved health literacy of persons with disabilities and their family members 4) New channels of cooperation established between Čakovec County Hospital and the field nurse service of Čakovec Healthcare Centre 5) Number of established residential communities 6) Care within the Day Center made available 7) Mobile support service established.

4.2.4.2. Target 2: Integration of people with disabilities into the working sector

Activities: 1) Ensure employment with the support of the open economy and sheltered workshops, in the form of work-related activities 2) Determine priorities in the employment of people with disabilities, with the motivation and education of potential employers 3) Assist independent persons with disabilities in their finding work in the open economy by educating employers 4) Offer a good solution for a certain number of people with disabilities who need support at work, e.g. form sheltered workshops 5) Lobby for the systematic implementation of the National Strategy for Equal Rights of Persons with Disabilities.

Indicators: 1) Number of employees with the support of the open economy and sheltered workshops 2) Number of sheltered workshops established 3) Number of people with disabilities working in sheltered workshops 4) Clear priorities established for the employment of people with disabilities 74

5) Number of educational workshops for employers conducted.

4.2.5. Objective 5: Improve the position of high risk families

There are many reasons for families to find themselves in a difficult or at-risk situation. For instance, families can experience violence, drug abuse, a member's mental illness, economic issues, loss of a family member etc. A typical risk factor for families is domestic violence. In Međimurje County there is a centre for domestic violence victims or Safe House, which is a social welfare institution. To its users, victims of domestic violence, it offers accomodation, food, personal hygiene and care, but also provides psychosocial treatment. The centre is part of the Register of Social Welfare Institutions since 13 January 2010 and is funded from the county budget. In addition, a agreement was signed with the former Ministry of Health and Social Welfare, today known as the Ministry of Social Politics and Youth, which defined rights, obligations and responsibilities with regard to providing and funding services of temporary accomodation of children and adults who are victims of domestic violence, type, range and quality of services, accomodation price, payment method, breach of contract, liability for damages and the court's jurisdiction. As stated in the contracted, the Ministry has been helping meet the costs since 1 June 2010, by providing 3,200.00 HRK monthly for each user, while fully funding only six users. The centre has throughout the years of service partaken in a number of projects whose task is to strengthen and offer support and assistance in the employment of victims of domestic violence.

In February 2010, the Safe House started providing accomodation to women. The first female user was admitted on 3 February 2010, and since then 81 users have been admitted, of which 43 were children. The centre can at the same time admit no more than seven users. Since 2010 until today (30 June 2013), due to lack of capacity a number of people could not be admitted: 260 users altogether, of which 98 women, 161 children and 1 man. The accomodation is realised by means of the resolution on the recognition of the right to use temporary accommodation service of the Centres for social welfare. In Međimurje County the centre is the only institution to accomodate victims of domestic violence, both adults and children. The centre does not only admit users within the county, but also provides shelter for users from other counties.

In Međimurje County family counseling was non-existent until 2011, when the Family Centre of Međimurje County was founded. Although founded in 2011, it began with its work no sooner than 2012. That year a director was appointed, while first top professionals (a lawyer and a psychologist) were recruited in June 2013. As part of Family Centre activities, individual work with users and counseling for families are conducted, the users are given support on personal level, assistance in terms of change or situation acceptance is provided, they are

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encouraged and their personal development strengthened. Also, the centre works with bigger groups of users by means of lectures and workshops.

OBJECTIVE 5 Improve the position of high risk families

Target 1 Target 2 Target 3

Promotion of good Offer accomodation to Work on other victims of family family life means of help to violence and improve accomodation those in need capacities of the Safe house

4.2.5.1. Target 1: Promotion of good family life

Activities: 1) Identify high risk families by means of intersectoral cooperation: to provide education on good parenting, preserving health of the family and improvement of communication among family members 2) Identify high risk families by means of intersectoral approach and improve the dynamics of family relations on individual level, focusing on specific features of the family 3) In terms of universal prevention, celebrate important dates and other promotional activities by means of public discussions and workshops, to promote the basic values necessary for the adjustment of future generations 4) Employ the media in the promotion of the importance of family values 5) Come up with a plan for further action by means of research activities

Indicators: 1) Improved intersectoral cooperation with an effective system of identifying families at risk created 2) Number of training programmes and the number of families participating 3) Number of discussions and workshops held 4) Scope of media coverage for promoting the importance of family values.

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4.2.5.2. Target 2: Offer accomodation to victims of family violence and improve accomodation capacities of the Safe House

Activities: 1) Lobby for the Ministry of Social Politics and Youth to provide more financial resources when it comes to placing people in the safe house 2) Find other sources of financing – through EU and other projects.

Indicators: 1) Ministry of Social Policy and Youth has provided funding to increase accommodation capacity in the safe house 2) Secured funding from other sources (EU and other projects or donations).

4.2.5.3. Target 3: Work on other means of help to those in need

Activities: 1) by means of public actions, emphasise the importance of tolerating differences and particularities, emphasising the struggle against prejudice, reducing the distorted perceptions of social relationships with people in need 2) generally improve the social attitude towards vulnerable population groups by means of interventions targeted at key persons in the community, including the media 3) come up with new activities in the area of violence prevention through cooperation of different sectors 4) design intervention programmes which would focus on groups such as victims of violence, court witnesses, people with disabilities, long-term unemployed, single parents, etc. through support programmes, social or economic inclusion in the community etc.

Indicators: 1) Number of public actions carried out 2) Number of new activities in the field of violence prevention 3) Number of intervention programmes designed.

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4.3. Aim 3: Place health inequalities at the centre of attention of both the community and the individual

Health being the basic human right, the state needs to ensure equal opportunities for all its citizens to use that right. Good health increases working productivity, workforce supply, success in education and overall savings; therefore, it is essential for the economic growth and development of a country. Poor health, on the other hand, brings high economic and social costs and can lead to poverty. Every individual as well as society as a whole should, thus, show interest in the improvement of their own health and the health of the general population. Health responsibility should be observed in the context of the main determinants of health. Health system, as organised and developed as it may be, is no more than one link of the chain on which depends our lifespan, how long we shall live without illness or disablement, shall we live a fulfilled life or the life filled with despair and helplessness. Social determinants of health, i.e. the social conditions in which people live, can have a reverberating effect on their chances to remain healthy or become ill. Poverty, social exclusion and discrimination, poor housing, unhealthy conditions during the earliest phases of a child’s development and low occupational status are important determinants of most illnesses, deaths and health inequalities between and within countries (WHO, 2004). The World Health Organisation therefore emphasises that certain factors contribute to the disease burden in Europe – apart from the ‘classic’ 10 factors of risky behaviour, such as smoking, high blood pressure, high cholesterol level, obesity, diets lacking in fruits and vegetables, physical inactivity, addictions, irresponsible sexual behaviour and iron deficiency, there are other more general health risks that are not covered by any precise quantitative analysis (global neoliberal trade policies, income inequality, poverty, workplace health hazards and lack of social cohesion (5). The above stated leads us to conclude that state options (together with regional and local communities) when it comes to the reduction of health inequalities and prevention of social deprivation lie in numerous fields – tax policies, employment and work policies, housing policies, social and family policies, education and health policies, and finally environmental policies (5,6). Therefore, in order to reduce health inequalities it is essential to form partnerships between different sectors and social groups, and to strengthen the community as well as the individuals in the field of health promotion and thereby the reduction of health inequalities (5,6,79,80).

Through the programme County Public Health Capacity Building Programme – ''A Healthy County'', carried out in Međimurje County since 2004, we have helped raise awareness of decision-makers, experts and the general public on health as the basic principle of well- being, individual and community development. However, in the forthcoming period additional efforts are required to further strengthen awareness of decision-makers on the importance of creating positive health policies. This is due to the fact that every four years

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local and national elections are held, this resulting in frequent changes in organisation and politics and turnover of people, which makes continuity harder. There is also experience in drafting strategic health documents, chosen by the participative method and in accordance with the views of political leaders, expert staff and direct users of the community. Through education as part of the programme ''A Healthy County'', drafting of county's strategic documents for health and implementation of different projects and activities related with the Health Plan of Međimurje County, communication and cooperation between and within individual sectors of regional and local self-government, political leaders, health and social sector, education, non-governmental organisations and the media. Extra efforts are needed to create infrastructure for this network and to more successfully define protocols for the functioning of the network and contribution of each member to the network (81).

AIM 3 Place health inequalities at the centre of attention of both the community and the individual

Objective 1 Objective 2 Objective 3 Objective 4

Set up a Raise the awareness Raise the Raise the surveillance system awareness and of regional and local for health knowledge of awareness of decision-makers and stakeholders about inequalities and local population experts belonging the importance of compose an to different about health health for evidence-based sectors about inequalities and community and database that health individual well- would include inequalities, as the possibilities being, and pinpoint indicators and well as the of their their responsibility interventions for possibilities for in the process of reduction reducing health the reduction of their reduction, inequalities health inequalities and encourage through health them to cooperate promotion

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4.3.1. Objective 1: Set up a surveillance system for health inequalities and compose an evidence-based database that would include indicators and interventions for the reduction of health inequalities through health promotion

In order to monitor and assess the situation in connection with health inequalities and evaluate interventions for reducing health inequalities, it is necessary to form databases and define indicators that would be monitored. Given that resources are usually restricted, it is necessary to focus on interventions whose efficiency has been proven. It is also necessary to form a database of policies, programmes, interventions, etc. to reduce health inequalities. Therefore it is recommendable to create a database of successful interventions as a means of encouragement, guidance and coordination of prevention activities in the community. A few years ago, the need to manage prevention activities has been identified on national level and work on forming a system for management of prevention activities began. This year the Croatian Institute of Public Health formed the Department for the Management of Prevention Activities (82,83).

OBJECTIVE 1 Set up a surveillance system for health inequalities and compose an evidence-based database that would include indicators and interventions for the reduction of health inequalities through health promotion

Target 1 Target 2

Create databases Form a database of good practice examples, i.e. and define successful interventions, indicators to programmes and projects monitor health for the reduction of health inequalities (on national inequalities and regional level)

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4.3.1.1. Target 1: Create databases and define indicators to monitor health inequalities

Activities: 1) Lobby at national, regional and local levels for collection and processing of data on health determinants (representative on county level) important in the assessment of health inequalities 2) Lobby for the publication of data on health inequalities in health and other yearbooks, also at county level (National Bureau of Statistics, Croatian Employment Service, Croatian Institute of Public Health, etc.) 3) Carry out research continuously and periodically so as to determine, monitor, control and reduce health inequalities 4) Lobby for research on health of the nation that would be representative at county level to open the possibility of comparison and evaluation of county projects and programmes (next year the European Health Survey of 2014 will be carried out (EHIS 2)) 5) Carry out research on healthy lifestyles and health needs of persons in a socially unfavourable position in order to create the most needed programmes of health promotion and their evaluation.

Indicators: 1) Research on lifestyles, health needs and health inequalities at local and regional levels conducted 2) Databases formed and indicators to be collected defined 3) Continuous assessment system of health inequalities.

4.3.1.2. Target 2: Form a database of good practice examples, i.e. successful interventions, programmes and projects for the reduction of health inequalities (at national and regional levels)

Activities: 1) Lobby at national level for a clear definition of criteria for evaluating the efficiency and quality of certain measures, policies, programmes, projects and interventions 2) Lobby at national level for a catalogue of successful interventions (certain steps have already been made therefor) 3) Based on clearly defined criteria, create a county catalogue of successful interventions, programmes and projects

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4) Inform representatives of all stakeholders on the existence of international sources of good practice examples in interevntions, programmes and projects in the field of tackling health inequalities 5) Once a year, organise conferences where good practice examples would be shown (at national and/or local levels), in the field of the reduction of health inequalities.

Indicators: 1) Defined and accepted national criteria for the evaluation of efficiency and quality of certain measures, policies, programmes, projects and interventions 2) Complete national and county catalogue of successful interventions created 3) Regular and occassional conferences at county and national levels with good practice examples in the field of reducing health inequalities.

4.3.2. Objective 2: Raise the awareness and knowledge of experts belonging to different sectors about health inequalities, as well as the possibilities for their reduction, and encourage them to cooperate

If we recall the health determinants as represented by Dahlgren and Whitehead, it is clear that multidisciplinary and multisectoral cooperation is imperative in the reduction of health inequalities. Unfortunately, the general opinion that health sector is the (only) crucial factor in the process remains. A true challange is how to include and motivate experts from different sectors to participate. For a successful cooperation it is required that one find one's interest, i.e. it is necessary to ensure a win-win situation. Given that most health determinants are socially and economically conditioned, the ''Health in All Policies'' approach is of crucial value to in solving the problem of health inequality (5,6,84,85).

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OBJECTIVE 2 Raise the awareness and knowledge of experts belonging to different sectors about health inequalities, as well as the possibilities for their reduction, and encourage them to cooperate

Target 1 Target 2

Raise the awareness and knowledge of experts about Motivate and enhance health inequalities and cooperation of experts increase their capacities in from different social the field, as well as lobby to sectors to reduce health include health inequalities inequalities through in the policies of all social health promotion sectors

4.3.2.1. Target 1: Raise the awareness and knowledge of experts about health inequalities and increase their capacities in the field, as well as lobby to include health inequalities in the policies of all social sectors

Activities: 1) Raise the awareness of experts about health inequalities by presenting them with the results of the situation analysis and needs assessment at county and national levels 2) Organise different forms of informing and educating experts about health inequalities and possibilities of their reduction through health prommotion programmes, and by using Structural Funds in printed materials of promotional and educational character, organisation of lectures, workshops, round tables, etc. 3) Use every opportunity to include the topic of health inequalities in different professional activities and events 4) Lobby different social sectors for the inclusion of their own interventions in the catalogue of successful national/local interventions in the reduction of health inequalities, as well as the use of experience acquired from good practice examples in their work 5) Lobby different social sectors for taking notice of the influence of certain policies on the general health of population while adopting them.

Indicators: 1) Experts are familiar with health inequalities at both county and national level

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2) Number of distributed promotional and educational materials 3) Number of workshops, lectures and round tables held and the number of participants 4) Number of interventions included in the intervention catalogue 5) Number of adopted policies and strategies for the reduction of health inequalities within and outside the health sector.

4.3.2.2. Target 2: Motivate and enhance cooperation of experts from different social sectors to reduce health inequalities through health promotion

To be as effective as possible in the implementation of the Strategic Plan for Tackling Health Inequalities in Međimurje County, it is important to create successful partnerships between different social sectors, as well as between different disciplines within these sectors. Different strategies can be used – such as networking, coordination, cooperation and collaboration – with the aim of strengthening partner capacities. Close cooperation is needed between politicians, health experts and professionals from other sectors, the civil society organisations, the media and even the private sector. Only such cooperation allows the balance between the general social interest in promoting health and interests of the private sector (a variety of industries - from food to tobacco industry), which thus become partners rather than opposing sides. Such cooperation is a great challenge but also the key to success.

Activities: 1) Present the Strategic Plan for Tackling Health Inequalities in Međimurje County through Health Promotion 2) Identify key stakeholders, partners in health prommotion programmes 3) Motivate parners to take part in the programmes – explain to them the advantages of cooperation (at personal as well as community level) 4) Define criteria, ways and levels of cooperation – create a form and send invitations to participate in the programmes (the invitation is not for one time only, but is of continuous nature) 5) Define the procedure for information flow 6) Organise different activities (seminars, counsels, conferences) to increase capacities for working on the reduction of health inequalities through methods of health promotion and by using structural and other funds 7) Lobby different social sectors for the inclusion of interventions from their sectors in the catalogue of successful national/local interventions in the field of reducing health inequalities, as well as the use of experiences acquired from good practice examples in their work

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8) Different activities jointly organised.

Indicators: 1) Key stakeholders identified and motivated to participate 2) Criteria of cooperation and procedures for information flow defined 3) Number of partners in the network and their reactions 4) Number of partners informed 5) Number of realised campaigns, activities, programmes and projects.

4.3.3. Objective 3: Raise the awareness of local population about health inequalities and the possibilities of their reduction

We may assume that people of Međimurje are not sufficiently aware of what affects their health and lifestyle. Therefore it is very important to inform the public about the social determinants of health. People should become aware of the fact that the level of their health is determined by their income, whether they are employed or not and the working conditions. Apart from that, the possibilities of acquiring education as well as the level of education, and social networks within the community – family support, friends, working environment and the community as a whole. Our health also relies on the type and quality of health and social services, diet and housing, as well as a number of other factors (i.e. the functioning of different social sectors). Thus people should be encouraged and informed so as to become aware of political, social and personal responsibility for their own health and to take part in making choices that are good for their health (5,6,84,85).

OBJECTIVE 3 Raise the awareness of local population about health inequalities and the possibilities of their reduction

Target 1 Target 2

Systematically educate and Encourage the residents inform the public about of Međimurje County to health inequalities and actively participate in possibilities of their making decisions reduction through programmes of health regarding their health promotion

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4.3.3.1. Target 1: Systematically educate and inform the public about health inequalities and possibilities of their reduction through programmes of health promotion

Activities: 1) Organise a media campaign so as to raise awareness about social determinants of health 2) Inform about and encourage the healthy life choices – regular physical activity, healthy diet, life free of smoking, alcohol and psychoactive drugs, acquired methods to better cope with stress (as presented by the media, printed materials, workshops, discussions and lectures) 3) Lobby, especially within health and education system, for keeping the public informed about the social determinants of health and encourage their participation in the programmes of health promotion 4) Encourage the public to take responsibility of their own health – it is important to stress the fact that it is much easier to prevent a disease than to cure it, to point to the importance of preventive examinations and the possibility of the early detection of diseases by taking part in the programmes for early detection of malignant, cardiovascular and other diseases 5) Inform the public through different sectors about services, programmes and projects offered by certain institutions and organisations aiming at the reduction of health inequalities 6) Inform the public, especially parents, about the importance of investing in their children’s education and the importance of life-long learning, given that the education system and health literacy greatly affect health 7) Encourage the public to fully engage into finding jobs, to fight for their working rights, to be included in the process of lobbying for a better working environment (if employed), to ask for employers’ full engagement and cooperation when it comes to health promotion in the working environment.

Indicators: 1) Number of campaigns organised 2) Number of designed, printed and distributed educational and informative materials 3) Number of reports in the media 4) Response to programmes of early detection of chronic diseases 5) The public informed about the services (thet affect the reduction of health inequalities) offered by health, social and non-governmental sectors.

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4.3.3.2. Target 2: Encourage the residents of Međimurje County to actively participate in making decisions regarding their health

Activities: 1) Teach residents how to identify negative factors in the environment and pinpoint them with relevant organisations and institutions 2) Encourage residents (i.e. interest groups) to actively participate in shaping different plans of regarding the physical environment 3) To encourage residents to participate in the work of non-governmental organisations and other forms of coming together based on common interests (from different sectors: sports and recreation, women’s, youth and pensioner associations, patient groups and political parties) and in this way take part in shaping health policies on local and regional level 4) Inform residents about the importance of social support for individual and community health – encourage volunteer work, good neighbourly relations, participation in different programmes organised by the local community, etc. 5) Help the solidarity for those close to us or in need become prized in society 6) encourage the local community to lobby with those responsible to take into considederation the impacts of different policies on population health when adopting them 7) Lobby the members of parliament for the adoption of laws, programmes and regulations that would help reduce health inequalities.

Indicators: 1) The residents’ level of involvement in adopting plans, projects and programmes 2) Number of non-governmental organisations active at county level and their members and activities 3) Number of volunteers and participation in different programmes 4) Adopted laws that help reduce health inequalities.

4.3.4. Objective 4 Raise the awareness of regional and local decision-makers and stakeholders about the importance of health for community and individual well-being, and stress their responsibility in the process of reducing health inequalities

As already stated, each individual needs to be supported in their efforts to increase control over their own health and enhance it through methods of health promotion, which is a process that brings about health and well-being, reduces costs and enables healthy aging. At national level, health promotion results in the reduction of disease burden, control of health 87

care costs, increased productivity and socio-economic development which is both sustainable and affordable. However, health is determined by a number of social, economic and ecological factors and the cultural norms of the community, which is often beyond the control of idividual. These determinants of health are associated with a number of lifestyle factors (physical activity, dietary habits, alcohol, drugs and other addictive substances, stress and one's reaction to stress). One's lifestyle is thus influenced by policies and activities of different social sectors. It is therefore very important for decision-makers to be well informed (at national, regional and local levels) in order to take consideration of health in the decisions of various sectors at all levels, and to improve decision-making based on scientific evidence (and good information). In Croatia and Međimurje County there are numerous strategies, programmes and laws that help reduce health inequalities and through which mortality and morbidity of cardiovascular and other chronic diseases are being reduced. However, in the following period, it is necessary to ensure, in particular with regard to this objective, the reshaping of political will, in the form of national or regional policies, into appropriate resources to achieve goals. This is the responsibility of decision-makers and the public sector. Additional resources can and should be looked for in other sectors, but the leading role has to remain within the public sector. Apart from that, politicians and political leaders at national, regional and local levels should be aware of the slow and small effects of interventions, as well as of the time needed to conduct a clear evaluation. Therefore, interventions should be protected from rash expectations and short time intended for political programme plans. In spite of that, both the public and politicians should be given clear, timely and comprehensive information with regard to different indicators and interventions when it comes to reducing health inequalities (5,6,49,68,84,85).

In the following text listed are some measures that can be taken at population level and are quite efficient in reducing health inequalities, primarily for cadiovascular but also for other chronic non-communicable diseases. These are: higher tax rates on unhealthy food, adopting regulations on the reduction of salt intakes in bread and other food, more efficient regulations when it comes to listing ingredients on the labels of food and drink products, offering healthy food in restaurants, workplaces and public cafeterias, and dietary guidelines in schools and faculties. The measures should also include affordability of public transport, incentives for coming to work on foot or by bicycle, construction of pedestrian paths and cycling tracks, parks and playgrouds. Also, taxes on cigarettes should be significantly higher and a law on obligatory pictorial warnings on cigarette packs adopted, while smoking in public places as well as in all workplaces should be completely forbidden (including restaurants and cafes), and a better control and surveillance established with regard to following regulations for the reduction of cigarette and alcohol accessibility to adolescents. Similarly, tax on alcohol should be higher, thus making it less accessible to both adolescents and adults, advertising of alcoholic drinks should be forbidden and all types of shops selling

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alcohol restricted, age level for buying alcoholic beverages should be raised with high fines for those who ignore them, etc. (72,73) .

OBJECTIVE 4 Raise the awareness of regional and local decision-makers and stakeholders about

the importance of health for community and individual well-being, and stress their responsibility in the process of reducing health inequalities

Target 1 Target 2

Systematically educate and Create social health policies inform decision-makers from (where health is recognised as regional and local self- a value, potential and basis of goverenments and politicians the state's development) and about health inequalities and the encourage political possibilities for reducing them responsibility for health through programmes of health

promotion

4.3.4.1. Target 1: Systematically educate and inform decision-makers from regional and local self-governments and politicians about health inequalities and the possibilities for reducing them through programmes of health promotion

Activities: 1) Raise the awareness of decision-makers from regional and local self-governments and politicians about health inequalities by presenting them with the results of situation analysis and needs assessment conducted in Međimurje County (at national level, as well) and the Strategy for improving health and reducing health inequalities in Međimurje County (by organising conferences, lectures, workshops, lobbying, etc.) 2) Organise different means of continual informing and education of the responsible individuals from regional and local self-governments and politicians about health inequalities and the possibilities of reducing them through programmes of health promotion and the use of Structural Funds, e.g. printed promotional and educational materials, organisation of lectures, workshops, round tables, etc. 3) Inform decision-makers from regional and local sel-governments and politicians about the results of continuous and periodic research to determine, monitor, control and reduce health inequalities

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4) Stress the importance of conducting research on health of the nation that would be representative at county level in order to enable the comparison and evaluation of county programmes and projects 5) Stress the importance of conducting research on the lifestyle and health needs of persons in a socially unfavourable position in order to create the most needed programmes of health promotion and evaluate them.

Indicators: 1) Decision-makers from regional and local self-governments and politicians familiar with health inequalities in Međimurje County and Croatia 2) Number of distributed promotional and educational materials 3) Number of workshops, lectures, round tables held and the number of participants 4) Decision-makers informed about the results of continuous and periodic research.

4.3.4.2. Target 2: Create social health policies (where health is recognised as a value, potential and basis of the state's development) and encourage political responsibility for health

Activities: 1) Lobby the Assembly of Međimurje County to adopt the Strategy for Reducing Health Inequalities in Međimurje County 2) Stress the importance of ensuring the necessary resources to implement the Strategy 3) Lobby at national, regional and local levels for balanced investment, i.e. a fair allocation of resources for health promotion, and preventive and curative health care 4) Encourage the responsible individuals from regional and local self-governments and politicians to take into consideration the effects adopted laws, programmes and regulations have on the population's health (''Health in All Policies'') 5) Include health inequalities into the Development Strategy of Međimurje County.

Indicators: 1) Recognition of the Strategic Plan for Tackling Health Inequalities by the Assembly of Međimurje County 2) The question of health inequalities included in the Development Strategy of Međimurje County 3) Resources provided for implementing the Strategic Plan 4) Number of adopted laws, regulations and measures for tackling health inequalities.

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4.4. Aim 4: Lobby for clean, healthy and sustainable environment

There are immense differences as to the extent of exposure to environmental factors throughout Europe, which is reflected in the differences in health and life expectancy. These differences are evident in Croatia, as well as the County of Međimurje. People of lower social status usually live in a less agreeable environment, which has negative impact on their health. Exposure to pollution of all types, including noise and bad traffic infrastructure to say the least, is associated with a number of negative health incomes (cardiovascular diseases, respiratory diseases, cancer, injuries, traffic accidents, insufficient physical activity).

Public water supply system of Međimurje covers 99.2% of the county, although it has only 76.7% households connected, and almost all economic entities and public institutions. In Parag, the largest Roma settlement in Međimurje, no more than 16% of households are connected to the public water supply system. Even though Međimurje County has been investing in the drainage system for a number of years now, even greater investments are needed (as well as the equipment for wastewater treatment) in order to eliminate the negative impact of wastewater on the environment. In order to reduce the negative effect of environment risk factors on health and quality of life, constant monitoring, assessment, prevention and adjustment are applied so as to reduce pollution and health risks. Apart from that, it is very important to promote a healthy lifestyle and the use of technologies that do not represent risk for health and the environment (86,87).

AIM 4

Lobby for clean, healthy and sustainable environment

Objective 1 Objective 2

Raise awareness about the Encourage choices that importance of environmental support clean, healthy and conservation, sustainable sustainable environment agriculture and development in general

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4.4.1. Objective 1: Raise awareness about the importance of environmental conservation, sustainable agriculture and development in general

Activities: 1) Raise the public awareness about the importance of high-quality drinking water, thereby increasing the number of private households within the network of public water supply system, by organising campaigns in the media, workshops etc. 2) Educate members of the Romani population about the importance of hygienic/ecological waste treatment and the impact of environment on health in general 3) Organise workshops for agricultural workers on the importance of sustainable agriculture. 4) Encourage farmers to embrace organic farming methods through repurchase liability from community facilities through the system of public procurement (with the specified minimum percentage of organic food in procurement).

Indicators: 1) Number of media campaigns carried out and the number of participants 2) Percentage of private households connected to public water supply system 3) Situation regarding the disposal of solid and liquid waste in Romani settlements 4) Number of organic farms in the county.

4.4.2. Objective 2: Encourage choices that support clean, healthy and sustainable environment

Activities: 1) Lobby for the construction of the system for wastewater drainage and treatment, especially in rural areas and Romani settlements 2) Lobby for the development of traffic infrastructure a. construct pedestrian paths and cycling tracks to increase safety level in road traffic and to increase the number of physically active people (making easier the choice for a healthy way of transport – walking, cycling, and free time physical activity) b. construct footpaths so as to increase the safety level in road traffic and encourage physical activity 3) Lobby for the enhancement of public transport in all parts of the county 4) Lobby for the construction, expansion and equipping of infrastructure to be used for sports and recreation, especially in rural areas 92

5) Build infrastructure for the ill, old and infirm 6) Build infrastructure for children and youth care.

Indicators: 1) Monitor the sistuation regarding the drainage system and wastewater treatment 2) Length of pedestrian paths and/or bicycle tracks constructed 3) Monitor the situation regarding public transport enhancement 4) Number of sports and recreation facilities constructed or renovated and the status of sports equipment.

5. Communication strategy and partners in the implementation of the Strategic Plan for Tackling Health Inequalities in Međimurje County through Health Promotion

Communication strategy is an inherent part of the Strategic Plan for Tackling health Inequalities in Međimurje County through Health Promotion. Aim 3 – Place health inequalities at the centre of attention of both the individual and the community – places special emphasis on the neccessity of forming partnerships between different services and sectors, and social groups, at the same time strengthening both the community and individuals when it comes to health promotion and reduction of health inequalities. Through objectives and targets of Aim 3, partners have been selected to be motivated for cooperation in the forthcoming period. Finally, activities within the targets of Aim 3 define the special tasks that need to be carried out in order to create the methods and tools of a successful communication strategy.

Communication strategy plays an extremely important part in the identity of the Strategic Plan for Tackling Health Inequalities through Health Promotion as well as the realisation of the strategy goals. In order to succeed in that, it is necessary to ensure transparency and participation, both in drafting the strategy as well as implementing and evaluating it (monitoring development). Therefore, before adopting the final document, one more process of consulting the stakeholders from the public, private and non-governmental sectors, so that the proposed strategy is accepted by all. The Strategic Plan for Tackling Health Inequalities in Međimurje County through Health Promotion will thus be presented to a great number of stakeholders with a request for suggestions and comments that will also be included in the final draft of the document.

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The document will be available on the official website of the Institute of Public Health of Međimurje County as well as the websites of Međimurje County and ACTION-FOR-HEALTH project. The final draft will be presented on the closing conference to all stakeholders. Apart from that, a press conference will be held for our press release, accompanied by other ways of presenting the strategic plan to stakeholders and the general public.

The partners anticipated to partake in the implementation of the Strategic Plan for Tackling Health Inequalities in Međimurje County through Health Promotion are the following:

According to the new law on health care adopted at the end of 2008, forming one- and three-year health plans is legally binding for the county, and therefore Međimurje County is interested in adopting this strategic plan. The Strategic Plan receives its full legitimacy after being approved by the Međimurje County Assembly. Thus, as part of Aim 3 (Place health inequalities at the centre of attention of both the individual and the community), Objective 4 (Raise the awareness of regional and local decision-makers and stakeholders about the importance of health for community and individual well-being) and Target 2 (Create social health policies and encourage political responsibility for health, certain activities have been proposed. For example, lobby for accepting the Strategic Plan by the Međimurje County Assembly, stress the importance of ensuring the necessary resources to implement the strategy, lobby at national, regional and local levels for balanced investment, i.e. a fair allocation of resources for health promotion, and preventive and curative health care, etc.

Međimurje County has been partaking in the project “Public Health Capacity Building Programme - Healthy Counties” since 2004, and three of its officials from the Department of Social Services have completed training as part of the programme. In the forthcoming period it is necessary to be more successful in motivating other divisions from Međimurje County to participate in the Healthy Counties programme and the implementation of the Strategic Plan.

According to its statutory powers, Međimurje County cooperates with all units of local self- government (towns and municipalities). In fact, it has its Council of Mayors, a body which discusses and makes decisions regarding all important aspects of the population's life and health.

The Međimurje County multidisciplinary team of professionals (members of the Health Team and the implementation of the Health Plan for the Population of Međimurje County) completed two phases of training as part of the Healthy Counties programme. In phase I of the training ("Health - Plan for It" County Public Health Capacity Building Programme), the goal was to support the county administrative bodies and self-governments in the decentralisation process, and to emphasize the necessity of inter-sectoral approach to

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solving complex public health issues. Phase II, on the other hand, was intended to prepare a team for a successful implementation of the county Health Plan (with a mentoring team, professors from the School of Public Health "Andrija Štampar", School of Medicine, University of Zagreb, classes were in Phase II conducted by coaches from the consulting firm ADIZEZ Southeast Europe). In Phase II of the training, key internal weaknesses of the team were identified (insufficient number of people, the lack of clearly defined forms of cooperation with partners, insufficient number of professionals, the lack of time available to work in a team, the lack of financial resources), which need to be eliminated so that the team might continue to work well and participate in the implementation of the Strategic Plan.

In December 2008 a new Law on Health Care (NN150/08) was adopted, thanks to the positive achievements in the work of the counties participating in the County Public Health Capacity Building Programme. By new laws, the local (regional) self-government has to adopt a health care plan for the local (regional) self-government and one-year and three- year plans of health promotion, prevention and early detection of diseases, and organise and conduct public health measures in accordance with these plans. In order to achieve the rights, obligations, tasks and objectives in the field of health care, the local (regional) self- government formed the Health Council, represented by a group of independent experts in the fields of health and social welfare as well as representatives of different interest groups in the field of population's health care.

Through training as part of the Healthy County programme, drafting county strategic documents for health, the work of the Health Council of Međimurje County and implementation of a number of projects and activities associated with the Health Plan for Međimurje County, communication and cooperation within and between individual sectors has been enhanced. This applies to regional and local self-government, decision-makers, social sectors, education, civil society organisations and the media. A successful cooperation has been accomplished at county, as well as national and international levels (Croatian Institute of Public Health, Croatian Healthy Cities Network, Faculty of Kinesiology, University of Zagreb, National Institute of Public Health, Regional Unit Murska Sobota, International Sport and Culture Association).

In the forthcoming period we will continue to motivate the stakeholders from both public and civil sector (with the aim of exchanging knowledge, resources and experience), so that we are more successful in implementing the Strategic Plan for Tackling Health Inequalities in Međimurje County through Health Promotion (primary and secondary schools and other public institutions, all health institutions, including private practices at the primary

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healthcare level, Croatian Medical Association and Croatian Medical Chamber – the Čakovec Branch, civil society organisations, food industries, the media).

Apart from that of the public and civil sector, the motivation of the private sector is also very important, especially if we bear in mind the broader health risks as highlighted by the World Health Organisation, i.e. the global neo-liberal economic policies, income inequality, poverty, health hazards associated with the workplace and the lack of social cohesion. It is important to pinpoint the need to support social entrepreneurship or the concept of eco-social economy in which each individual is equally entitled to access the available information, knowledge and resources. In addition, the private profit sector should be interested in health and satisfaction of its employees because this plays a part in the prosperity of private companies. Moreover, the technology used should not be directly harmful when it comes to the employees' health or the environment. After all, the private sector is crucial in creating new workplaces and thereby prosperity in general.

6. Funding of the Strategic Plan

Securing funding for the implementation of the Strategic Plan for Tackling Health Inequalities in Međimurje County is very important and necessary but also extremely complex, given its comprehensiveness. In its implementation will be (and/or already are) involved various public institutions with defined sources of funding for their regular work. But these funds are certainly not sufficient and it is therefore necessary to secure funds from other sources (and not only for public institutions but also for civil society organisations whose role in the implementation of the Strategic Plan is very important). The proposed sources of funds for the Strategic Plan are the state budget, or the budgets of line ministries, county budget, local, private and other sources. Croatia is planning to establish a Health Promotion Fund/Foundation, which could in the forthcoming period become a significant source of financing health promotion activities at both national and county level. Given that the Strategic Plan is primarily a framework for action and will certainly be a topic of interest in the long run, in the forthcoming period it is necessary to prepare annual operational plans with clearly defined funding.

A partial funding for the implementation of the Strategic Plan for Tackling Health Inequalities has already been ensured as part of the ACTION-FOR-HEALTH project, under whose wing the plan has been created. The implementation of the ACTION-FOR-HEALTH project and dissemination of the project results will increase the capacity of our experts in the field of reducing health inequalities and will give way to new knowledge and skills as well as the exchange of experiences and good practice examples. Experts from various sectors and

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other interested parties from Međimurje County and beyond will have access to publications as part of the project: Situation Analysis and Needs Assessment in Seven EU Countries and Regions - ACTION-FOR-HEALTH, Reducing Inequalities in Health, A Strategic Approach to Inequalities in Health in the Region Pomurje and Slovenia and Reducing Health Inequalities through Health Promotion and Structural Funds. Finally, it is very important to introduce the content and gain access to Structural Funds, as they are expected to be a significant source of funds for the Strategic Plan for Tackling Health Inequalities through Health Promotion.

The Republic of Croatia is in the process of developing the Strategic Framework for Programming and Partnership Agreement with the EU in connection with the use of ESI funds for the period 2014 - 2020. The proposed investment strategy in the Partnership Agreement of the Ministry of Regional Development of the Republic of Croatia and EU, all investment priorities, measures and activities should contribute to achieving three main objectives: 1) increase the competitiveness of economy and the employment, and ensure growth by engaging local knowledge and skills, 2) reduce poverty and strengthen social inclusion, 3) reduce regional disparities and ensure quality living conditions.

As part of the ACTION-FOR-HEALTH project, the implementation of one of the objectives from the Strategic Plan for Tackling Health Inequalities in Međimurje County through Health Promotion is planned, for which funds have been provided. The implementation of the activities is planned during the first 3-4 months of 2014.

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7. References

1. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. 2. Breslow L. Health Measurement in the Third Era of Health. Am J Public Health.2006 January; 96(1):17-19 3. Diagram by Whitehead M and Dahlgren C, in “What can be done about inequities and health?”. The Lancet, 338, 8774, 26 October 1991, 1059-1063. 4. Newell KW, ed. Health by the people. Geneva, World Health Organization, 1975.Ottawa Charter for Health Promotion. First International Conference on Health Promotion, Ottawa, Canada, 17–21 November 1986. Geneva, World Health Organization, 1986 (WHO/HPR/HEP/95.1; http://www.who.int/healthpromotion/conferences/previous/ottawa/en/, accessed 10 October 2013) 5. Dahlgren, D. and Whitehead, M., World Health Organization (WHO). (2007) European Strategies for Tackling Social Inequalities in Health: Levelling Up Part 2 [Online]. Available from: http://www.thehealthwell.info/node/91930 [Accessed: 2nd November 2013]. 6. Health 21: health for all in the 21st century. Copenhagen, WHO Regional Office for Europe, 1999 7. Šućur Z, Zrinščak S. Differences that Hurt:Self-Perceived Health Inequalities in Croatia and European Union.Croat Med J.2007 October;48(5)653-666 8. The national health care development strategy 2012-2020 (Nacionalna strategija razvoja zdravstva 2012.-2020.); Government of the Republic of Croatia, Ministry of Health of the Republic of Croatia, September 2012, Zagreb. 9. The Croatian Bureau of Statistics (2011), Census of Population, Households and Dwellings 2011, available at http://www.dzs.hr/default.htm 10. Sorensen K et al., Health literacy and public heath: A systematic review and integration of definitions and models.BMC Public Health 2012, 12:80 11. Croatian Health Service Yearbook 2011, the Croatian National Institute of Public Health, Zagreb, 2012. 12. Croatian National Institute of Public Health, Croatian Central Bureau of Statistics. Deaths, by cause of death, age and sex, 2010 13. Joint Memorandum on Social Inclusion of the Republic of Croatia (Zajednički memorandum o socijalnom uključivanju). Government of the Republic of Croatia, 2007 14. National Strategy of Welfare Development in the Republic of Croatia 2011-2016 (Strategija razvoja sustava socijalne skrbi u Republici Hrvatskoj od 2011.-2016. godine), Government of the Republic of Croatia, 2011

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15. The Croatian Strategic Development Plan of Public Health, 2012-2015 (Strateški plan razvoja javnog zdravstva od 2013.-2015. godine), 2013 16. Rural development strategy of the Republic of Croatia, 2008-2013 (Strategija ruralnog razvoja Republike Hrvatske, 2008. – 2013.), Ministry of Agriculture, Fisheries and Rural Development, 2008 17. Hrvatski zavod za javno zdravstvo. Izvještaj o osobama s invaliditetom, 2013 18. The Croatian Bureau of Statistics. Employment and Wages 2011. Statistical reports, Zagreb, 2012, available at http://www.dzs.hr/Hrv_Eng/publication/2012/SI-1476 19. The Croatian Bureau of Statistics. Poverty indicators, 2011-Final Results, February, 2013, available at http://www.dzs.hr/Hrv_Eng/publication/2012/14-01- 03_01_2012.htm 20. Rubil I.Accounting for regional poverty differences in Croatia:Exploring the role of disparities in average income and inequality.Munich Personal RePEc Archive (MPRA), 2013 21. The Croatian Employment Service, The branch of Čakovec, 2012, unpublished data 22. Šlezak H. The Role of the Roma in the Demographic Resources of Međimurje County (Uloga Roma u demografskim resursima Međimurske županije). Sociologija i prostor, 51 (2013) 195 (1): 21-43 23. The Croatian Employment Service. Monthly Statistics Bulletin, 2012, available at: http://www.hzz.hr/DocSlike/stat_bilten_10_2012.pdf (the Croatian Employment Service, 2012) 24. Life expectancy at birth, 1980-2011 (years).png, EUROSTAT, available at http://epp.eurostat.ec.europa.eu/statistics_explained/index.php?title=File:Life_expe ctancy_at_birth,_1980-2011_(years).png&filetimestamp=20130129120827 25. The Croatian Bureau of Statistics. Population projections of the Republic of Croatia, 2010-2061 (Projekcije stanovništva Republike Hrvatske od 2010.-2061.), Zagreb, 2011 26. Institute of Public Health of Međimurje County, 2012, unpublished data 27. Doko Jelinic J, Pucarin-Cvetkovic J, Nola A I, Senta A, Milosevic M, Kern J. Regional diferences in Dietary Habits of Adult Croatian Population. Coll.Antropol.33(2009) Suppl.1:31-34. 28. Fišter K., Kolčić I., Musić Milanović S., Kern J.The prevalence of Overweight, Obesity and Central Obesity in Six Regions of Croatia: Results from the Croatian Adult Health Survey. Coll.Antropol.33(2009)Suppl.1:25-29. 29. Erceg M., Kern J., Babić-Erceg A.Regional Differences in the Prevalence of Arterial Hypertension in Croatia. Coll.Antropol.33(2009)Suppl.1:19-23. 30. Milosevic M, Golubic R, Mustajbegović J, Doko Jelinic J i sur. Regional Pattern of Physical Inactivity in Croatia. Coll.Antropol.33(2009) Suppl.1:33-38. 31. Bencevic-Striehl H, Malatestinic Dj., Vuletic S.Samardzic S, Vuletic Marvinac G, Prlic A. Regional diferences in Alcohol Consumptions in Croatia. Coll.Antropol.33(2009) Suppl.1:39-41. 32. Samardzic S, Vuletic Marvinac G, Prlic A. Regional Patterns of Smoking in Croatia. Coll.Antropol.33(2009) Suppl.1:43-46.

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33. Kern J., Polašek O., Musić Milanović S et al. Regional Pattern of Cardiovascular Risk Burden in Croatia. CollAntropol.33 (2009)Suppl.11-17. 34. Kutnjak Kiš R., Najman Hižman E. Qualia javnog zdravstva, Kvalitativno istraživanje zdravstvenih potreba stanovnika Međimurske županije u procesu izrade Županijske slike zdravlja te odabira prioriteta i izrade Strateškog okvira županijskog Plana za zdravlje, str. 45-56, Medicinski fakultet Sveučilišta u Zagrebu, Škola narodnog zdravlja «Andrija Štampar«, Zagreb, 2013. 35. Barić H. Institute of Public Health of Međimurje County, 2012, unpublished data 36. Šikić Vagić J., Psihosocijalne karakteristike kao čimbenici rizika u hospitaliziranih koronarnih bolesnika u Hrvatskoj, PhD thesis, Medicinski fakultet Sveučilišta u Zagrebu, Zagreb, 2010. 37. Uvodić Đurić D. Qualia javnog zadravstva. Mladi i alkohol - prikaz rezultata kvalitativnog istraživanja pijenja alkohola među djecom i mladima Međimurske županije, str. 57-72, Medicinski fakultet Sveučilišta u Zagrebu, Škola narodnog zdravlja «Andrija Štampar«, Zagreb, 2013. 38. A.Kaic-Rak.I.Kulier, J.Pucarin-Cvetkovic. Prehrambene navike. Prostorna distribucija kardiovaskularnih rizika u Hrvatskoj, znanstveni simpozij. Knjiga sažetaka,2005. 39. Bergman Markovic B, Vrdoljak D., Kranjcevic K et sur. Continental-Mediterranean and rural-urban differences in cardiovascular risk factors in Croatian population. Croat Med J.2011 August;52(4):566-575. 40. Stipeševic Rakamaric I (2011). Nejednakosti mortaliteta u urbanim i ruralnim sredinama Hrvatske, master thesis. University of Zagreb, Prosinac 2011. 41. Pristaš Iv., Bilić M., Pristaš Ir., Voncina L. and collaborators. Health Care Needs Utilization and Barriers in Croatia – Regional and Urban-Rural Differences. Coll.Antropol.33 (2009) Suppl. 1:121-130. 42. Međimurje County. Long-term County Health Plan 2008-2012, 2008, available at http://www.medjimurska-zupanija.hr/images/zdravstvo/Plan_zdravlja_MZ.pdf 43. Međimurje County. County Health Care Plan, 2010, available at http://www.medjimurska- zupanija.hr/images/stories/Zdravstvo/Plan_zdravtvene_zastite_za_MZ_2010.pdf 44. Regional Development Agency (REDEA).Development Strategy of Međimurje County 2011-2013, available at http://www.redea.hr/images/stories/razno/5-2012/razvojna- strategija-medimurske-zupanije-2011-2013.pdf 45. Međimurje County. The Social Map of Međimurje County, 2012, available at http://www.medjimurska- zupanija.hr/images/stories/Zdravstvo/socijalna_karta_medjimurske_zupanije_3_201 2.pdf 46. Regional Development Agency (REDEA). Rural Development Strategy of Međimurje County, 2009, available at http://www.redea.hr/images/stories/razno/strategija- ruralnog-razvoja-medjimurske-zupanije.pdf

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47. Regional Council of Aquitaine, Addressing Inequalities Interventions in Regions (the AIR project) , available at http://healthinequalities.eu/sites/default/files/AIR- Anglais.pdf 48. National Action Plan to reduce Health Inequalities 2008-2011.Helsinki 2008.79pp., available at http://pre20090115.stm.fi/pr1227003636140/passthru.pdf 49. CSDH (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organisation. 50. The National Strategy of mental health protection for 2011-2016, available at http://www.mzss.hr/layout/set/print/ministarstvo/strategije_i_planovi/nacionalna_s trategija_zastite_mentalnog_zdravlja_za_razdoblje_od_2011_2016_godine 51. Kregar, K. (2001.): Zdravi gradovi: primjer lokalnog razvoja i organiziranja zajednice, Ljetopis Studijskog centra socijalnog rada, 8 (1), 51-69 52. Božičević, V., Brlas, S., Gulin, M. (ur.) (2011.): Psihologija u zaštiti mentalnog zdravlja, Prijedlog smjernica za psihološku djelatnost u zaštiti i promicanju mentalnog zdravlja, ZZJZ "Sveti Rok" Virovitičko-podravske županije, Virovitica 53. Brlas, S., Gulin, M. (ur.) (2010.): Psihologija u zaštiti mentalnog zdravlja, ZZJZ "Sveti Rok" Virovitičko-podravske županije, Virovitica 54. Sakoman, S., (2012). Koncept zaštite mentalnog zdravlja, u: Božičević, V., Brlas, S., Gulin, M. (ur.): Psihologija u zaštiti mentalnog zdravlja, Priručnik za psihološku djelatnost u zaštiti i promicanju mentalnog zdravlja, ZZJZ "Sveti Rok" Virovitičko- podravske županije, Virovitica 55. Brlas, S., Pleša, M. (2013): Psihologija u zaštiti mentalnog zdravlja, Proaktivna skrb psihologa o mentalnom zdravlju psihički bolesnih odraslih osoba, ZZJZ "Sveti Rok" Virovitičko-podravske županije, Virovitica 56. Bijedić, M. (2010.): Čimbenici učinkovitosti izvaninstitucionalnih intervencija usmjerenih djeci i mladima rizičnog ponašanja, Odgojne znanosti, 12, 1, 131-149 57. Brajša-Žganec A. i sur. (2011.), Analiza stanja prava djece i žena u Hrvatskoj, Zagreb, Unicef 58. National Youth Program for 2009-2013 (Nacionalni program za mlade od 2009. do 2013. godine, available at http://narodne- novine.nn.hr/clanci/sluzbeni/2009_07_82_1988.html 59. Guidelines for planning, implementation and evaluation of prevention and treatment programmes for the protection of children from violence (Smjernice za planiranje, provedbu i evaluaciju prevencijskih i tretmanskih programa zaštite djece od nasilja), 2010, available at http://www.google.hr/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=2&ved=0 CC4QFjAB&url=http%3A%2F%2Fwww.mspm.hr%2Fcontent%2Fdownload%2F7694%2 F60918%2Ffile%2FSmjernice.pdf&ei=08ydUoS4FcjnygP474KIDA&usg=AFQjCNFl0o96L FJFnLuFpxy7VhMaeFGTcQ 60. Janković. J., Bašić. J. (ur.)(2001): Prevencija poremećaja u ponašanju djece i mladih u lokalnoj zajednici, Povjerenstvo Vlade RH za prevenciju poremećaja u ponašanju djece i mladeži i zaštitu djece s poremećajima u ponašanju, Zagreb 61. WHO.Global Action Plan for the prevention and control of noncommunicable diseases 2013-2020.World Health Organization,2013 101

62. WHO.Global Strategy on diet, physical activity and health. Resolution WHA 55.23.,World Health Organization, 2004 63. Cavill N, Kahlmeier S, Racioppi F. Physical activity and health in Europe: evidence for action. Copenhagen, World Health Organization, 2006. 64. Steps to health A European framework to promote Physical activity for Health. Copenhagen, World health Organization, 2007. 65. Kutnjak Kiš R, Bijelić L., Najman Hižman E. Promoting physical activity and active living in the local community through project “Public Health Capacity Building Programme- Healthy Counties”-the example of Međimurje County (Croatia), Bled, Sport Citiezens Forum, ISCA, 18-21 Nov 2010 66. G W Heath and others. Evidence-based intervention in physical activity: lessons from around the world. The Lancet. Physical Activity.July, 2012 67. Musić Milanović, Sanja (2010) Demografske, bihevioralne i socioekonomske odrednice debljine odraslih u Hrvatskoj. Doctoral disertation, Univerity of Zagreb 68. WHO. Equity, social determinants and public health programmes, World Health Organization, 2010 69. WHO.Global Status Report on Alcohol and Health, World Health Organization, 2011 70. National Strategy on Combating Drugs Abuse 2010-2014 (Nacionalni program prevencije ovisnosti za djecu i mlade u odgojno-obrazovnom sustavu, te djecu I mlade u sustavu socijalne skrbi od 2010.-2014. godine). Government of the Republic of Croatia, 2010 71. Kutnjak Kiš R.Promjene u strukturi smrtnosti od kroničnih nezaraznih bolesti u Međimurskoj županji te mjere promicanja zdravlja, prevencije i ranog otkrivanja koje provodi Zavod za javno zdravstvo Međimurske županije sa suradnicima. Croatian Yournal of Public Health (electronic yournal), vol.7, broj 28, 2011, available at http://www.hcjz.hr/old/clanak.php?id=14539 72. Kralj V.Kardiovaskularne bolesti. Croatian Yournal of Public Health, vol.7, broj 28, 2011 73. Rainer Z. Actions to be taken at the level of the population to reduce the risk of CVD.Cardiol Croat.2012;7(9-10):234-239) 74. Working in Health Promoting Ways. A strategic framework for DHHS 2009.-2012., Tasmanian Government, 2010. 75. WHO.Physical Activity Promotion in Socially Disadvantaged Groups:Principles for Action.World Health Organisation, 2013 76. Siromaštvo, nezaposlenost i socijalna isključenost. Zagreb: UNDP, 2006. 77. Podrška sustavu socijalne skrbi u procesu daljnje deinstitucionalizacije socijalnih usluga, Ministarstvo socijalne politike i mladih, available at http://www.mspm.hr/fondovi_eu/ipa_iv_razvoj_ljudskih_potencijala/projekti/usluge /projekti_u_tijeku/projekt_podrska_sustavu_socijalne_skrbi_u_procesu_daljnje_dein stitucionalizacije_socijalnih_usluga , unpublished date 78. Herbig B, Dragano N, Angerer P: Health in the long-term unemployed.Dtsch Arztebl Int 2013; 110(23–24): 413–9. DOI: 10.3238/arztebl.2013.0413

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79. WHO. World Conference on Social Determinants of Health. Summary Report-All for Equity, Brazil, 2012 80. WHO. Intersectoral Governance for Health in All Policies. Structures, actions and experiences. World Health Organization, on behalf of the European Observatory on Health Systems and Policies, 2012 81. Kutnjak Kiš R, Najman Hižman E. Međimurska županija-zdrava županija, Programa “Rukovođenje i upravljanje za zdravlje u lokalnoj zajednici”. Croatian Yournal of Public Health (electronic yournal), vol.7, number 23, 2010, available at http://www.hcjz.hr/old/clanak.php?id=14296 82. WHO. Developing indicators for the Health 2020 targets. First meeting of the expert group Utrecht, the Netherlands, World Health Organization, 2012 83. Kern J., Erceg M, Poljičanin T. Učinkovitost javnozdravstvenih nadzornih sustava. Acta Med Croatica, 64 (2010) 415-423 84. Allen M at al. Working for Health Equity: The Role of Health Professionals. UCL Institute of Health Equity,2013 85. WHO. How health systems can address health inequities through improved use of Structural Funds. Copenhagen, WHO Regional Office for Europe, 2010 86. Agencija za zaštitu okoliša. Odabrani pokazatelji stanja okoliša u Republici Hrvatskoj, 2012 87. European Environment Agency. Environment and Human Health. Joint EEA-JRC report No5/2013. European Environment Agency, 2013, European Union, 2013 88. Belović B., Buzeti T., Kranjc Nikolić T et al. Health promotion strategy and action plan for tackling health inequalities in the Pomurje region. Murska Sobota:Zavod za zdravstveno varstvo;Brussels:Flemish Institute for Health Promotion, 2005 References later added: 89. Znaor, D., 2009 Organic fruit and vegetables sector in Croatia: the way forward. Study commissioned by the German international cooperation organisation for sustainable development (GTZ). 90. Kristiansen, P., Taji, A., Reganold, J. (2006): Organic Agriculture, A Global Perspective, CSIRO Publishing, Australia, CABI Publishing, Wallingford, UK 91. S.Wright, D. McCrea (2000): Handbook of Organic Food Processing and Production, Second Edition (S.Wright, D. McCrea, Eds), CRC Press, New York

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8. Partners in the ACTION-FOR-HEALTH Needs Assessment and other important steps in the creation of the Strategic Plan

We would like to thank the following partners for their contribution in the implementation of the situation analysis and the creation of the strategic plan: Verica Kralj, primarius MD, Tanja Ćorić, MD, Iva Pejnović-Franelić, MD, PhD, and Sandra Mihel, MD, from the Croatian Institute of Public Health; Ana Kralj, dipl. oec., from REDEA – Regional Development Agency Međimurje; Rusalka Majer, project manager from the Autonomous Centre – ACT Čakovec; Damir Kregar, dipl. ing., from Čakovečki mlinovi d.d. Čakovec; and Marina Kodba, dipl. soc., from the Croatian Employment Service – Regional Office of Čakovec.

For their enormous help and support in the development of the Strategic Plan and the organisation of the pilot implementation we thank Branislava Belović, MD prim.mag., Tatjana Kranjc-Nikolić, MD and asist.mag., as well as other experts from the project team of the National Institute of Public Health – the Regional Unit of Murska Sobota. Their experience in the development and implementation of the Health Promotion Strategy and Action Plan for Tackling Health Inequalities in the Pomurje Region, which they had made in 2005(88), was of great help to us, for which we are indebted to them.

A big thank you to Međimurje County, its towns and municipalities, as well as a number of partners who have participated in the assessment of needs and possibilities in connection with the implementation of the Strategic Plan:

HEALTH COUNCIL

JELENA ČUGALJ, dipl. soc. ped.; Department for Children, Youth and Family, Centre for Social Care Čakovec VLATKA PLEH, MD, Private Family Practice, Čakovec MARIJA PREKUPEC, dipl. med. techn, Institute of Public Health of Međimurje County, Department for Public Health; representative of nurses in the Health Council of Međimurje County LIDIJA BIJELIĆ, head of the Administrative Department for Health Care, Social Protection and National Minorities, the County of Međimurje ELIZABETA NAJMAN HIŽMAN, graduated social worker; senior health care associate, member of the Health Council of Međimurje County KARMEN FRANIN, senior economic advisor, the City of Čakovec, member of the Health Council Task Force, County of Međimurje BOŽENA MALEKOCI–OLETIĆ, journalist for the Local Paper ''Međimurske Novine'', member of the Health Council of Međimurje County 104

PHYSICIANS - NEUROLOGISTS, CARDIOLOGISTS AND FAMILY DOCTORS

JASNA MUNĐAR PALAŠEK, neurologist and assistant manager at Čakovec County Hospital, Department of Neurology ROBERT MARČEC, neurologist and head of department at Čakovec County Hospital, Department of Neurology JASNA CMREČNJAK, internist at the Stationary Unit of Čakovec County Hospital - Coronary Unit Of County Hospital Čakovec MILICA GABOR, internist - cardiologist at the Department of Cardiology, Čakovec County Hospital ZDENKA IVANOVIĆ-AZENIĆ, MD, Private Family Practice, Domašinec

CROATIAN CHAMBER OF NURSES, THE ČAKOVEC BRANCH

DARINKA ŽVORC NOVAK, bacc. med. techn, ophtalmology head nurse, Čakovec County Hospital, head of the Croatian Chamber of Nurses, the Čakovec Branch TANJA KRNJAK, bacc. med. techn, neurology head nurse, Čakovec County Hospital, a member of the Executive Board of the Croatian Chamber of Nurses, the Čakovec Branch BRANKA IVACI bacc. med. techn, health manager of the Čakovec Nursery School, secretary of the Executive Board of the Croatian Chamber of Nurses, the Čakovec Branch MARIJA ŽIGNIĆ, bacc. med. techn, field nurse; head nurse in the Healthcare Centre Čakovec VESNA VUKŠIĆ, bacc. med. techn, field nurse in the Healthcare Centre Čakovec; member of the Croatian Chamber of Nurses, the Čakovec Branch

ASSOCIATIONS OF MEĐIMURJE COUNTY

FRANJO KRAVARŠĆAN, head of the Čakovec Pensioner Association of Međimurje County LJUBO RITONJA, head of the ''Mura Club'', the Association for Persons with Mental Retardation of Međimurje County BALOG JOSIP, head of the Romani Association of Međimurje DAMIR IGNAC, representative of the Association ''For a Better Tomorrow'' BARBARA HADELJAN, associate of the Association ''For the Wellbeing of the Romani People Goričan'' MIODRAG NOVOSEL, head of GP EKOM d.o.o. Čakovec (swimming centre) MARINA KOLAR, executive director of and trainer in the association ''Zora'' MARIJAN VUGRINČIĆ, secretary in the Sports and Recreation Association of Međimurje ''Sports for All'' SANJA GOLEŠ, administrator at the Croatian Red Cross – Red Cross Community of Čakovec TEO PETRIČEVIĆ, executive director of the Autonomous Centre – Act

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REPRESENTATIVES OF VARIOUS SECTORS IN THE COUNTY

BOŽIDAR DOLAR, director of State Inspectorate, the Čakovec Branch DUBRAVKA KEČKEŠ, professional associate - pedagogue in the First Primary School of Čakovec, director of the Pedagogue Committee of Primary Schools ANDREJA ZADRAVEC BARANAŠIĆ, professional associate - a pedagogue in the Primary School of Štrigova, director of the School Prevention Programmes DAMIR KREGAR, dipl. ing., from Čakovečki mlinovi d.d. ANA KRALJ, head of the Department for Strategic Planning, Regional Development Agency of Međimurje Redea d.o.o. TANJA LILIĆ, professional associate – pedagogue in the Secondary School of Prelog, director of the Pedagogue Committee of Secondary Schools DANIJEL JURAKIĆ, senior assistant at the Faculty of Kinesiology, University of Zagreb ANTUN HOBLAJ, parish priest in the Parish of St Jacob, Prelog and rector of the parishes of Lower Međimurje CROATIAN EMPLOYMENT SERVICE, REGIONAL OFFICE OF ČAKOVEC. In a group meeting for the unemployed a short presentation of the project ''ACTION-FOR-HEALTH'' was given, followed by a brief summary of needs assessment. After a short discussion, those present filled out a semi-structured questionnaire (26 participants).

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Authors: Jing Wu, Prof. Merike Sisask, Prof. Dr. Airi Värnik

Estonian-Swedish Mental Health and Suicidology Institute (ERSI)

Tallinn, Estonia, 2013

3

Contents

INTRODUCTION ...... 4 General data ...... 4 Health inequalities in Rapla County...... 5 The needed actions for tackling health inequalities in Rapla County ...... 6 Main direction of health promotion – mental health promotion ...... 6 New trends of national health policies and Structural Funds (2014-2020) in Estonia ...... 9 FRAMEWORK OF THE ACTION PLAN ...... 12 Aim 1: Put health inequalities in the center of attention of the community and of individuals ...... 12 Aim 2: Reducing health inequalities in the region through health promotion activities ..... 14 Aim 3: Reducing health inequalities in the region by supporting groups at risk ...... 17 Aim 4: Maintaining a clean and healthy environment...... 24 ACKNOWLEDGEMENTS ...... 26 REFERENCES ...... 27

4

INTRODUCTION

General data

Rapla County is a rural area and located in the north-western part of Estonia. Due to the geographical closeness to Tallinn, the country’s capital, Rapla County has been called the bedroom of Tallinn. Building, transport and agriculture are the primary industries there (1). Moreover, public administration, schools, health and social service play an important role.

In total Rapla County of Estonia has 10 rural municipalities (2) and Rapla town is the center/capital of the County. Rapla County has a population of 34 442 in 2013, of which 48.2% was male and 51.8% was female (3). The population of Rapla County constitutes approximately 2.7% of the total population of Estonia (4).

Even though Rapla County has a lower unemployment rate (8.7% in 2012) than the national average (10.2% in 2012) (5), its average income of 534 euros in 2011 is lower than that of the national average (672 euros in 2011) (6). The percentage of people of total population who live under 60% the income-poverty line in Rapla County equaled the national average of 17.5% in 2011 (7). In addition, the life expectancy at birth in Rapla County in 2010/2011 (75.73 years in total, 70.44 years in males and 81.00 years in females) is slightly lower than the national average in 2011 (76.28 years in total, 81.09 years in males and 71.16 years in females) (8, 9). As to the main causes of death, even though the percentage of people who died of cardiovascular diseases is lower in Rapla County than that of the national average in 2011 (48.9% versus 53.7%) (10), the percentage of people who died of injury and poisoning and cancer are still higher than those of the national average (9.4% versus 7.4%; 25.1% versus 24.2%) (10). Estonia has the highest mortality rates due to injuries in the EU (11, 12). Hence, injuries and health inequalities due to injuries in Rapla County will be our concern in the action plan.

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Health inequalities in Rapla County

According to the World Health Organization (WHO), “health inequalities” is defined as “differences in health status or in the distribution of health determinants between different population groups” (13). Health inequalities are accepted as wholly preventable and unjust, and they exist throughout the EU, between and within countries and regions (14). Health inequalities are caused by differences in social status and are increasingly a problem for modern societies (15). In the context of mental health, the concept of inequalities means the unequal distribution of the factors which are detrimental to mental health and well-being and/or which promote positive mental health; and the unequal distribution of mental illness/mental health problems between different population groups (16). The people who are subject to discrimination in many forms (such as racism, sexism, homophobia, ageism, discrimination on the grounds of disability) and the people who are victims of violence or abuse or who are socioeconomically deprived are more likely to experience poor mental well-being and are more likely to be at risk of developing mental health problems or illness (17).

Poisoning can be caused by poisoned water, alcohol poisoning and drugs. Alcohol plays a very important role in death by injury not only among middle-aged men but also among youth and adolescents (7). In Rapla County, poisoning and suicide rank first in death by injury in males in the 20-60 year age group (7). Suicide is defined by WHO as “the act of killing oneself deliberately initiated and performed by the person concerned in the full knowledge or expectation of its fatal outcome” (18). Suicide is strongly linked to emotional health and psychological conditions (19), e.g. depression. Depression is a common mental disorder which can lead to suicide at the most severe and impairs an individual’s ability to function at work or school or cope with daily life; however, this disorder can be reliably diagnosed and treated by non- specialists as part of primary health care (20).

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The needed actions for tackling health inequalities in Rapla County

Prevention of injuries and alcohol poisoning is more effective if access to alcohol is limited (7). Rapla County introduced one of the first bans on the retail sale of any kind of alcoholic drinks at night in Estonia in 2003 and since the summer of 2008, the same ban has been enforced throughout Estonia (21). In addition, preventive activities related to alcohol are always combined with prevention of other addictions (e.g. smoking, drug abuse etc.) (21, 22).

Based on the information collected from the focus group with specialists and stakeholders of Rapla County (22), it is known that Rapla County is lacking of sufficient knowledge and other resources for implementing situation analyses and evaluating the effectiveness of programs, especially the impact assessment of mental health as a determinant of injuries (e.g. stress, mental health problems, suicide and related alcohol and drug consumption). Moreover, unstable financing support and legislations that don’t encourage ‘grass’ level health promotion will be obstacles for building a network organization on this level (22). Therefore, the capacity for recognizing and solving mental health problems/disorders and suicide attempts and sustainable political and financial support from the national government should be taken into account in our action plan for tackling health inequalities in Rapla County (7).

Main direction of health promotion – mental health promotion

Mental health is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community (23).

“Mental health promotion aims to promote positive mental health by increasing psychological well-being, competence and resilience, and by creating supporting living conditions and environments. Mental disorder prevention has as its target the reduction of symptoms and ultimately of mental disorders. It uses mental health promotion strategies as one of the means to achieve these goals. Mental health

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promotion when aiming to enhance positive mental health in the community may also have the secondary outcome of decreasing the incidence of mental disorders.”(24)

According to WHO (25), promoting mental health depends largely on inter-sectorial strategies. Specific ways to promote mental health include:  Early childhood interventions (e.g. home visits for pregnant women, pre- school psycho-social activities, combined nutritional and psycho-social help for disadvantaged populations);  Support to children (e.g. skills building programs, child and youth development programs);  Socio-economic empowerment of women (e.g. improving access to education and microcredit schemes);  Social support for elderly populations (e.g. befriending initiatives, community and day centers for the aged);  Programs targeted at vulnerable groups, including minorities, indigenous people, migrants and people affected by conflicts and disasters (e.g. psycho- social interventions after disasters);  Mental health promotional activities in schools (e.g. programs supporting ecological changes in schools and child-friendly schools);  Mental health interventions at work (e.g. stress prevention programs);  Housing policies (e.g. housing improvement);  Violence prevention programs (e.g. community policing initiatives); and  Community development programs (e.g. 'Communities That Care' initiatives, integrated rural development

WHO stresses on the strategies of mental health promotion (25) as follows. Mental health promotion involves actions to create living conditions and environments that support mental health and allow people to adopt and maintain healthy lifestyles. These include a range of actions to increase the chances of more people experiencing better mental health. National mental health policies should not be solely concerned with mental disorders, but should also recognize and address the broader issues which promote mental health. This includes mainstreaming mental health promotion into policies and programs in government and business sectors including education,

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labor, justice, transport, environment, housing, and welfare, as well as the health sector (25).

Likely, one report ‘Mental Health Promotion and mental disorder prevention: a policy for Europe’ (26) lists out five common principles and ten action areas in the work of mental health promotion as follows, which can be used as guideline for our action plan preparation.

Five common principles:

 Expand the knowledge base for mental health  Support effective implementation  Build capacity and train the workforce  Engage different actors  Evaluate policy and program impact

Ten action areas:

 Support parenting and the early years of life  Promote mental health in schools  Promote workplace mental health  Support mentally healthy ageing  Address groups at risk for mental disorders  Prevent depression and suicide  Prevent violence and harmful substance use  Reduce disadvantage and prevent stigma  Involve primary and secondary health care  Link with other sectors

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New trends of national health policies and Structural Funds (2014- 2020) in Estonia

In Estonian National Health Plan 2009-2020 (27), it is known that various health policy visions have been drafted in Estonia since the beginning of the 1990s and the first health policy document was approved by a Government of the Republic decision on 2 March 1995. The National Health Plan establishes strategic objectives for maintaining and continued improvement of public health. An important priority for the Estonian government is achieving population growth, increasing life expectancy and healthy life years, and these objectives constitute the basis of all targets and actions highlighted in this National Health Plan. The general objective of the National Health Plan 2009-2020 is to increase the number of healthy life years by decreasing mortality and morbidity rates. The Plan defines five thematic areas: 1) focusing on the increase in social cohesion and equal opportunities, 2) ensuring healthy and safe development of children, 3) development of a health-supportive environment, 4) promotion of healthy lifestyle, and 5) securing sustainability of the healthcare system. The priorities of all these thematic areas are based on fundamental values of the Plan, including human rights, common responsibility for health, equal opportunities and justice, social inclusion, evidence-based knowledge and conformity with international documents. Highlighting social cohesion and equal opportunities provides a signal to all members of society that they are invited to participate in the actions and decisions of the society. Ensuring healthy and secure development for children and adolescents provides them with the opportunity to grow healthy and become active members of the society. Healthy living, working and learning environment is equally important for the children and other members of society. A clean and safe environment is the basis that enables people to benefit most from the opportunities both as individuals and a society, which means that reduction and elimination of environmental risks is of crucial importance.

The National Health Plan 2009-2020 (27) provides a link with many existing or envisaged strategic documents. Population health is the common element in all programs, strategies and development plans referred to in this Plan. The precise connections between the following strategies and development plans and the

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National Health Plan and the strategic fields thereof have been elaborated in the source documents of the National Health Plan as follows.

 Ministry of Social Affairs - National Strategy for Prevention of Cardiovascular Diseases 2005–2020 - Development of Children and Families 2012–2020  Ministry of the Environment - Estonian Environment Strategy until 2030 - National Radiation Safety Development Plan 2008–2017  Ministry of Education and Research - Bullying Prevention Program 'Safe School'

On 29th November 2012 Estonian government proposed that in national level the structural support of European Union during new period 2014-2020 will be focused on the development of these areas: education, economy, environment, energy, transport, and information technology (28).

Under the proposal of Estonian Government, five national objectives are main priorities of Estonia as follows (28).

 High-quality and accessible Education which considers the needs of learners and society  High employability and high-quality working life  Knowledge-intensive and internationally competitive economy  Pure and diverse natural environment and the efficient use of natural resources  Meet the needs of residents and support the sustainable connections and motilities of business

In Estonia, the European Social Fund (ESF) creates for the period 2014-2020 new opportunities for employees by offering them new skills and know-how through training and lifelong learning. It also helps excluded groups to join the workforce – such as the long-term unemployed and older job-seekers. ESF funding helps also to educate and train young people to meet the future needs of Estonia’s evolving jobs market (29). On 30th October 2013 in Tallinn the Estonian Ministry of Social Affairs organized a seminar with the topic of ‘new period of European Social Fund – what to

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take and what to leave?’. Some thematic priorities will be considered and funded by ESF, e.g. ‘increasing employability of youth’, ‘increasing employability of working- age population and preventing unemployment’, ‘welfare measures to support labor market participation’, ‘decreasing the obstacles of labor market participation of people who have difficulties in coping skills (incl. social problems and burden of care)’, ‘childcare and disable children welfare service development and availability not only to decrease care burden (kindergarten, school, rehabilitation center) but also to decrease the care burden of parents which participate in labor market’, ‘increasing the employment rate and tackling the obstacles of labor market participation’, and ‘alcohol abuse and drunk-driving prevention, early defection and counseling, treatment service and rehabilitation system establishment and development’ etc.

Based on these upcoming policies and programs provided by ESF in Estonian national level, we composed the action plan for tackling health inequalities using a health promotion life-course perspective within the region of Rapla County and for the long run between different regions and even throughout the whole country.

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FRAMEWORK OF THE ACTION PLAN

PRIMARY GOAL: REDUCTION OF HEALTH INEQUALITIES IN RAPLA COUNTY USING A HEALTH PROMOTION LIFE-COURSE PERSPECTIVE

Aim 1: Put health inequalities in the center of attention of the community and of individuals

Health is defined as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (30). There are multiple factors influencing health of the community and of individuals. Generally speaking, the determinants of health include: 1) the social and economic environment, 2) the physical environment, and 3) the person’s individual characteristics and behaviors (31). Health inequalities exist not only across the EU level (32) but also at national, regional and local levels. Hence, in order to tackling health inequalities, it is of importance to increase the awareness of health inequalities both in the general population and in policies and activities of different sectors.

Objective 1: Increase the awareness and responsibility of the professionals about health inequalities

Activities:

 Include health inequalities topics in professional events  Educate professionals  Share knowledge and experience

Indicators:

 Involvement inequalities post in professional events  Number of trainings and participants

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Objective 2: Increase the awareness and responsibility of the population about health inequalities

Activities:

 Organize local health promotion activities  Situate the content of health inequalities in different local events  Proactively communicate with the media

Indicators:

 Participation level in local health promotion activities  Local activity  Media publication

Objective 3: Included health in other policies and programs in the region

Activities:

 Identify and raise awareness of relevant stakeholders in the environment  Situate the content in regional health policies and programs  Develop and implement a common cross-cutting activities, projects and programs

Indicators:

 Includes content in regional health policies and programs  Joint activities

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Aim 2: Reducing health inequalities in the region through health promotion activities

In general, there are diverse social determinants related to the health problems, e.g. biological factors (including age, gender and hereditary factors), socio-economic factors (education, income, employment), lifestyle factors and cultural and environmental factors (housing, access to sanitation, access to clean tap water, clear air) (7). These factors should be considered when reducing health inequalities. In Rapla County, the social determinants which influence health problems are alcohol consumption, drug use, life- and study- and work related stress, emotional health, psychological conditions etc. In the action plan, discovering all root causes and solving all social determinants which lead to health inequalities won’t be the focus; on the contrary, health promotion will be utilized to reduce these health inequalities. Health promotion is the process of enabling people to take the responsibility and to improve their health and health care costs can be diminished through health promotion and disease prevention (15).

Objective 1: Mental health promotion

Target: Inform and raise awareness about the importance of mental health

Activities:

 Information about the importance of mental health  Education of the general and professional public on approaches to build positive self-esteem, constructive problem-solving and stress management  Encouraging the creation of a positive school and work environment, and also social integration

Indicators:

 Professional contributions and media announcement  Activities, events and numbers of participants in the field of mental health promotion  The number of workplaces introducing stress reducing programs

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Objective 2: Injury prevention

Target 1: Encourage safe behavior on the road

Activities:

 Promote driving without the influence of alcohol  Promote respect of the speed limits  Promote use of seatbelts and helmets

Indicators:

 Media coverage  The number of programs to encourage safe driving and road safety  The number of participants in the programs

Target 2: Encourage safe living and working environment

Activities:

 Promote use of appropriate safety equipment  Supporting the program to promote safety at home, work and other environment

Indicators:

 Professional contributions and media announcements  Programs in the field of injury prevention  The number of participants in the programs

Objective 3: Increase early detection of chronic non-communicable diseases

Target 1: Educate people to recognize early signs of disease and to seek advice

Activities:

 Inform the target groups about the early signs of disease  Encourage people to seek advice at an early stage of symptoms

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Indicators:

 Professional contributions and media announcements  The number of events and workshops to inform and raise the awareness of the population  The number of participants in the programs

Target 2: Increase the use of services in the field of secondary prevention of cardiovascular disease and cancer

Activities:

 Warning of the need for adequate access to prevention programs and early diagnosis in target groups  Encourage people to participate in prevention programs

Indicators:

 Professional contributions and media announcements  The number of activities to encourage participation in prevention programs  The number of participants in the programs

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Aim 3: Reducing health inequalities in the region by supporting groups at risk

Support for children and adolescents

Health at childhood and adolescence exerts a big influence on health in adulthood so that it is very important to create a healthy lifestyle and a healthy environment for sustainably favorable health in childhood and adolescence (15). In Rapla County, alcohol consumption and drug abuse are main risk behaviors among youth and adolescents. A study on alcohol consumption implemented in 2010 in Rapla County showed that our of all eleventh grad students aged 17-19 years old, 45% of the boys and 35% of the girls consumed hard liquor every month; moreover, the percentage of eleventh graders who had tried drugs had grown by 9% from 2008 to 2010 (from 28% to 37%) (33). Since promotion of the healthy awareness and healthy behavior of children and adolescents are so important that Estonian Population Policy 2009-2013 proposed the three priorities of actions of improving health of children and adolescents: 1) promotion of the physical and mental health and social development; 2) prevention of injuries and violence; 3) prevention of chronic diseases and their risk factors (34). These principles become very firm base of this section of our action plan for children and adolescents.

Objective 1: Promoting healthy environment for children and adolescents

Activities:

 Support the implementation of standard of healthy nutrition and physical exercise to kindergartens, schools and other educational institutions in the region  Implement a whole-school approach to healthy eating in the school setting  Training on healthy nutrition for teachers and food organizers  Provide information on noxiousness of smoking and second-hand smoking in childhood and adolescence

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Indicators:

 Number of institutions implementing standards for healthy nutrition  Number of schools involved in the implementation of a whole-school approach  Number of participants in the training  Number of campaigns/activities among target groups  Level of awareness on the harmful effect of smoking

Objective 2: Increase early identification of mental disorders and signs of suicidal behavior among children and adolescents

Target 1: Understand study-related stress

Activities:

 Organize the training course for children/adolescents, parents and school staff on depression, suicidality and other mental disorders  Assess the study-related stress and the negative emotions  Promote positive self-image  Target high-risk groups

Indicators:

 The awareness and the ability to recognize the early signs and symptoms of mental health problems and mental disorders  The availability of and access to appropriate services for assessment and treatment  The involvement of professionals and parents

Target 2: Manage school bullying

Activities:

 Organize the training course for children/adolescents, parents and school staff on school bullying  Assess the severity of school bullying through interviews  Take actions to prevent school bullying

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Indicators:

 The number of participants in the training course  The ability to understand school bullying  The ability to seek help when school bullying happens  The involvement of professionals and parents

Target 3: Promoting healthy life without the use of illegal drugs and the consumption of alcohol

Activities:

 Organize training course for children and adolescents on health, social and other consequences of alcohol and drug use/abuse  Cooperate with schools to create more constructive leisure time for children and adolescents

Indicators:

 The number of children and adolescents participating in the training course  The amount of alcohol consumption and drug use  The involvement of professionals and parents

Support for working-age population

Supported by Structural Funds 2007-2013, ‘Rapla rural municipality health promotion co-operation project 2012’ was in force since 08-02-2012. It belongs to the category of promotion of healthy lifestyle and project beneficiary is Rapla rural municipality government. The purpose of the project is to support the working-age population and implement health promotion or prevention for unemployed and inactive people in order to reduce health reasons from the labor market. The target group is working population aged 15-65 years old. The project is community-based and the evidence- based health promotion is carried on simultaneously in two directions: 1) to solve health problems (low levels of physical activity, injuries, etc.); 2) to raise the ability of people in community. The upcoming Structural Funds with new programming period 2014-2020, especially European Social Fund (ESF), also focuses more on increasing employment rate and preventing unemployment. Therefore, based on these guidelines above, how to tackling obstacles of work (e.g.

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work-related stress, negative emotions, unhealthy lifestyle, etc.) of working-age population and how to increase the social and coping skills of the unemployed will be the main issues in this section of our action plan.

Objective 1: Supporting the improvement of health of working-age population

Activities:

 Development of an adequate approaches and programs to promote healthy behaviors among working-age population  Include physical activity into public events  Awareness and motivation for regular physical activity of working-age population in workplaces  Organized regular physical activity in workplaces

Indicators:

 The number of physical activity events  Professional contributions and media announcements  The proportion of the physically active working-age population

Objective 2: Increase early identification of mental disorders and signs of suicidal behavior among working-age population

Target 1: Support mental health improvements of working-age people with special needs

Activities:

 Understand the work-life-family balance  Assess the work-related stress and the negative impact of stress  Organize workshops or training courses on stress management  Establish a positive and effective communication with employers

Indicators:

 The number of people attending the workshops or training courses  The ability to make a good balance of work-life-family  The ability to control the work-related stress  The ability to express special needs with employers

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Target 2: Increase social and coping skills of the unemployed people

Activities:

 Organize training course of re-entering into labor market for the unemployed people  Organize career counseling for the unemployed people  Organize the communications between workplaces which offer jobs and the unemployed people who need jobs

Indicators:

 The skills how to search jobs and do a job interview  The ability of re-socialization into labor market  The involvement of Unemployment Funds

Support for older people

In the age structure of the population, in Estonia the people aged 60 years and over accounted for 24% of the total population in 2013 and in Rapla County those aged 60 years and over occupied 25% of the general population in 2013 (35). Ageing is a natural part of life that is influenced by individual and cultural differences and some issues associated with growing older can be uniquely challenging, e.g. widowhood, the death of loved ones and friends, loneliness, declining physical and cognitive ability, stressful life events, loss of roles due to retirement, social exclusion etc. (36). Moreover, depression, as the most prevalent mental health disorder among older people, is linked with medical disorders including the development of cardiovascular diseases (36).

WHO in 2002 proposed the concept of ‘active ageing’ (37), that is, the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age and it applies to both individuals and population groups. Since ageing takes place in the context of friends, work colleagues, neighbors and family members, interdependence as well as intergenerational solidarity are important in the area of active ageing (37).

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Objective: Promoting mental well-being, social participation, mobility and autonomy of older people

Target 1: Increase early identification of mental disorders and signs of suicidal behavior among older people

Activities:

 Assess emotional and social loneliness among older people  Implement brief psychological interventions to prevent depression and anxiety among older people  Target high-risk groups of suicidal ideas, suicidal plans, suicidal attempts

Indicators:

 The awareness and the ability to recognize the early signs and symptoms of mental health problems  The availability of and access to appropriate services for assessment and treatment  The involvement of professionals

Target 2: Encourage social participation of older people in community

Activities:

 Organize singing and musical activities for older people  Organize regular self-help or discussion group among older people in libraries and culture centers  Encourage retired older people to do part-time work or volunteer work as a professional in the community

Indicators:

 The number of older participants each time  The times of older participants in the activities  Professional contributions of older people for the community

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Target 3: Improve capacity of family members and friends to provide home care

Activities:

 Organize training course of ageing, elderly mental health and well-being to family members and friends of older people  Support family caregivers in positive ways

Indicators:

 The number of family members and friends that participate into the training course  Mutual trust between family members and older people  Older people’s perceptions of love and affection from family caregivers and older people  Satisfaction from own care giving skills among family caregivers

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Aim 4: Maintaining a clean and healthy environment

The physical environment has a huge impact on health (15). There is a need not only to focus on the direct pathological effects of various chemical, physical and biological agents but also to pay attention to the effects on health of the broad physical and social environment, e.g. housing, urban development, land-use and transportation, industry, and agriculture (38). Therefore, both the general population and the policy makers should be encouraged to make and promote an environment-friendly choice (15).

Objective 1: Promoting positive behavior of people towards physical environment.

Activities:

 Providing knowledge of a healthy environment and raising public awareness on its impact on people’s lives  Developing programs and actions to discourage polluting behavior of the population  Implementation of the programs  Organizing activities to encourage people to apply measures for environmental protection and make choices conducive to the environment  Providing media support for these activities

Indicators:

 Number of messages about a healthy environment  Number of implemented programs to prevent pollution  Number of activities for making an environmentally-friendly choice  Media coverage of these activities

Objective 2: Promoting an environmental protection policy at the regional level

Activities:

 Providing knowledge and training of field-related stakeholders and key actors to develop an environmental protection policy  Lobbying for environmental protection strategies

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Indicators:

 The number of environment-friendly policies and workshops  The number of stakeholders attending the workshops

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ACKNOWLEDGEMENTS

Some insights related to mental health promotion in this action plan draft are inspired by and adopted from Mental Health Promotion Handbooks funded by the EU Health Programme 2008-2013 (Agreement Number: 2009 12 13) and published by the MHP Hands Consortium in 2013.

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29. European Social Fund (2013). http://ec.europa.eu/esf/main.jsp?catId=377&langId=en, updated on 10 March 2013. 30. World Health Organization (1946). WHO definition of health. http://www.who.int/about/definition/en/print.html. 31. Word Health Organization (2013). Health Impact Assessment (HIA) - The determinants of health. http://www.who.int/hia/evidence/doh/en/index.html. 32. Whitehead, M. & Dahlgren, G. (2007). Concepts and principles for tackling social inequities in health: levelling up, part 1. Copenhagen: WHO Regional Office for Europe. http://www.euro.who.int/document/e89383.pdf, accessed 6 July 2010. 33. Rapla County injuries profile, Rapla County, Estonia, 2010. 34. Principles and actions of Estonian Population Policy 2009-2013 (2012). http://www.monitoringris.org/documents/imp_nat/main_principles_of_population_polic y.pdf. 35. Statistics Estonia, http://pub.stat.ee/px-web.2001/Dialog/Saveshow.asp, updated 10 June 2013. 36. MHP Hands Consortium (2013). Mental Health Promotion: older people’s residential setting handbook. 37. World Health Organization (2002). Active ageing: a policy framework. Geneva: World Health Organization. 38. Dahlgren, G. & Whitehead, M. (1991). Policies and strategies to promote equity in health. Copenhagen: Institute for Future Studies.

REDUCTION OF HEALTH INEQUALITIES IN ROKISKIS

DISTRICT MUNICIPALITY

REDUCTION OF HEALTH INEQUALITIES IN ROKISKIS

DISTRICT MUNICIPALITY

An Action Plan

Authors: dr. Laura Narkauskaitė, Jolanta Valentienė

Institute of Hygiene, Vilnius, 2013

This publication arises from the project ACTION-OR-HEALTH which has received funding from European Union, in the framework of the Health Programme

3

Contents

Introduction ...... 4

I. The Development of the Action Plan ...... 6

1. Health inequalities in Rokiskis district municipality ...... 6

2. Framework of the Action Plan ...... 7

II. Content of the Action Plan ...... 7

Aim 1. Encourage public health and primary health care sectors collaboration and enhance public health specialists and family doctors' awareness of health inequalities in the region ...... 7

Aim 2. Reducing health inequalities in maintaining / supporting risk groups...... 9

Aim 3. Reduce health inequalities carrying out health strengthening and healthy lifestyles ...... 11

Aim 4. Improve population mental health...... 12

Aim 5. Ensure for all equal opportunities to natural resources...... 13

III. Conclusion ...... 15

IV. References:...... 16 4

Introduction

“Health disparity”, in the context of public health and social science, therefore has begun to take on the implication of injustice, but nonetheless may be distinguished from the general term “inequality”. A health disparity should be viewed as a chain of events signified by a difference in: (1) environment, (2) access to, utilization of, and quality of care, (3) health status, or (4) a particular health outcome that deserves scrutiny. Such a difference should be evaluated in terms of both inequality and inequity, since what is unequal is not necessarily inequitable [1].

Health inequities are avoidable inequalities in health between groups of people within countries and between countries. These inequities arise from inequalities within and between societies. Social and economic conditions and their effects on people’s lives determine their risk of illness and the actions taken to prevent them becoming ill or treat illness when it occurs [2].

1 figure. The main determinants of health [3].

The development of public health care services to prolong the lifetime without disease improves quality of life and reduces health inequalities between different population groups. If public health is developed by community level it would effectively add the primary health care system.

Social development of Lithuanian regions is highly variable and partly dependent on the economic growth and structure. The unequal rates of economic process, different demographic and social composition, all these increase the gap between villages and towns and cities, as well as between different regions of the country. In recent years, increased 5

disparities of income caused, increased unemployment and emigration, death rates, decreased fertility which is influenced health decline by of total population.

In national progress program 2014-2020 shall be established to implement the State Progress strategy “Lithuania progress strategy “Lithuania 2030” and create an innovative, modern and strong state, characterized by an intelligent society, knowledge economy and the smart management of the tune. On the basis of the priority objectives of the national program will be to develop an action plan which should satisfy with the 2014-2020 EU structural support resort approved European Parliament and the Council [10]. 6

I. The Development of the Action Plan

1. Health inequalities in Rokiskis district municipality

The main human factors affecting the prevalence of cardiovascular diseases in Lithuania and Rokiskis district municipality are the age, sex, marital status, location and lifestyle.

In Rokiskis district municipality live 34 235 people in January 1st in 2012 (15 923 males, 46,5%; 18 312 females, 53,5%).

Job loss is one of the biggest stressors which negative influenced health. One of the most vulnerable groups in Rokiskis district municipality is unemployed, which present a significant part of region population. The unemployment rate in 2012 was 11.7% (14.6% male, 10.6% female). The unemployment rate on 2013 March 1st was 14,2 % (15.3 % among men and 13 % women). The unemployment rate of 18-29 years persons was 6,7 %.Unemployed total of were 2888, women's - 1261 and men's- 1627, youth 18-29 years - 275 on March 1st 2013 in Rokiskis district municipality. In 2011 years food products support from EU got 8589 inhabitants, in 2012 years - 7491. In these numbers are included the social allowance recipients. The percentage of the total population at risk of living under 60% of the income-poverty line in 2011 is quite high, namely 20.0%

Department of statistics of Lithuania data shows average income for the Rokiskis district was 532.47 euros in 2012 III quarter.

The major health problem in Rokiskis district municipality as in all country is cardiovascular diseases. This problem is distributed unequally among age groups and by gender. There is no certain area where prevalence or mortality of cardiovascular diseases would be especially high – rates mostly depend on the age structure of population and social conditions. The High cardiovascular risk primary prevention programme is implemented with aim to decrease mortality from cardiovascular diseases in all country.

Prevalence of cardiovascular diseases in Rokiskis district municipality in 2011 was 25 798,0/100 000 pop. More accurate data about geographical distribution over selected region is unavailable. Considering the prevalence urban population (31 901,8/100 000 pop.) was affected more by cardiovascular diseases than rural population (20 509,0/100 000 pop.) in Rokiskis district municipality in 2011. Also females (31 533,7/100 000 pop.) were affected more than males (19 269,8/100 000 pop.).

Standardized mortality rates of cardiovascular diseases (I00-I99) in Rokiskis district municipality in 2011 was 519,3/100 000 pop. (739,1/100 000 pop. for males; 360,7/100 000 pop. for females).

Prevalence of cardiovascular diseases in Rokiskis district municipality in 2011 was 25 798/100 000 pop. (19 269,8/100 000 pop. for males; 31 533,7/100 000 pop. for females). Prevalence of hypertensive diseases was 20 642,2/100 000 pop. (14 534,4/100 000 pop. for males, 26 008,6/100 000 pop. for females). 7

The main cause of death and one of the most significant social, economic and health problems in Rokiskis district municipality is cardiovascular diseases.

2. Framework of the Action Plan

The action plan has been developed as part of the DG SANCO funded project entitled ‘Reducing health inequalities: Preparation for action plans and structural funds projects’ (ACTION-FOR-HEALTH) (2012-2014).

Planning method

The Action Plan for Rokiskis district municipality requires preparation and a process which can inform the plan. A situational analysis was carried out in order to gather evidence and information on the key issues for the health of Rokiskis district municipality population.

II. Content of the Action Plan

The main goal - reduction of health inequalities in Rokiskis district municipality using health promotion

Aim 1. Encourage public health and primary health care sectors collaboration and enhance public health specialists and family doctors' awareness of health inequalities in the region.

According to the WHO, now more than ever is necessary for cross-sectorial collaboration [4]. Leadership and innovation provides one hundred per cent chance and minimum health inequalities [5]. Collaboration between primary health care and public health sectors aren’t in Lithuania. In order to more efficient and higher quality health care to reduce health inequalities must be cooperation between these two sectors [6-7].

Objective 1.1 Increase public health and primary health care sectors awareness of health inequalities.

Activities:

1. Organize public health and primary health care sectors meetings, discussions, workshops on issues of health inequalities in the region. 2. Establish and maintain relationships between public health and primary health care professionals.

Indicators:

1. Number of different health communication activities (meetings, discussions, workshops). 8

Objective 1.2 Increase public health specialists and family doctors expertise on health inequalities reduce. 9

Activities:

1. Develop a training program for reduction of health inequalities. 2. Arrange training for public health and primary health care specialists on health inequalities issue.

Indicators:

1. Developed training programme. 2. Number of trainings and participants who participated in trainings

Objective 1.3. Strengthen public health and primary health care specialists collaboration through health promotion activities.

Activities:

1. Develop recommendations for a clear definition of public health and primary health care specialists function in order to avoid duplication of services. 2. Create public health and primary health care specialists collaboration model to purse the the State non-infectious disease prevention programs. 3. Organize common health promotion events.

Indicators:

1. Created public health and primary health care specialists collaboration model. 2. Number of common health promotion events

Aim 2. Reducing health inequalities in maintaining / supporting risk groups.

The main health problem is cardiovascular diseases in Rokiskis district municipality. This problem is distributed unequally among the municipalities of Lithuania, among different population age groups and by gender.

According to study of clinically oriented primary cardiovascular prevention in Lithuania (2003-2005) very low activities in this field were identified: both on the primary health care institution level as well as the lack of the specialized cardiovascular prevention units in the country conducting clinically oriented cardiovascular prevention. The lack of the cooperation between the primary health care practitioners and the specialists was observed. The Lithuanian High Cardiovascular Risk (LitHiR) primary prevention programme for the identification of patients at high-risk of cardiovascular disease and the implementation of methods of primary prevention reimbursed from the Statutory Health Insurance Fund was started in Lithuania since 2006 [8].

Prevalence of cardiovascular diseases was higher amongst the urban population and women than amongst rural and men in Rokiskis district municipality. The most affected age group were aged 64 years and over.

Main stream unequal availability of health care services distribution between urban and rural regions. Lack of a consistent health policy and its implementation. Distribution of health care professional contravene health care services. The lack of them in the rural area. 10

First of all it should be deal with the lack of physical activity and eating problems. Physical inactivity and unhealthy eating is a complex issue which entails not only cardiovascular diseases, but also other diseases.

Objective 2.1 Promote non-infectious diseases early diagnosis, increase awareness of the State noncommunicable disease prevention and early detection programs, and increase people's motivation to participate in it.

Activities:

1. Develop and produce information materials (e.g. flyers, brochures, posters about the State noncommunicable disease prevention and early diagnosis programs). 2. Organize open days, lectures for residents to learn more about the noncommunicable diseases (diabetes, cardiovascular diseases and malignant tumors).

Indicators:

1. Designed, developed and published material number. 2. Organized event number and number of participant.

Objective 2.2 Increase risk groups knowledge of damage of bad cholesterol in the blood.

Activities:

1. To organize seminar/lecture about damage of bad cholesterol in the blood to risk groups. 2. Arrange free cholesterol testing for risk groups in a public space and it is important to explain the possible damage of bad cholesterol in blood.

Indicators: number of events.

Objective 2.3 Encourage region’s risk groups physical activity organizing mass events.

Activities:

1. Organize Nordic walking lessons. 2. Organize afternoon exercise in nature.

Indicators:

1. Number of events. 2. Number of participants.

Objective 2.4 Encourage region‘s risk groups to follow healthy eating principles.

Activities:

1. Organize lectures/seminars about healthy eating principles, the basic rules. 2. Arrange healthy products fair.

Indicators:

1. Number of lectures/seminars, number of participants. 2. Organized fair. 11

Aim 3. Reduce health inequalities carrying out health strengthening and healthy lifestyles.

Lifestyle - whole of habits and mores, which are affected, changed, promoted of process of socialization throughout life. Lifestyle consists of diet, physical activity, alcohol and tobacco consumption and other habits. All of them interact with each other, strengthening or harming health.

According to Lalonde the biggest influence on health has lifestyle and behaviour (50 percent). Unhealthy lifestyle, gore example smoking, alcohol consumption, poor diet, lack of physical activity, adversely affect human health, increased risk of chronic diseases. In order to reduce the population health inequalities must be promoted health strengthening [9].

Objective 3.1 Encourage people to follow a healthy eating principles.

Activities:

1. Develop events about healthy diet promoting (workshops, lessons) 2. Provide knowledge and skills of healthy diet. 3. Provide knowledge of salt damage and salt rational usage.

Indicators:

1. Health literacy about healthy diet, salt damage before and after events. 2. Number of organized events.

Objective 3.2 Promote physical activity.

Activities:

1. Provide knowledge and skills of daily physical activity benefit. 2. Organize physical activity events.

Indicators:

1. Health literacy about benefit of physical activity before and after events. 2. Number of organized events

Objective 3.3 Encourage the development of a society without alcohol and tobacco use.

Activities:

1. Provide knowledge and skills of harmful effects of tobacco and alcohol consumption. 2. Organize events against consumption of tobacco and alcohol. 3. Raise awareness, especially among young people, that they could socialize without consumption of alcohol and tobacco.

Indicators:

1. Health literacy about benefit of physical activity before and after events. 2. Number of organized events. 12

Objective 3.4 Enhance region population health literacy on health prevention.

Activities:

1. Provide information about benefit of early diagnostic of non-infectious diseases. 2. Provide knowledge of preventive health programs. 3. Provide clearly and understandable prepared material non-infection diseases (brochures, etc.).

Indicators:

1. Increased health literacy. 2. Number of prepared material

Aim 4. Improve population mental health.

Lithuania is between countries which are characterized by extremely poor public mental health indicators: high rate of suicides, number of murders and violent crimes (committed in the juveniles), alcohol consumption and mortality associated with alcohol use. Children and adolescents increasingly use alcohol and drugs, are spreading a new addiction and behavioural disorders. Surveys show that Lithuanian children - unhappiest in Europe, including the high prevalence of bullying. As mental health very dependent on the first year of life, promotion of children and adolescent mental health is an investment in the future. Teaching parenting skills can improve a child's development.

Holistic training approach can improve social skills and capabilities to regain physical and spiritual strength, reduce bullying, anxiety and depressive symptoms. It is also very important to work actively for older people’s mental health strengthening, develop and implement promotion of mental health at the workplace. Mental and behavioural disorders are becoming one of the major health problems.

Objective 4.1 To improve parenting skills, encourage nurse visits to prospective and new parents' at home.

Activities:

1. To organize courses-trainings for parents. 2. Create nurses, who attend prospective and new parents at home, incentive mechanism.

Indicators:

1. Number of courses-trainings. 2. Created incentive mechanism for nurses.

Objective 4.2 To form a sympathetic school environment and promote the norms of acceptable behaviour in it.

Activity: 13

1. To organize lectures package for parents and teachers about mental health and its prevention.

Indicators:

1. The number of lectures and 2. The number of participants.

Objective 4.1 Strengthening the elderly social support networks and encouraging participation in community programs.

Activities:

1. To organise discussions with aging issues dealing NGOs, and civil organizations to promote older people to speak about the values of health promotion and healthy aging. 2. To organise psychotherapy sessions for the elderly people.

Indicators:

1. The number of organized discussions and psychotherapy sessions.

Aim 5. Ensure for all equal opportunities to natural resources.

A clean and safe environment is one of the most important determinants of human health. Therefore, achieving this objective is to be solved essential people's physical and mental health negative influenced environmental problems. It must also take into account other harmful for people's health and the environment risk factors.

About 660 000 of the population (most of them - live in rural areas) still use groundwater from wells, which are often contaminated and does not meet drinking water requirements.

It is very important to change public behavior in regard to natural environment and natural resources, to educate self-awareness of the population, to create the conditions for the formation of the appropriate lifestyle, which help to conserve natural resources.

Objective 5.1 Promote to environmental friendly society.

Activities:

1. To arrange politicians / community meetings / discussions on environmental issues. 2. To organize a campaign for encourage people to domestic using of environmentally friendly implements. 3. To develop social advertisements, articles in local media about the harmful effects of the environment on health.

Indicators:

1. The number of meetings and discussions. 2. The number of campaigns/programs. 14

3. The number of social advertisements and prepared articles.

Objective 5.2 Keep the environment clean and ensure that it is conducive to human health.

Activities: 1. To organise the environment cleaning days (garbage collection day in forests, etc.) 2. To inform residents about environmental pollution and the potential harm to health.

Indicators: 1. The number of organized events. 2. The number of prepared information messages. 15

III. Conclusion

This action plan promotes a range of activities and goals which all aim to improve the health and wellbeing of Rokiskis district municipality population. The action plan adopts a health promotion approach to reducing health inequalities which result in lowered life expectancy and increased morbidity, which thus impacts on quality of life and economic activity. This approach has been taken in addressing the risk factors for chronic disease, in particular the biggest killer for Rokiskis district municipality, CVD. 16

IV. References:

1. Carter-Pokras, Baquet C. What is a „health disparity“? Public Health reports, September-October 2002, vol. 17, p. 426-434

2. WHO, http://www.who.int/social_determinants/thecommission/finalreport/key_concepts/en/

3.Whitehead M., Dahlgren C., in “What can be done about inequities and health?” The Lancet, 338, 8774, 26 Oct 1991, 1059-1063.

4. Martin-Misener R, Valaitis R, Wong ST, Macdonald M, Meagher-Stewart D, Kaczorowski J et al. A scoping literature review of collaboration between primary care and public health. Prim Health Care Res Dev 2012 Feb 21;1-20.

5.Cornell S. Public health and primary care collaboration – a case study. J Public Health. 1999;21:199-204

6. Gurevičius R, Valentienė J, Kutkaitė S. The family doctors attitude on collaboration with public health sector, Visuomenės Sveikata (Public Health). 2012; 2(57): 25-35.

7. Gurevičius R, Kutkaitė S, Valentienė J. The public health specialist’s attitude to collaboration with primary health care sector.Visuomenės sveikata (Public Health). 2012; 2(57): 36-44.

8. Laucevicius et al. Lithuanian High Cardiovascular Risk (LitHiR) primary prevention programme – rationale and design. Seminars in Cardiovascular Medicine.2012; 18:3.

9. Javtokas Z. Summary of health strengthening. Vilnius. 2009:6-8

10. About 2014–2020 National progress program approval. Zin. 2012-12-11, Nr. 144-7430.