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The aim of this study is to evaluate the use of EriscssonMobileHealth (EMH) system for rural, distant, older, chronically ill patient monitoring in SisakMoslavina County in the region of ASSC. The aim is to evaluate quality, patient satisfaction, health care provider satisfaction with EMH system as well as possible obstacles and points for possible cost savings.

U ruralnim područjima živi 47, 6 % ukupnog stanovništva Hrvatske. Procjenjuje se da ima 1.485.647 članova poljoprivrednih kućanstava u koje ubrajamo pored radno aktivnih muškaraca i žena, djecu te starije i invalidne osobe. Na članove poljoprivrednih kućanstava ne primjenjuju se mjere i pravila sigurnosti za osiguranje njihove zaštite zdravlja, ni nadzor nad njihovom primjenom temeljem postojećih zakona jer nije zasnovan radni odnos. Broj ozljeda i profesionalnih bolesti se ne može utvrditi jer ne postoji obveza prijavljivanja. Cilj rada je utvrditi postojeće stanje zaštite zdravlja i sigurnosti članova poljoprivrednih kućanstava na području Požeško-slavonske županije, opasnosti i štetnosti koje se javljaju prilikom obavljanja poljoprivrednih poslova zbog uređivanja i donošenja specifičnih mjera i minimalnih uvjeta za zaštitu zdravlja i sigurnost kojima se mogu otkloniti i smanjiti ozljede te profesionalne bolesti. Upitnikom su prikupljeni podaci o članovima poljoprivrednih kućanstava, najčešćim ozljedama, profesionalnim bolestima, nošenju zaštitne opreme te uporabi pesticida. Istraživanje je provedeno na području Požeško- slavonske županije u razdoblju od veljače do travnja 2011. godine, a obuhvatilo je 164 ispitanika, od toga 104 žene (dobi od 18 do 83) i 60 muškaraca (od 18 do 93 godina). Ozljede prilikom obavljanja poljoprivrednih poslova zadobilo je 32 (19, 5 %) ispitanika. Utvrđene ozljede klasificirane su kao lakše i teže, a otrovanje pesticidima zabilježeno je u 6 ispitanika (3, 6 %). Zaštitnu opremu, uglavnom rukavice, nose njih 84 (51, 2 %). Od ukupno 91 djeteta, njih 58 (63, 7 %) obavlja poljoprivredne poslove u kućanstvima. Prikazani podaci o stanju zaštite zdravlja i sigurnosti upućuju na potrebu proširivanja istraživanja ruralnih područja RH te pristupanja uređivanju i donošenju mjera i pravila kojima bi se svim članovima poljoprivrednih kućanstava osigurali bolji uvjeti rada i zaštite zdravlja.

The aims of this paper are to investigate the change in prevalence of psychological distress (PD), to investigate the cumulative incidence of the psychological distress and to indicate are there any differences between genders and various age groups in Croatian adult population. Psychological distress status was measured by the five-item Mental Health Scale (MHI-5) of the Short Form questionnaire (SF-36).Psychological distress was present in 28.5% (95% CI 25.7%-31.2%) of men and 32.1% (95% CI 30.1%-34.0%) of women in 2003. In 2008 PD was present in 33.0% (95% CI 30.1%- 35.9%) of men and 34.1% (95% CI 32.1% - 36.0%) of women. The highest incidence of PD, both for men and women, was in the oldest age group (>65 years). Results of this study demonstrating the fact that every third adult men and woman in Croatia are in psychological distress, the fact that there is an increase in PD prevalence for men and women should be taken into account in the future mental health policy planning.

Nutritional habits between urban and rural population differ as much as life style and socioeconomic standards of these populations. In Croatia, rural populations are mostly live stock producers. Their nutrition frequently depends on their own production, which includes high quantity of cured meat products, eggs and dairy products. Data were obtained from longitudinal the Croatian Adult health Survey and pilot cross-sectional survey in three villages in Sisacko-moslavacka county. Our findings show that there is no great difference between urban and rural population regarding salt intake. The difference is in the type of food and food preparation, as well as life style. We propose combination of more culturally and socially sensitive questionnaires along with analytical methods that include biological matrix, such as 24-hour urine collection.

The aim of this article was to identify parameters that determinate PCS and MCS values, and analyze 5-year changes in those values according to the age, sex and geographic region. Cohort of 3229 participants was obtained from the CAHS 2003-2008. Results revealed no statistically significant differences between same age group, sex, and different region regarding PCS and MCS. When chronic conditions were in the model difference was present, PCS being more influenced by all conditions but bronchial asthma. The strongest influence comes from musculoskeletal conditions; followed by weak heart. Values for PSC and MSC decreased in 2008 compared with 2003, but only in few cases decrease was statistically significant. Values of PCS and MCS are higher in men in all regions, but they show higher variability than woman. Our results support the findings that data obtained through SF-36 could be the useful for public health interventions regarding chronic diseases.

This study examined individual and combined influence of smoking, physical inactivity, alcohol drinking, and unhealthy diet on total mortality. Relationship between individual and combined poor health behaviours and total mortality were examined using Cox proportional hazards regression. Out of 7490 individuals included in the study, during 5 years follow up 808 died. Adjusted hazard ratios (HRs), and 95% confidence intervals (95% CIs) for men with health behaviour scores 1, 2, 3, and 4 compared with those with score 0 were 1.67 (1.24-2.24), 2.28 (1.64-3.18), 2.24 (1.32-3.84), and 2.86 (0.77-11.70), respectively (p value for trend < 0.001). Adjusted HRs (95% CIs) for women with health behaviour scores 1, 2, and 3 compared with those with score 0 were 1.17 (0.97-1.42), 1.37 (1.02-1.86), and 1.20 (0.37-3.61), respectively (p value for trend = 0.04). A unit of the health behaviour score increased mortality risk equivalent to being 5.9 and 2.9 years older, for man and woman respectively.

The aims of this paper are to investigate the change in prevalence of psychological distress (PD), to investigate the cumulative incidence of the psychological distress and to indicate are there any differences between genders and various age groups in Croatian adult population. Psychological distress status was measured by the five-item Mental Health Scale (MHI-5) of the Short Form questionnaire (SF-36). Psychological distress was present in 28.5% (95% CI 25.7%-31.2%) of men and 32.1% (95% CI 30.1%-34.0%) of women in 2003. In 2008 PD was present in 33.0% (95% CI 30.1%-35.9%) of men and 34.1% (95% CI 32.1%-36.0%) of women. The highest incidence of PD, both for men and women, was in the oldest age group (> 65 years). Results of this study demonstrating the fact that every third adult men and woman in Croatia are in psychological distress, the fact that there is an increase in PD prevalence for men and women should be taken into account in the future mental health policy planning.

The aim of this study is to identify factors that influence the success of the implementation of the primary and secondary prevention programs in Croatia by the visiting/community services. Two main sources of information were used: reports about regular visiting nurse services in Croatia and research about visiting nurse participation in the Croatian Adult Health Cohort Study (CroHort) 2008. Out of the total number 9,070 respondents who participated in CAHS 2003 survey, during CroHort 2008 program 3,229 (35.6%) participants were re-interviewed. The qualitative analysis was done with a sample of 34 visiting nurses, which participated in the CroHort 2008. Results show that there are three key problems which limit preventive programs: inability of the health care system to recognize the importance of the primary prevention; visiting nurses' lack capacity to implement prevention and populations' lack of motivation and education.

Croatia has a long tradition of non-communicable disease prevention, but also obstacles to the implementation of preventive programs related to the general attenuation of public health and primary health care sector. The aim of this study was to determine trends in behavioral and biomedical risk factors and evaluate primary non-communicable disease and cardiovascular prevention. Physical inactivity was a leading risk factor with increasing trend and prevalence of 33.9% and 38.9% in men and women in 2008. In 2008, obesity was present in 26.1% and 34.1%, and hypertension in 65.8% and 59.7% of men and women. During the follow-up only smoking and alcohol consumption in men decreased significantly, while alcohol consumption and obesity in women, and hypertension in both sexes significantly increased. In the present situation, with the existing trends and environment it will not be possible to stop negative trends. Revitalization of public health activities and primary health care is essential.

Drafting the Strategy was based on a partnership approach, and was organised in such a manner to include as wide a circle of interested expert and general public as possible. The process implementers were the Minister of health as the Editor in Chief and the Editorial Board.

Eliminating four behavioral risk factors (tobacco use, physical inactivity, unhealthy diet and harmful use of alcohol) could contribute to a decrease of up to 80% in burden of non-communicable diseases, including cardiovascular diseases. Primary healthcare providers have a unique position within the healthcare system, which allows them to actively contribute to the prevention of cardiovascular behavioral risk factors (CVBRFs) by providing individual counseling. The aim of this article is to show the change in frequency and the effects of counseling on CVBRFs by healthcare providers between two periods: up until 2003 and between 2003 and 2008. Results, obtained within the CroHort study, show a low frequency and undesired effects of counseling within the healthcare system in both studied periods. This points to a lack of consistency with which the healthcare system tackles prevention of behavioral risk factors for cardiovascular diseases.

Rural areas, where 47.6% of the Croatian population lives are not generally the focus of research ; yet there are chal-lenges which affect the rural population that often go unreported. These communities often exhibit disadvantages inmany areas of health. The aim of this study is to examine the specific health needs and related determinants of rural pop-ulations influenced by transition that were affected by the consequences of war. The focus of the research is rural lifestyle, behaviour and cardiovascular risk factors in three villages of Sisa~ko-moslava~ka County. Results show that partici-pants generally understand that their own lifestyles influence their health, but they often neglect to change their behav-iour to improve their health. This can be explained through complex socio-economic conditions and traditional values oftheir heritage. These results suggest a need for further research on health status, attitude, and behaviour of Croatia’s ru-ral population. Specific public health intervention and services for rural populations must be promoted.

Rural areas, where 47.6% of the Croatian population lives are not generally the focus of research; yet there are challenges which affect the rural population that often go unreported. These communities often exhibit disadvantages in many areas of health. The aim of this study is to examine the specific health needs and related determinants of rural populations influenced by transition that were affected by the consequences of war. The focus of the research is rural lifestyle, behaviour and cardiovascular risk factors in three villages of Sisacko-moslavacka County. Results show that participants generally understand that their own lifestyles influence their health, but they often neglect to change their behaviour to improve their health. This can be explained through complex socio-economic conditions and traditional values of their heritage. These results suggest a need for further research on health status, attitude, and behaviour of Croatia's rural population. Specific public health intervention and services for rural populations must be promoted.

Razvojem specifičnih sadržaja o ruralnom zdravlju u programu obrazovanja budućih liječnika moguće je unaprijediti kvalitetu skrbi za zdravlje stanovnika ruralnog područja te pridonijeti lakšem odlučivanju za rad u ruralnoj zajednici.

Pharmaceuticals have important role in curing and preventing diseases but if improperly disposed in environment they might have adverse effect on various ecosystems. Although pharmacovigilance is well defined and organized in most of the countries, potential harmful effect of the pharmaceuticals on the environment lately has been in the focus of scientific interest. As a consequence, European directives on pharmaceuticals request environmental risk assessment prior to the marketing. Often neglected problem is disposal of unused or unwanted pharmaceuticals from the households. Stronger education of both primary health care and patients is needed, but advices and recommendations must be acceptable and applicable for each specific group of patients and health care users.

Aim To compare the results of a series of public opinion surveys on experiences with the health care sector in Croatia conducted in the time of elections and to analyze whether political party affiliation had any influence on issues of priority ranking. Methods The surveys were conducted during 2005, 2007, and 2009. They were administered through a Computer Assisted Telephone Interviewing method to representative samples of Croatian population and were statistically weighted according to sex, age, level of education, and political party affiliation. The random sampling of the person within the household was done using the table of random numbers. Results Health and health care system was the most important issue (58%) during the 2007 parliamentary election and the second most important issue during the 2005 and 2009 elections (46% and 28%). In the 2007 election, health care was viewed as most important by women, respondents with lower education levels, and respondents with lower income. In 2005, the most important health care issues were corruption and lack of funding (45% and 43%, respectively), in 2007 poor organization and lack of funding (43% and 42%, respectively), and in 2009 lack of funding and corruption (51% and 45%, respectively). Health and health care system were consistently among the top two issues in all elections from 2005 to 2009. The top three most important health care sector issues were corruption, poor organization, and lack of funding. This indicates that political parties should include solutions to these issues in their health care policymaking.

Rad opisuje nove zakonske obavaze i mogućnosti koje su dobile županije nakon reforme sustava na kraju 200

Rad prikazuje najvažnije sastavnice i ishode u projektu "Rukovođenje i upravljanje za zdravlje".

Health and human rights – an essence in health policy development and planning

Cilj ovog rada je utvrditi opseg i sadržaj recenziranih znanstvenih publikacija koje donose rezultate istraživanja zdravstvenog sustava u Republici Hrvatskoj u razdoblju od 1990. do 2010. godine. Osnovne odrednice istraživanja usklađene su s metodologijom projektom Health Services Research into European Policy and Practice (HSREPP) koji se provodi s ciljem identifikacije, evaluacije i unaprjeđenja doprinosa istraživanja sustava zdravstva razvoju zdravstvene politike u Europi. Istraživanje u ovom radu obuhvaćalo je znanstvene publikacije indeksirane u bazi PubMed te magisterije i doktorske disertacije objavljenje na medicinskim fakultetima Sveučilišta u Zagrebu, Osijeku, Splitu i Rijeci. Navedenim metodama nađeno je ukupno 536 publikacija indeksiranih u PubMed-u i 22 doktorske disertacije te 70 magisterija koji udovoljavaju nekom od kriterija istraživanja. Za daljnju analizu zasebno su razmatrani magisteriji i doktorske disertacije, te znanstvene publikacije indeksirane na PubMed-u. Baza znanstvenih publikacija indeksiranih u PubMed-u sužena je uz pomoć ključnih riječi podijeljenih u 4 skupine prema uputama HSREPP. Zadane kriterije, nakon analize sažetaka, zadovoljilo je 158 radova. Nakon analize sadržaja sažetaka magisterija i doktorskih disertacija izdvojeno je 6 disertacija i 35 magisterija koji udovoljavaju kriterijima istraživanja. U svim objavljenim publikacijama nije moguće pronaći sustavnost istraživanja zdravstvenog sustava, međutim prepoznat je trend porasta broja radova koji se bave istraživanjima sustava zdravstva u Republici Hrvatskoj tijekom proteklih 20 godina.

This article explores who among the doctors, other health care workers, family or somebody else most frequently advised women about their lifestyle changes related to cardiovascular health (including smoking, nutritional habits and physical activity). We analyzed who advised the most, in relation to the parameters important in the etiology of cardiovascular diseases: age, systolic blood pressure and body mass index (BMI). Sample was a part of comprehensive Croatian Adult Health Survey, comprised of women from Primorje-Goran, Istra and Lika-Senj Counties. Results indicated low frequency of advising on lifestyle changes in primary health care in all three counties, with most advice from general practitioners on nutritional habits. Family and other health care workers advised about smoking and nutrition and had strong influence in the youngest age groups. The GPs failure to counsel younger population and disease-free women could be regarded as the missed opportunity for avoidance of preventable risk factors that are associated with cardiovascular diseases. Other subjects in the health care process, as well as the family and media could fill the gaps between the patients and health care system messages. In order to create and develop such heterogeneous network approaches to training various programs and activities have to take into account all specific gender and regional characteristics.

The objective of this study was to investigate regional gradient of a synthetic cardiovascular burden (CVRB) in Croatia. Analysis was based on a multistage stratified sample representative of general adult population in six regions of Croatia (Croatian Adult Health Survey). Synthetic CVRB was defined by incidents (heart attack, stroke), blood pressure, overweight/obesity (BMI, waist circumference), and risky behaviours (smoking, physical inactivity, high alcohol consumption, inadequate nutrition). Total CVRB in Croatia was 44.7% for men and 50.3% for women. Combining both high and moderate CVRB, men were found to be under more risk than women (72.8% vs. 61.7%, respectively). The result showed an east-north-west gradient in continental Croatia, with high CVRB in Eastern (40.2%) and Central region (44.3%), City of Zagreb (45.7%) and Northern region (53.1%). Mountainous region had the lowest prevalence of respondents with high CVRB (39.2%). Coastal region with the prevalence of 46.3% of high CVRB was nearly the same as the City of Zagreb. The results suggest the presence of substantial regional differences in the cardiovascular risk burden.

Psychological distress (PD) is being increasingly recognized as a risk factor for cardiovascular diseases (CVD). Our aim was to recognize an association of PD and CVD in the Croatian adult population. We also explored association's strength obtainable as relative risk of PD on three levels; cardiovascular risk behaviors, conditions and diseases. This study used Croatian Adult Health Survey 2003 (CAHS 2003) data (N = 9,070). PD status was measured by the five-item Mental Health Scale of the Short Form questionnaire (SF-36) hence one distinguished subgroup consisted of population with PD and other without PD. Prevalence of cardiovascular risk behaviors, cardiovascular risk conditions and self-reported cardiovascular diseases within each subgroup were calculated using bootstrap method. Women had higher prevalence of PD in general population. Among distressed population women had higher prevalence of body mass index over 30, metabolic syndrome and angina pectoris. Men with PD had higher prevalence of high blood pressure and myocardial infarction with contradictory lower prevalence of angina pectoris then myocardial infarction. Physical inactivity was proven to be a risk behavior determinant with most impact on mental health. All CVD are consistently associated with higher prevalence and relative risks for PD both in men and women.

Cardiovascular diseases are the leading cause of death in Croatia, with significant regional differences. Despite high mortality rates, high prevalence of various cardiovascular risk factors and well organized public health network, comprehensive system for cardiovascular disease monitoring and interventions does not exist. In this study we analyzed legislation framework and responsibilities of stakeholders relevant for cardiovascular disease surveillance and prevention. According to the international experiences we analyzed characteristics of cardiovascular disease prevention in Croatia and causes of the problems appeared in the preventive programs in Croatia. Analysis showed that primary problem is not inefficiency, but the existence of barriers in preventive activities definition, responsibilities distribution and task implementation. Main cause for such situation is incompatibility of the existing practices in clinical medicine and public health with recommendations from other countries. For the successful prevention of cardiovascular disease in Croatia at least three changes need to be made--define new terms and contents of prevention, define new responsibilities distribution and provide equity in health as basic criterion for successful preventive programs.

The poster presents historical development, aims, contents, working format and academic recognition of the Pan-european module in Public Health and Health Promotion at master's level, reviewed and accredited in the EU countries. The presentation is focused on international experiences, including benefits and obstacles, in development and implementation of the European postgraduate training module.

Na zdravstveno stanje stanovništva utječe mnogo faktora koji se nalaze izvan domene sustava zdravstva, i upravo ti, vanjski, makrosocijalni faktori imaju značajno veći upliv na zdravlje nego sam sustav zdravstva. Tjelesna (in) aktivnost populacije koja između ostalog ovisi i o fizikalnoj strukturi zajednice (određena je dakle i urbanim dizajnom) upravo je takav primjer.

Lessons learned from the Pan-european postgraduate module on Strategies for Health in Europe

Cardiovascular diseases are the leading causes of death in Croatia, and significant differences in cardiovascular risks between regions in Croatia are found. Despite high mortality rates, high cardiovascular risks and organized public health network, comprehensive system for cardiovascular disease monitoring and preventive intervention does not exist. In this research we analyzed legislation framework and responsibilities of stakeholders relevant for prevention. According to international experiences we analyzed specificity of prevention in Croatia and root causes of the problems appeared in the preventive programs in Croatia. Analysis showed that primary problem is not inefficiency, but there are limits in preventive activities definition, responsibilities distribution and task implementation. Main cause for such situation is incompatibility with current trends in medicine and public health in the world. For the successful prevention of cardiovascular disease in Croatia it is necessary to: define new terms and contents of prevention ; new responsibilities distribution ; equity in health as basic criteria for successful preventive programs.

For few decades the value of a community, empowerment, community-based care, population-based needs assessment was discussed, but not so much of the evidence of this commitment was found in the public health interventions. Potential contributions from the social sciences tend to be overwhelmed by the appeal of the biomedical and behavioural sciences. Three concepts and notions notion of community in public health were dominated: First, community- a lots and lots of people or community as the population; second could be described as community as “giant reinforcement schedule” or community as setting, with aspects of that setting being used as levers to support and maintain individual behaviour change. The third, newest, approach sees community as “eco-system with capacity to work towards solutions to its own community identified problems” or to see it as a social system. This notion of community focused on strengths instead merely on deficits. Two groups of research activities (systematic study of communities and inequality research) supported with evidence from many applied researches done through development of European Healthy Cities Project contributed to this shift in perception of the value of the community. In this course we elaborate inequity research, “System” study of communities and present case study: „Community applied research in Croatia- “triggered” by Healthy Cities“., Programmes for Training on Research in Public Health for South Eastern Europe, Programmes for Training on Research in Public Health for South Eastern Europe. Vol. 5: Management in Health Care Practice: A Handbook for Teachers, Researchers and Health Professionals

The World Health Organization (WHO), Office for Europe initiated the Healthy Cities Project in 1986 as a long-term international development project that seeks to put health on the agenda of the local, city level political decision-makers. Healthy City is a process; it is about the change, innovation and formal system reorientation. It is not award recognizing past merits; it is a tool helping to address our cities present and future societal and developmental challenges. The Healthy City Project challenges city administrations to take seriously the process of developing health–enhancing public policies and create physical and social environments that support health but, as well, strengthen citizens’ participation., Programmes for Training on Research in Public Health for South Eastern Europe, Programmes for Training on Research in Public Health for South Eastern Europe. Vol. 5: Management in Health Care Practice: A Handbook for Teachers, Researchers and Health Professionals

The use of qualitative and consensus building techniques enables better understanding and improved collaboration among “policy stakeholders” (politicians, administration, public health professionals and community) involved in needs assessment and health policy formulation. War, migration, and transition in South East Europe hardened most of public health activities but especially made the process of health needs assessment and formulation of health policy very difficult. Qualitative analytical methods have been introduced in Croatia over the last 10 years. Nine Croatian cities and 15 Croatian counties created City/County Health Profiles and City/County Health Plans by using qualitative methods. The greatest gain from introducing the qualitative analytical approach is wider participation in planning and managing of the resources for health at all levels, from community and regional to national level. Qualitative analytical approach was conducted through an intense and prolonged contact with a field, and real community life, enabling gaining of a 'holistic' overview of the local community., Programmes for Training on Research in Public Health for South Eastern Europe, Programmes for Training on Research in Public Health for South Eastern Europe. Vol. 5: Management in Health Care Practice: A Handbook for Teachers, Researchers and Health Professionals

U okviru 15. Motovunske ljetne {;kole unapre|enja zdravlja, u Grožnjanu, Motovunu i Labinu održano je ukupno osam radionica i te~ajeva. Posebnu pozornost struke, političara i medija pobudila su dva tečaja: „Mediji i zdravlje: kakvu reformu zdravstva želimo?“ i „Zdravstveni sustav – ... kad doktori nisu samo liječnici?!?“

The theory and practice of health planning and decision-making are marked by two different models: the centralized - one size fits all - model (delivered through state administration) and the decentralized model. In the 1990s, decision making in Croatia was markedly centralized. Currently, as a result, provision of health and social care are not adequately tailored to local needs and preventive and health promotion programs are largely underprovided. The significant rise of health care expenditures has not resulted in adequate improvement of the health of the population. Counties public health capacity building program (Healthy Counties) started in 2002 as a joint project of the Ministry of Health, Ministry of Labour and Social Welfare, Counties, and Andrija Štampar School of Public Health. Its aim was to support regional and local government bodies during the process of decentralisation of health and social welfare systems. Given the change at the head of the Ministry of Health and Social Welfare, and halt in decentralisation process, the project has continued within the framework of the Croatian Healthy Cities Network since 2004. From 2002 to 2007, 18 (out of 20) Counties and the City of Zagreb (about 200 participants) were included in the first (educational) phase of the program. From 20 to 25 February 2006, a series of county evaluation workshops were held and results (success and failures in project implementation) discussed with the counties in late 2006. As a result of it in 2007, through a series of meetings, goals and content of the second (implementation) phase of the Program were agreed on. In 2008 the 2nd round of education modules has started, and simultaneously, training support is assured for the counties that have not yet finished their Health Plans (i.e. complete the first phase of the programme). As a results of the Program (2010) we expect: a) increased public health and managerial capacity of local and regional administration, b) improved cooperation between local key stake holders: political structures (county and city governments and assemblies), executive structures (departments), technical structures (institutes of public health, health and social welfare institutions) and the community (NGOs, charities, interest groups etc.), c) competent professional public health, d) active employment of participative methods in health care needs assessment, e) more efficient health care interventions and f) more efficient systems of health and social care provision.

funding health care

Issue: Decentralisation appears in all transition countries as an important element of health care reforms. Croatia has a broad range of experiences with decentralization dating from socialism, but also during the last fifteen years of transition. Description: We analysed decentralization processes and models performed in Croatia. Furthermore, we analysed general and specific settings for the decentralization. Lessons: During the last fifteen years Croatia experienced huge demographic changes. Together with some general crisis, health care system was faced with specific financial and organizational crises relevant for the decentralization. Additional challenges for the decentralization were professional and management crisis in health care. Although the Government implemented much effort to decentralize the system, it is still highly controlled and regulated by central administration. Among many arguments for such situation such as inappropriate management capability, financial crisis, etc. we also found such as quality assurance, higher efficiency and equity issues. Conclusions: The decentralisation in health care has to be planned to suit the needs of regions and population (bottom-up), and not to follow the uniform model devised by the central government. The processes of decentralisation can have negative effects on the quality of health care, increase prices and emphasise inequity in health. Poorly managed decentralisation can slow down development and block changes.

The introduction of DRGs in Croatia

Iako Hrvatska s pravom ističe svoju slavnu prošlost u javnozdravstvenom djelovanju, podaci dobiveni Hrvatskom zdravstvenom anketom 2003 te epidemiološka izvješća pokazuju da stanje kardiovaskularnih rizika i ishoda u populaciji nije pod kontrolom. Standardizirana incidencija koronarne bolesti srca se kreće u rasponu od 250-550 na 100 tisuća. CVI nakon MI 22.6 (95%CI 16.3-30.6) na 1000 osoba mjeseci Prema HZA 2003 rizici u Hrvatskoj: - pušenje: M: 39.1. Ž: 24.8 - alkohol: M:10.0, Ž: - - prehrana: M: 23.3, Ž: 11.6 - fizička neaktivnost: M: 27.4, Ž: 22.2 - opseg struka: M(>102cm): 34.8, Ž(>88cm): 44.9 - povišeni tlak (>140/90 mm Hg): M: 26.4, Ž: 17.2 Bar jedan ponašajni rizik: M: 69.7, Ž:49.3 Cirkulacijske bolesti: Hrv. Slo. Europa 77 52 120 Ishemična bolest srca: Hrv. Slo. Europa 35 20 58 Cerebrovaskularne bolesti: Hrv. Slo. Europa 21 13 28 Činjenica je da populacija demografski stari čime se povećava vjerojatnost obolijevanja od kardiovaskularnih bolesti. S druge strane rezultati provedenih istraživanja pokazuju izraženu opterećenost populacije rizicima za nastanak kardiovaskularnim bolesti. Među rizicima posebno valja istaknuti visoku prisutnost rizičnih ponašanja koji često negiraju prisute stereotipe o višim rizicima samo u s nekim regijama. Zato je problem kardiovaskularnih bolesti nužno razmatrati kao nacionalni prioritet, ne samo kao problem zdravstvenog sustava već kao problem cijelog društva. Usprkos dokazanim rizičnim ponašanjima i visokom mortalitetu u cijeloj populaciji sustav preventive nije adekvatno funkcionalan. Promatran u okvirima strateškog planiranja, tzv. SWOT analize (Strengths, Weaknesses, Opportunities, and Threats ), sustav preventive u Hrvatskoj ima izražene slabosti u redovnom funkcioniranju i manjak potrebne snage za sustavan odgovor na nove izazove. Iako rezultati i svi pokazatelji o stanju zdravlja govore u prilog nužnosti intervencija, prilike za reaktiviranje ostaju neiskorištene. Pri tome rastu prijetnje da se pojedine komponente izdvajaju u samostalne i kratkoročne programe koji dugoročno ne osiguravaju održivost i željeni učinak. Stoga je podatke Hrvatske zdravstvene ankete 2003 i 2008 potrebno puno intenzivnije koristiti u pripremi specifičnih, ali povezanih komponenti koje moraju sačinjavati sustavan nacionalni program prevencije nastanka kardiovaskularnih bolesti. Literatura [1] Baklaić Ž, Rodin U, Kuzman M (ur). Hrvatski zdravstveno-statistički ljetopis za 2005. godinu. Zagre: HZJZ 2006. [2] Witt BJ, Brown RD, Jr., Jacobsen S, Weston SA, Yawn BP, Roger VL. A community based study of stroke incidence after miocardial infarction. Annals of Internal Medicine 2005 ; 143(11): 785-792. [3] Lowther M, Mordue A. Primary prevention of cardiovascular disease in Scotland. Edinburgh-Glasgow: NHS Health Scotland 2005, p.11. [4] Hrvatska zdravstvena anketa 2003. Projekt Ministarstva zdravstva RH.

Kardiovaskularne bolesti (KVB) vodeći su uzrok pobola i pomora u Hrvatskoj. Poznato je da danas u Hrvatskoj 52% ljudi umire od KVB. U podlozi KVB, baš kao i čitavog spektra drugih kroničnih nezaraznih bolesti, gotovo uvijek leže loše životne navike. Loše životne navike poput pušenja, nepravilne prehrane, tjelesne neaktivnosti ili prekomjerne konzumacije alkohola dovode do prekomjerne tjelesne težine i debljine, a one leže u podlozi povišenog krvnog tlaka i povišene razine masnoća u krvi. Debljina, povišen tlak i masnoće posljedica su pogrešno naučenog ponašanja, prekomjerne konzumacije nezdrave hrane i nedovoljnog kretanja. S druge strane, u podlozi su razvoja bolesti današnjice, KVB, nekih sijela raka, te dijabetesa tipa 2. Prema podacima HZA2003, ako definiramo kao visoki rizik za razvoj KVB indeks tjelesne mase iznad 29.99, opseg struka veći od 101cm za muškarce, odnosno 88cm za žene, tlak iznad 159/99, uz prisutvo povišene masnoće u krvi ili povišenog šećera ili preboljelog srčanog infarkta ili angine pektoris čak 54, 71% muškaraca i 62, 30% žena ima visok rizik za prvi ili ponovni razvoj problema s kardijalnim zdravljem. Prevenciju KVB treba istovremeno provoditi na razini promicanja zdravlja i razini primarne i sekundarne prevencije. Na razini promicanja zdravlja prevencija se provodi javnozdravstvenim modelom usmjerenim na opću populaciju, a on obuhvaća edukaciju pučanstva, podržavajući okoliš i kontrolu okoliša, oglašavanja, prodaje i cijena. Samo istodobnim zajedničkim djelovanjem svih nabrojanih aktivnosti moguće je postići rezultat – usvajanje pravilnih životnih navika – čime čuvamo zdravlje od najranije životne dobi. Ukoliko je zdravlje narušeno djelovanjem loših životnih navika, potrebno ih je mijenjati. Životne navike su rezultat naučenog ponašanja, a svako naučeno ponašanje je promjenljivo. Jedan od važnih zadataka medicinskih sestara u patronažnoj djelatnosti usmjeren je, kroz svakodnevnu praksu, na identifikaciju visoko rizičnih čimbenika za razvoj KVB i edukaciju u cilju osposobljavanja ljudi da preuzmu kontrolu nad vlastitim zdravljem mijenjajući loše životne navike. Osobitu ulogu u prevenciji za medicinsku sestru u patronažnoj djelatnosti ima činjenica da istodobno provodi i individulani i grupni intervencijski model. Pružajući informaciju pojedincu, indirektno pruža informaciju i djeluje i na cijelu obitelj i širu grupu. Cilj je intervencijskog modela pružiti znanje, kako ispitaniku tako i njegovoj obitelji. Nakon identifikacije kardiovaskularnih rizika pojedinog ispitanika i osobne motivacije za promjenu pojedinog rizika, patronažne sestre napravit će individualni plan aktivnosti koje bi trebale djelovati na pogrešno naučeno ponašanje i promjeniti lošu životnu naviku koja dovodi do razvoja bolesti. Literatura [1] Kern J, Strnad M, Coric T, Vuletic B. Cardiovaskular risk faktors in Croatia: struggling to provide the evidence for developing policy recommendations. BMJ 2005 ; 331(7510):208-10. [2] Hobbs FDR. Cardiovascular Disease: Different Strategies for Primary and Secondary Prevention? Heart 2004 ; 90:1217-1223. [3] Gaining health. The European Strategy for the Prevention and Control of Noncommunicable Diseases. WHO EURO, EUR/RC56/8, June 2006. [4] Mojsović Z i sur. Sestrinstvo u zajednici. Zagreb: Zdravstveno veleučilište, 2006.

Starenjem populacije kardiovaskularna opterećenost se povećava, a preventiva nije adekvatno funkcionalna što se jasno pokazuje primjenom SWOT analize. Stoga je potrebno podatke iz HZA 2003 kao i one koji će se prikupiti 2008 na istom uzorku ispitanika intenzivnije analizirati i rezultate uključiti u sustavan nacionalni program prevencije nastanka kardiovaskularnih bolesti.

Gospodarenje medicinskim otpadom, koji po svojim svojstvima može biti opasan i/ili inertan, u Hrvatskoj je regulirano trima temeljnim pravnim aktima: Zakonom o otpadu, Pravilnikom o vrstama otpada te Naputkom o postupanju s otpadom koji nastaje pri pružanju zdravstvene zaštite. Uz njih još su i Zakon o prijevozu opasnih tvari i Zakon o otrovima akti koji podupiru provedbu ovih propisa. Slijedom razvoja suvremenih cjelovitih sustava za gospodarenje otpadom razvijen je i cjeloviti sustav za gospodarenje medicinskim otpadom koji se zasniva na hijerarhijskome načinu postupanja s otpadom, i to od kontrole mjesta nastanka do mjesta konačne dispozicije. Prioritet je svakako izbjegavanje nastanka otpada, tj. smanjenje potencijala otpada, međutim to nije uvijek moguće, stoga je otpad potrebno sortirati, primjereno predobraditi, na poseban način transportirati, konačno obraditi te ostatke prikladno deponirati. Konačna metoda obrade mora biti ona koja će proizvesti najmanji rizik za ljudsko zdravlje i okoliš. Provođenjem cjelovitog sustava gospodarenja otpadom velike količine otpada mogle bi se zbrinuti u okviru tehnološkog i komunalnog otpada, čime bi zbrinjavanje opasnoga medicinskog otpada zahtijevalo manja financijska sredstva. Svaki od ovih koraka zakonski je definiran i opisan, međutim njegovo je provođenje najveći problem. U lancu od mjesta nastanka u zdravstvenim ustanovama pa sve do konačne dispozicije nailazimo na neprimjereno rukovanje, nepoštivanje propisa o ambalaži, pa sve do obrade u postrojenjima bez uporabne dozvole. Nema potpunih podataka o količinama i tokovima medicinskog otpada, ali ni sustava državne kontrole putem sanitarne inspekcije. Poseban su problem lokacije za konačno odlaganje, tj. nedostatak sanitarnih odlagališta. Hrvatska je potpisnica međunarodnih konvencija o nadzoru prekograničnog prometa opasnog otpada i njegovu odlaganju (Baselska konvencija). U okviru projekta CARDS započeta je izrada analize stupnja usklađenosti zakonodavstva RH s pravnom stečevinom EU-a za područje gospodarenja otpadom., Medical waste management in Croatia is regulated by three fundamental legal acts: Waste Act, Ordinance on Waste Types and Directive on Manipulation of Waste Generated in Health Care. The implementation of these acts and waste management in general are also supported by Transport of Hazardous Materials Act and Toxic Substances Act. Modern trends in waste management promote an integral approach also called “waste chain”. This integral approach to medical waste management is based on hierarchical structuring of waste management structure from the point at which the waste is produced to its final disposal. Priority is always given to reducing the amount and the harmfulness of waste by replacing harmful materials with those that are not, but where this is not possible, waste management includes reduction by sorting and separating, pretreatment on site, safe transportation, final treatment and sanitary disposal. Methods of choice for the final treatment should be the least harmful for human health and environment. Integral medical waste management could greatly reduce quantities of medical waste and consequently financial strains. Even though Croatian regulations define and cover all steps in the waste management chain their implementation is one of the country’s greatest issues. Improper practice is seen from waste production in healthcare institutions to the final disposal, and includes handling, sorting, use of containers, or treatment in incinerators. Information on quantities, type and flow of medical waste are inadequate, just as sanitary control. In addition, Croatia lacks locations for sanitary landfills. Croatia has signed international conventions on the supervision and control of transfrontier waste shipments. Within the CARDS project, Croatia has started to harmonise its laws with acquis communitaire related to waste management. Although waste management is one of the priorities defined within the National Environment Action Plan, Croatia still has not made a strategy for waste management.

Patient's rights

Reguliranje zbrinjavanja medicinskog otpada u Hrvatskoj

The aim of this article is to present public health needs emerging in rural areas of Croatia that are under the special state protection. The examined region is about 90 km south-east of Zagreb in Sisačko-moslavačka county. Three elements concerning public health are investigated: drinking water supply, waste disposal and health services. Both, water supply systems and waste disposal sites, were examined in situ, sanitary water analysis were performed, whereas local population was interviewed about health care needs. The results revealed serious problems in all three areas. Part of the population never had running water in their homes. Local water supply systems are run down and remained population can not maintain them properly. Water springs themselves are good, but technical capacities of supply systems are very low, so water is microbiologically contaminated. Further, where water supply systems existed, water wells were poorly maintained, so water is also microbiologically contaminated. So far, waste was burned or disposed on wild dumpsites. Today the problem deepened due to the large number of abandoned houses that are decomposing and at the same time becoming nucleuses where other waste is disposed. The whole area is sparsely inhabited without a critical mass that could lobby against transport of the waste from other counties. There was more than one suggestion that hazardous waste could be disposed in these areas, without any evaluation of relevant parameters. There is a trend of increased demand for health care services due to the elderly population as well as large number of single households. Population cannot reach health care centers because there is no public transportation, and existing model of patronage is not able to cover the area due to poor roads, distances between villages and households, so population remains without preventive work as well. It is evident that new concept of health care organization is needed to meet the needs of the communities in such rural regions. It should mobilize all local resources and integrate all the elements of the population and the environment.

HUMOR, MENTAL WELLBEING AND ADOLESCENT SELFESTEEM

Svrha je ovog rada bila opisati metodu kojom su se koristili hrvatski gradovi u izradi svojih strateških dokumenata za zdravlje: "Gradske slike zdravlja" i "Gradskog plana za zdravlje". Metoda odabrana kao najprikladnija bila je metoda brze procjene zdravstvenih potreba zajednice. Tri su izvora informacija korištena u ovom istraživanju: eseji panelista (opis zdravlja, problema i potencijala grada), njihove opservacije (o tome što pridonosi, a što umanjuje ljepotu življenja u njihovom gradu) te informacije prikupljene iz pisanih dokumenata (izvještaj institucija i organizacija). Prikupljeni eseji obrađeni su metodom analize slobodnog teksta. Tijekom Konsenzusne konferencije panelu sudionika predočene su prikupljene informacije na temelju kojih su oni odabrali prioritetna područja rada projekta. Istraživanje je provedeno u šest hrvatskih gradova: Puli, Metkoviću, Rijeci, Karlovcu, Varaždinu i Zagrebu u razdoblju od 1996. do 2002. godine. Primjenom metode brze procjene: (a) dobivena je ocjena zdravlja (temeljem čega je izrađena Gradska slika zdravlja), (b) određena su prioritetna područja aktivnosti za rad projekta (Zdravi grad), (c) oformljene tematske grupe oko odabranih prioritetnih područja te (d) izrađen Gradski plan za zdravlje. Rezultatima dobivenim na razini gradova ova metoda potvrdila je da zajednica raspolaže kapacitetom prepoznavanja, ali i rješavanja vlastitih problema.

Public health, organization

The aim of this article was to describe the method that Croatian cities have used in the development of the City Health Profile and City Health Plan. Selected as the most appropriate and applied was the Rapid Appraisal to Assess Community Health Needs. Three sources of information were used in this research: panelist essays reflecting local community views on health, problems and potentials of their city, observations about what is diminishing and what is giving beauty of living in their city and information derived from the existing written data sources. A free-text processing program analyzed essays. During the Consensus conference, based on presented data, participants had selected (Healthy City Project) priority areas. Between 1996 and 2002 The Rapid Appraisal was applied in six Croatian cities: Pula, Metkovic, Rijeka, Karlovac, Varazdin and Zagreb. By applying the method of Rapid Appraisal the cities assessed their health and health needs and created the City Health Profile. They selected their (Healthy City Project) priority areas, established the working groups on priority areas, and developed the City (action) Plan for Health. The method proved that communities have the capacity to recognize and deal with their health problems.