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BACKGROUND Community-based recovery-oriented mental health services for people with severe mental disorders have not been fully implemented in Bulgaria, Croatia, Macedonia, Montenegro, and Romania. The RECOVER-E project facilitates the implementation of specialized mental health care delivered by setting up services, implementing the services, and evaluating multidisciplinary community mental health teams. The outcomes of the RECOVER-E project are assessed in a trial-based outcome evaluation in each of the participating countries with a health-economic evaluation linked to these trials. OBJECTIVE The aim of this protocol paper is to describe the methodology that will be used for the health-economic evaluation alongside the trials. METHODS Implementation sites have been selected in each of the five countries where hospital-based mental health services are available (care as usual [CAU]) for patients with severe mental disorders (severe depression, bipolar disorder, schizophrenia, and other psychotic disorders). The newly implemented health care system will involve community-based recovery-oriented mental health care (CMHC). At each site, 180 consenting patients will be randomized to either CAU or CMHC. Patient-level outcomes are personal and social functioning and quality-adjusted life years (QALYs). Data on participants’ health care use will be collected and corresponding health care costs will be computed. This enables evaluation of health care costs of CMHC as compared with CAU, and these costs can be related to patient-level outcomes (functioning and QALY gains) in health-economic evaluation. RESULTS Data collection was started in December 2018 (Croatia), February 2019 (Montenegro), April 2019 (Romania), June 2019 (North Macedonia), and October 2019 (Bulgaria). The findings of the outcome evaluations will be reported for each of the five countries separately, and the five trials will be pooled for multilevel analysis on a combined dataset. CONCLUSIONS The results of the health-economic evaluation of the RECOVER-E project will contribute to the growing evidence base on the health and economic benefits of recovery-oriented and community-based service models for health systems in transition. CLINICALTRIAL (1) ClinicalTrials.gov NCT03922425 (Bulgaria); https://clinicaltrials.gov/ct2/show/NCT03922425 (2) ClinicalTrials.gov NCT03862209 (Croatia); https://clinicaltrials.gov/ct2/show/NCT03862209 (3) ClinicalTrials.gov NCT03892473 (Macedonia); https://clinicaltrials.gov/ct2/show/NCT03892473 (4) ClinicalTrials.gov NCT03837340 (Montenegro); https://clinicaltrials.gov/ct2/show/NCT03837340 (5) ClinicalTrials.gov NCT03884933 (Romania); https://clinicaltrials.gov/ct2/show/NCT03884933 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/17454

The aim of this study was to analyse the association of poor self- -perceived health with demographic, socioeconomic and lifestyle factors using data from the European Health Interview Survey. When applying the multiple logistic regression model, two demographic (male sex, older age), all four socioeconomic (low education level, unemployed and retired, living in households with lowest income, poor social support) and only one lifestyle factor (no alcohol consumption) were revealed as associated with poor self-perceived health. The association of socioeconomic factors with self-perceived health among the adult population in Croatia is direct and not mediated exclusively through lifestyle factors., Cilj je ovog rada bio analizirati povezanost samoprocijenjenoga lošeg zdravlja s demografskim i socioekonomskim čimbenicima te životnim stilom na temelju podataka iz Europske zdravstvene ankete. Prilikom primjene modela multiple logističke regresije dva demografska (muškarci, starija dob), sva četiri socioekonomska (niska razina obrazovanja, nezaposleni i umirovljeni, osobe koje žive u kućanstvima s najnižim dohotkom, slaba socijalna podrška) i jedan čimbenik životnoga stila (osobe koje ne piju alkohol) prepoznati su kao povezani sa samoprocijenjenim lošim zdravljem. Povezanost socioekonomskih čimbenika sa samoprocjenom zdravlja među odraslom populacijom u Hrvatskoj izravna je i nije posredovana isključivo kroz životni stil.

BACKGROUND & AIMS: Undernutrition is a common and aggravating problem in people suffering from various chronic diseases as well as a source of material costs. The aim of this study was to investigate the prevalence of disease-related undernutrition among adults in Croatia in the year 2012, as well as the cost of undernutrition associated with tumour cachexia, chronic pancreatitis, inflammatory bowel disease, hepatic encephalopathy, chronic obstructive pulmonary disease, chronic renal insufficiency requiring dialysis, cerebrovascular insult, pressure ulcers, and femoral fractures in the elderly. ----- METHODS: A cost-of-illness analysis was conducted, including direct costs only. The study employed the dominant cost-of-illness method, which restricts the summation of medical expenditure to the disease of interest. The bottom-up, prevalence-based approach was used. The budget holder perspective was employed, and data sources include the list of reimbursed drugs, clinical opinions, and literature. ----- RESULTS: The prevalence of disease-related undernutrition in people over the age of 20 in Croatia in the year 2012 was estimated to be 33.7/1000. The total cost of adult malnutrition for selected diagnoses was 97.35 million EUR, accounting for 3.38% of the total Croatian national health care budget. The largest share was used for medications (43%), followed by 34% for hospitalizations, 13% for community health nursing, while parenteral and enteral nutrition contributed with 6% and 1% respectively. The average cost per patient was estimated at 1640.48 EUR. ----- CONCLUSIONS: The cost of malnutrition for the selected diagnoses in Croatia was substantial. These health costs will increase due to population ageing, which calls for undernutrition screening in people at risk as well as for effective approaches in nutrition supplementation.

Overweight is associated with hypertension, but longitudinal studies on the effect of weight gain on blood pressure are relatively rare. Aim of this study was to investigate association of long-term overweight status as well as of becoming overweight with hypertension. Odds of hypertension in 2008 were calculated for 1, 383 respondents from Croatian Adult Health Cohort Study (CroHort) who had normal blood pressure in 2003. The results showed that for women both long-term overweight status and recently becoming overweight (in the last 5 years) were significantly associated with development of hypertension, while for men this was true only for long-term overweight. Prevention activities aimed at maintenance of normal body weight should be important part of primary prevention of hypertension.

The aim of this study was to explore how the association of 5-year cumulative incidence of arterial hypertension (further 5-CIAH) and education varies according to body weight, age and sex. The study was conducted on cohort of 1383 subjects aged 18+ with initially normal blood pressure (systolic < 140 mmHg and diastolic < 90 mmHg, and not taking medication). Data were collected in 2003 and repeated in 2008. Methods of descriptive statistics, chi2 test and logistic regression were used. No association between education level and hypertension development was recorded in the group of men and in the group of woman aged 65+. In the group of women with normal body weight, younger than 65 years, significantly higher 5-CIAH values were recorded in those with less than 12 years of education (32.5% [22.0 to 42.9]) compared to those with 12 or more years of education (9.6% [6.1 to 13.1]).

The objective of this paper was to evaluate the 5-year incidence of obesity on a sample of 3229 adults and investigate the potential effect of several sociodemographic and lifestyle habits on weight change and obesity incidence in these individuals. The average annual rate of increase in the prevalence of obese adults between 2003 and 2008 was 10.60% for men and 11.08% for women. Analysis showed that development of obesity in 5-year period in women in Croatia is significantly positively associated with frequent consumption of »hidden« fats of animal origin and significantly negative with each higher education level. No significant predictor of obesity has been found in men. Obesity remains a serious health problem for the Croatian population ; the alarming rates of excess body weight continue to increase. Preventive measures should urgently be undertaken.

The aim of this study was to establish a five-year cumulative incidence of arterial hypertension (hereinafter 5-CIAH) and its dependence on initial prehypertension, body weight, age and gender. " Croatian Adult Health Cohort Study (CroHort)" data collected during 2003 and 2008 for the 1383 subjects aged 18 + with initially normal blood pressure (systolic

Aim of this study was to investigate association of controlled and uncontrolled hypertension with angina pectoris, non-fatal myocardial infarction and non-fatal cerebrovascular insult on a cohort from Croatian Adult Health Cohort Study (CroHort). Odds for angina pectoris, non-fatal myocardial infarction and non-fatal cerebrovascular insult were calculated for 227 respondents with controlled hypertension and 1, 287 respondents with uncontrolled hypertension compared to 1, 353 normotensive respondents. The results showed that among men uncontrolled hypertension was significantly associated with risk of non-fatal stroke, while among women no significant associations were recorded. Primary and secondary prevention of hypertension should be public health priority and would contribute to reducing the risk of stroke in Croatian population.

Health interview surveys are important source of health information. All previous adult population-based health interview surveys in Croatia until CroHort, were one-off projects with very limited possibility of data comparison. CroHort enabled repeated survey of CAHS 2003 respondents with almost identical questionnaire, thus providing comparable data on trends of different risk factors as well as their relation to the specific outcomes. Next follow-up survey of the CroHort cohort is foreseen for 2013. Health interview survey according to Eurostat methodology (EHIS) on the new representative sample of adult Croatian population is planned for 2014. As the data from health interview surveys are valuable in health policy, efforts should be made to increase their use by policymakers in Croatia.

Cilj ovog istraživanja bio je utvrditi postoje li međužupanijske razlike u bolničkom liječenju u Hrvatskoj te koji čimbenici na njih utječu. Na temelju podataka iz bolničke statistike Hrvatskog zavoda za javno zdravstvo za 2009. godinu, izračunate su i uspoređene prema dobi i spolu standardizirane stope hospitalizacija i bolničkih rehabilitacija u hrvatskim županijama. Uspoređene su i duljine trajanja hospitalizacija te udjeli hospitalizacija u ustanovama na području županije u kojoj je prebivalište pacijenta u ukupnim hospitalizacijama. Uspoređeni su i pokazatelji organizacije i funkcioniranja zdravstvenog sustava u županijama. Pearsonovim koeficjentom korelacije te postupnom multiplom linearnom regresijskom analizom ispitano je postoji li značajna linearna povezanost između stopa hospitalizacije te pokazatelja organizacije i funkcioniranja zdravstvenog sustava, kao i socioekonomskih obilježja županija. Utvrđeno je da u Hrvatskoj postoje značajne razlike između županija u stopama hospitalizacije i bolničke rehabilitacije, duljini trajanja hospitalizacija, udjelima hospitalizacija u ustanovama na području županije u kojoj je prebivalište pacijenta te pokazateljima organizacije i funkcioniranja zdravstvenog sustava. Za određene pokazatelje organizacije i funkcioniranja zdravstvenog sustava zabilježena je značajna povezanost sa stopama hospitalizacija i rehabilitacija, dok povezanost socioekonomskih obilježja županija sa stopama hospitalizacija i rehabilitacije nije potvrđena. Neke zabilježene razlike nije moguće objasniti isključivo na temelju rezultata ovog istraživanja. Međužupanijske razlike u korištenju bolničke zdravstvene zaštite i njihova povezanost s organizacijom i funkcioniranjem zdravstvenog sustava, upućuju na potrebu daljnjih istraživanja te sustavnog planiranja regionalnog razvoja zdravstvenog sustava s ciljem smanjenja neopravdanih međužupanijskih nejednakosti.

Cilj ovog rada bio je utvrditi posljedice proizvodnje i prerade azbestnih vlakana na zdravlje radnika i stanovništva pojedinih županija Hrvatske. Analizirane su baze podataka Hrvatskog zavoda za javno zdravstvo: bolničkog morbiditeta, umrlih, Registra za rak i Registra profesionalnih bolesti u razdoblju 2002.-2007. godine s obzirom na dijagnoze mezoteliom (C45), azbestoza i pleuralni plak (J61, J92). Prosječne šestogodišnje stope hospitaliziranih osoba na 100.000 stanovnika zbog mezotelioma, azbestoze i pleuralnog plaka za Splitsko-dalmatinsku (5,0), Dubrovačko-neretvansku (3,9), Istarsku (3,7) i Primorsko-goransku županiju (3,1) veće su od stopa za Hrvatsku (2,1). U promatranom razdoblju prijavljeno je 649 profesionalnih bolesti, a 11,7 % odnosilo se na bolesti uzrokovane azbestom. Najveći broj prijava (38) odnosio se na dijagnozu pleuralnog plaka uz azbestozu, slijede pleuralni plak (23), azbestoza (19) i mezoteliom (6). Stope profesionalnih bolesti povezanih s azbestom u promatranom razdoblju u Splitsko-dalmatinskoj i Primorsko-goranskoj županiji veće su od hrvatskog prosjeka. Mortalitet od bolesti vezanih uz azbest u istom razdoblju bilježi ukupno 312 umrlih osoba s prosječnom godišnjom stopom smrtnosti od 1,2 na 100.000 stanovnika. Četiri županije imaju veću stopu smrtnosti od hrvatskog prosjeka: Primorsko-goranska (3,4), Splitsko-dalmatinska (2,8), Istarska (2,8) i Brodsko-posavska (1,5). Incidencija mezotelioma u razdoblju 2001.-2005. godine veća je od hrvatskog prosjeka u Splitsko-dalmatinskoj, Primorsko-goranskoj i Istarskoj županiji. Pri tome u interpretaciji podataka treba uzeti u obzir mali apsolutni broj hospitaliziranih i umrlih osoba tijekom promatranog razdoblja i činjenicu da stope ovise o ukupnom broju te dobnoj i spolnoj raspodjeli stanovnika, a prijave profesionalnih bolesti vezane su i uz ostvarivanje određenih prava., The aim of this study was to identify the incidence and prevalence of asbestos-related diseases in Croatia, based on the Hospital Morbidity Database and General Mortality Database of the Croatian National Institute of Public Health. Both databases cover a period from 2002 to 2007), and include information from the Register of Occupational Diseases. Diagnoses in focus were mesothelioma (C45), asbestosis, and pleural plaque (J61 and J92). Yearly rates of inpatients treated for mesothelioma, asbestosis, or pleural plaque that were higher than the Croatian average (2.1) were recorded in the Counties of Split-Dalmatia (5.0), Dubrovnik-Neretva (3.9), Istria (3.7), and Primorje-Gorski kotar (3.1 per 100,000 people). From 2002 to 2007, 649 occupational diseases were reported, out of which 11.7 % were asbestos-related. The most frequent were pleural plaque with asbestosis (38 cases, 50.0 %), pleural plaque (23 cases, 30.3 %), and mesothelioma (6 cases, 7.9 %). Mortality attributable to asbestos was assessed using offi cial Croatian National Statistics Bureau reports for 2002 to 2007 at the county and national level. During that period, Croatia recorded 312 deaths with the average yearly rate of 1.2 per 100.000 people. Four counties had higher rates than the national average: Primorje-Gorski kotar (3.4), Split-Dalmatia (2.8), Istria (2.8), and Sl. Brod-Posavina (1.5). The number of inpatients treated for asbestos-related diseases was higher than the national average in the counties of Split-Dalmatia, Dubrovnik-Neretva, and Primorje-Gorski Kotar. Mesothelioma incidence was above the national average in the counties of Split-Dalmatia, Primorje-Gorski Kotar, and Istria. The rates of occupational, asbestos-related diseases were higher than the national average in the counties of Split-Dalmatia and Primorje-Gorski Kotar. We were aware that the interpretation of data is somewhat limited by the relatively small absolute number of treated persons and deaths for the observed period, by the fact that crude rates have not been adjusted for total numbers and for regional differences in population distribution by age and gender. The real extent of asbestos-related burden in Croatian general population remains unknown, because only occupational exposure has been monitored. Therefore, the National Public Health Institute and county public health institutes should implement a specifi c monitoring programme in collaboration with government environmental bodies to assess asbestos exposure of the population living in the vicinity of asbestos plants. It is also necessary to establish the number of exposed persons who have developed an asbestos-related disease. Their health should be monitored and their environment inspected on a regular basis.

ObjectiveThe purpose of the present study was to investigate the distribution of hypertension, its nutritional and other determinants and their association in Croatia.DesignPopulation-based, cross-sectional study.SettingCroatia.SubjectsRepresentative random sample of 9070 adults (18 years and older) from all Croatian regions, selected using multistage sampling.ResultsOverall prevalence of hypertension (arterial blood pressure ≥140/90 mmHg) in Croatia was 45·5 %, of which 40 % were newly diagnosed hypertensives. There was no difference in the percentage of hypertensives between the continental and Mediterranean parts of Croatia. Newly diagnosed hypertension was found to be positively associated with increased BMI, age and alcohol consumption in the total sample and with moderate consumption of coffee in women, as well as inversely associated with regular consumption of fruits and vegetables in the total sample and high consumption of coffee in the total sample and in men. No association with newly diagnosed hypertension was recorded for use of animal fat, consumption of whole milk, smoked meat products, for adding salt, smoking and leisure-time physical activity.ConclusionsHypertension is a major public health problem in both continental and Mediterranean parts of Croatia. Maintenance of normal body mass, its reduction if already increased, and regular consumption of fruits and vegetables are proposed as priorities for primary prevention of hypertension in Croatia.

Between 2001 and 2003, a project conducted in Croatia aimed to establish and develop a health information system based on the latest technologies. Extraordinary results in the trial run give the authors the ground to recommend such an approach to all transitional post communist countries. The development of such systems is feasible in transitional countries because most of them are still having one main insurer.

The aim of this study was to examine the association of weight gain and life expectancy at birth in Croatia. Mean body mass index was based on the data from the Croatian Adult Health Survey 2003. Birth rate and mortality data needed for life expectancy calculation were supplied by the Central Bureau of Statistics. The results suggest that the increase in mean body mass index value (1.31 kg m(-2) for women and 1.41 kg m(-2) for men) will shorten life expectancy at birth for one year. Obesity, if unchecked, might have a negative effect on life expectancy in Croatia. Despite widespread knowledge about how to reduce the severity of the problem, observed trends in obesity in Croatia continue to worsen. These trends threaten to diminish the health and life expectancy of current and future generations.

Based on repeated measurement of health behaviors the CroHort Study showed that health behavior explains a great deal more of class inequalities in mortality than observed in previous studies. These include decreasing prevalence of smoking and increase in obesity, hypertension and diabetes mellitus. The lowest prevalence of health risks was recorded among children and adolescents, followed by general adult population from the CroHort Study. Hospitalized coronary heart disease patients had higher risks prevalence than general population, while the highest prevalence of risks was recorded among patients in cardiac rehabilitation program. The higher levels of stress were associated to lower financial conditions, poorer social functioning and poorer mental health for both men and women. Higher levels of stress were also associated with heart problems, higher alcohol consumption in men while in women stress was associated to poorer general health, higher age and lower levels of education.

Health interview surveys are important source of health information. All previous adult population-based health interview surveys in Croatia until CroHort, were one-off projects with very limited possibility of data comparison. CroHort enabled repeated survey of CAHS 2003 respondents with almost identical questionnaire, thus providing comparable data on trends of different risk factors as well as their relation to the specific outcomes. Next follow-up survey of the CroHort cohort is foreseen for 2013. Health interview survey according to Eurostat methodology (EHIS) on the new representative sample of adult Croatian population is planned for 2014. As the data from health interview surveys are valuable in health policy, efforts should be made to increase their use by policymakers in Croatia.