Preventing Heart Disease and Cancer in Zagreb Worksite, Community, and Media

The Partnership Andrija Štampar School of Public Health (ASSPH) Andrija Štampar School of Public Health (ASSPH) London School of Hygiene and Tropical Medicine (LSHTM) London School of Hygiene and Tropical Medicine (LSHTM) University of California, San Francisco (UCSF, Institute for Global Health) University of California, San Francisco (UCSF, Institute for Global Health) EuropaPress Holding (EPH) EuropaPress Holding (EPH)

Investigators Luka Voncina, LSE, ASSPH Luka Voncina, LSE, ASSPH Stipe Oreskovic, ASSPH, Europress Holding Stipe Oreskovic, ASSPH, Europress Holding Luka Kovacic, ASSPH Luka Kovacic, ASSPH Martin McKee, LSHTM Martin McKee, LSHTM Susannah Tompkins, LSHTM Susannah Tompkins, LSHTM Thomas Novotny, UCSF Institute for Global Health Thomas Novotny, UCSF Institute for Global Health Usma Khan, IGH Usma Khan, IGH Larry W. Green, UCSF Larry W. Green, UCSF

Croatia at a Glance Population: 4,422,248 Population: 4,422,248 Literacy: 98.5% Literacy: 98.5% Infant mortality rate: 6.92 deaths/1,000 live births Infant mortality rate: 6.92 deaths/1,000 live births Life expectancy: men 69.1, women 76.6 Life expectancy: men 69.1, women 76.6 Population growth rate: 0.31 % Population growth rate: 0.31 %

Chronic Disease Mortality, Croatia vs. Eastern and Western Europe

Risk Factors Risk Factors Prevalence of physical inactivity by age group and sex, Croatia, Age Group MaleFemale Prevalence 18 – – – – –

Risk Factors Risk Factors Prevalence of elevated blood pressure (>160 systolic and/or >95 diastolic) by age group and sex, Age Group MaleFemale Prevalence ,401, ,705, ,8013, ,4023, ,2034, ,5038,10

Risk Factors Risk Factors Prevalence of obesity (BMI >30) by age group and sex, Croatia, Age Group MaleFemale Prevalence ,64, ,310, ,418, ,728, , ,826,9

Risk Factors Current smoking prevalence by age group and sex, Croatia, Age Group MaleFemale Prevalence ,331, ,829, ,131, ,321, ,99, ,85,9

Study Question Can a worksite-based health promotion and disease prevention program reduce CVD and cancer risk factors, morbidity, and unnecessary health care utilization among employees of a large media company, their families, and their communities? Can a worksite-based health promotion and disease prevention program reduce CVD and cancer risk factors, morbidity, and unnecessary health care utilization among employees of a large media company, their families, and their communities?

Subjects and variables – Phase 1 Subjects: adult employees of EPH in Zagreb, N=1200 Subjects: adult employees of EPH in Zagreb, N=1200 Comparison group: adult employees of EPH not in Zagreb, N=500 (estimated) Comparison group: adult employees of EPH not in Zagreb, N=500 (estimated) Variables: Variables: Knowledge about risks; Knowledge about risks; Risk behaviors; Risk behaviors; Health care utilization; Health care utilization; Screening practices; Screening practices; Physiological measurements Physiological measurements (depending on funding). (depending on funding).

Background Setting World Bank Project on CVD and Public Health Infrastructure World Bank Project on CVD and Public Health Infrastructure Croatian National Health Survey (ASSPH) Croatian National Health Survey (ASSPH) The Big Breakfast The Big Breakfast Say YES to No Smoking! (NGO/ASSPH) Say YES to No Smoking! (NGO/ASSPH) Healthy Cities Croatia Project Healthy Cities Croatia Project Tradition of worksite-based health and social welfare support in Former Yugoslavia Tradition of worksite-based health and social welfare support in Former Yugoslavia

The Big Breakfast – World Food Day 2003 BBC, CNN, Lancet etc. Croatians sit down to big breakfast Tens of thousands of Croatians sat down on Sunday for what is being described as the biggest breakfast in the world.

Study Concept: The Precede-Proceed Model Flexible and Scaleable Flexible and Scaleable Evidence-based and “Evaluable” Evidence-based and “Evaluable” Participatory Process Participatory Process Platform for Best Practices Platform for Best Practices

Proceed-Proceed Model of Health Program Planning and Evaluation

Hallmark: Participation Stakeholders: EPH, Union (TUCJ) Stakeholders: EPH, Union (TUCJ) Community (Center of Gravity): Families, communities in which employees live Community (Center of Gravity): Families, communities in which employees live Health as a Social Issue: tradition in Croatia Health as a Social Issue: tradition in Croatia Social Capital: reinforcement for EPH as employer and it substrate for employees Social Capital: reinforcement for EPH as employer and it substrate for employees Transdisciplinary Collaboration: epidemiology, policy, worksite health, health education, sociology, clinical medicine Transdisciplinary Collaboration: epidemiology, policy, worksite health, health education, sociology, clinical medicine

Methodology Employee-management-investigator steering committee—identify main issues Employee-management-investigator steering committee—identify main issues Community assessment using Croatian National Health Survey (possibly physiologic measurements)—baseline and yearly Community assessment using Croatian National Health Survey (possibly physiologic measurements)—baseline and yearly Interventions: Interventions: Education Education Policy Policy Health system Health system Community Community Worksite Worksite

Comparison Group Collect baseline and yearly information Collect baseline and yearly information Implement interventions after three years of initial intervention group (delayed application) Implement interventions after three years of initial intervention group (delayed application) Optional: use another comparable employee group Optional: use another comparable employee group Measure change in knowledge, risk behavior, screening practices, and basic health indicators over time. Measure change in knowledge, risk behavior, screening practices, and basic health indicators over time.

Dissemination and Sustainability— Phase 2 Translate successes to families, communities, other settings Translate successes to families, communities, other settings Local investments by EPH and other employers in risk factor reduction and health promotion based on evidence Local investments by EPH and other employers in risk factor reduction and health promotion based on evidence Ministry of Health, World Bank, Stability Pact, and others will support national and possibly regional dissemination. Ministry of Health, World Bank, Stability Pact, and others will support national and possibly regional dissemination.

Strengths Strengths: Strengths: Strong public health tradition in Croatia Strong public health tradition in Croatia EPH can provide media strength in interventions and dissemination EPH can provide media strength in interventions and dissemination We got the guy who wrote the book on community health planning We got the guy who wrote the book on community health planning International collaboration can build on diverse evidence base International collaboration can build on diverse evidence base Some strategic successes and investments already Some strategic successes and investments already

Weaknesses Comparison group may experience similar secular changes Comparison group may experience similar secular changes Fiscal uncertainty Fiscal uncertainty Target group may be resistant (journalists!!) Target group may be resistant (journalists!!) Significant loss to follow-up up with leaving EPH Significant loss to follow-up up with leaving EPH Resistance of local communities to policy changes for Chronic Disease approaches. Resistance of local communities to policy changes for Chronic Disease approaches.

Hvala!