PROGRAM FOR REDUCTION OF CARDIOVASCULAR AND CEREBROVASCULAR DISEASE IN THE CZECH REPUBLIC
The Partners in Health Program was launched at CECHE's initiative in 1992. Led by the University of California at San Francisco, it involved three American and three Czech partners. This program, modeled after the Stanford Five-City Project of Stanford University's Center for Research in Disease Prevention (SCRDP) involves the National Institute of Public Health (NIPH), The Institute for Clinical and Experimental Medicine (IKEM), and The Second Medical Clinic of the Third Medical Faculty of Charles University (SMC)—the Czech partners—who are now continuing the program on their own. The program is aimed at reducing the risks of cerebrovascular and cardiovascular disease (CVD)—the leading Czech killers-through medical, educational, and lifestyle changes. A two-pronged approach is the cornerstone of the high-risk and community intervention efforts in two Czech communities to advocate institutional development, program and policy reform and intensive professional training and public education. For the high-risk population with histories of post-myocardial infarction, coronary bypasses and high cholesterol levels, the consortium established three clinics in Prague and one in Litomerice, a district of 100,000, 100 miles north of the capital. A community intervention program was established in Dubec, a rural area east of Prague, to introduce healthy attitudinal and behavioral changes at the grass roots.
The Healthy Dubec community intervention program was based in the village of Dubec, ten miles east of Prague. It encompassed community-wide risk factor surveys, and community-based health education and intervention for primary prevention. A community survey in 1992 assessed the respondents' health status, and knowledge and opinions, together with personal and family history, smoking habits, eating patterns, social activities, physical activity and stress. The survey was followed by dietary, anti-smoking, physical activity, and other sustained interventions beginning in January 1993. A second survey was carried out in 1994 to assess the impact of 18 months of intervention.
The high risk program required establishment of three clinics: a High Risk Intervention Clinic (HRIC) at (SMC) for high risk patients from Dubec; a secondary prevention clinic at Litomerice District Hospital (LDH) north of Prague for patients surviving myocardial infarction; and a Secondary Prevention Clinic at (IKEM) for coronary artery bypass surgery patients. The diagnostic and treatment model, patterned after the Cardiovascular Research Institute of the University of California, San Francisco (UCSF/CVRI), aims at reducing morbidity and mortality in high-risk patients (primary prevention) or patients with established CVD (secondary prevention).
The Center for Communications, Health and the Environment (CECHE) in Washington, D.C. initiated the program, coordinating, providing support, and overseeing both program components until 1998, when the Czech partners took over. Three new core facilities modeled after CVRI and SCRDP: a lipid laboratory and a Central Administrative Unit at IKEM with state-of-the-art equipment and trained personnel, and a Central Data Management Center at NIPH, with trained personnel and modern computer equipment, were established to support the program.
This program was funded largely by the US Agency for International Development (AID), initially at $2 million for three years, and with additional funds in 1995, it was extended to 1998. The Czech Ministry of Health and three US foundations also provided support. The following summarizes the program's outcomes.Initial Lessons
The overall objective of the program was to undertake demonstration projects that could lead to a national program to reduce CVD as this program linked the community and the high risk intervention approaches in the population of Dubec. Inhabitants of Dubec identified at high risk in the community survey received intensive intervention at HRIC against specific risk factors, principally hyperlipidemia, hypertension, and tobacco use. Since over 20% of the adults surveyed at Dubec were identified at high risk, we postulated that a significant interaction between the two approaches would produce a synergistic behavior change and risk reduction. The population and high risk approaches--singly and uniquely in linkage in this program, the introduction of modern technology and approaches, the close contact with Czech health professionals, policy makers, the clinic patients, and the Dubec population--have all yielded important lessons that pertain to extension of our experience much more widely in the country.
First, a very high level of interest in personal lifestyle change was apparent from repeated requests for information from a significant portion of the Dubec population and among neighboring communities. Furthermore, all major facets of the community-the Mayor's office, school, kindergarten, and the community at large-became engaged in the intervention effort at Dubec. Analysis of data on knowledge and attitude indicated a strong, positive response to the benefits of increased consumption of fruits, vegetables, and cereals and decreased consumption of fats to reduce CVD risk; to intervention to lower dietary fat and cholesterol; and to perception of barriers to change. This enhanced the feasibility of extending the community approach on a national basis, which occurred beginning in late1994.
The most obviously effective activities in promoting education and behavior change in Dubec occurred in the primary school, and a successful program for dietary change was also achieved in the local nursery school. In Litomerice, with the cooperation of personnel from the District Hygiene Station, a pilot course focusing on dietary and other health behaviors to reduce cardiovascular and cerebrovascular disease risk was given in the local high school. In the Dubec primary school, the education program was bolstered by starting a school vegetable garden, which has captured the imagination of the faculty, the students, and the school administration. This addressed a problem we identified at the start-the need to match production to health needs. We were therefore encouraged to institute school education programs at the district level.
Second, we found that the community was readily attracted to join intervention programs in clinic settings. The three clinics we established were rapidly able to achieve their targets of 200 patients at the HRIC, and 100 patients each at the IKEM and Litomerice clinics. More importantly, the Czech physicians trained in California were able to obtain good compliance with intervention regimens, including treatment with drugs commonly used in the U.S. for lowering cholesterol and other lipids.
Early findings from the high-risk intervention itself were highly encouraging. There was virtually complete cessation of smoking within a year of therapy among the post-myocardial infarction patients at Litomerice and almost complete cessation in the HRIC and the post-coronary bypass patients at IKEM. Furthermore at IKEM, after a few months of dietary intervention, the percentage of patients with >300 mg/dl non-HDL/cholesterol was reduced from 15.5% to 9%, and those with 260-300 mg/dl from 40.5% to 26%. Furthermore, there was a significant decrease in total and non-HDL cholesterol and triglycerides and in the body mass index in HRIC patients. Based on the strong, positive response to two post-graduate courses sponsored by this partnership program for approximately 100 specialist physicians from most of the Districts of the country, and our experience in these clinics, we gained confidence that this high risk approach could be successfully extended to other regions as well as nationwide.
Third, lipid-lowering drugs-bile acid binding resins, nicotinic acid, and HMGCoA reductase inhibitors-have had very limited availability in the Czech Republic. Our program facilitated a satisfactory preparation of nicotinic acid in the Czech Republic, and facilitated its coverage and that of other already available drugs through the Czech General Health Insurance Co. The latter was partly to ensure proper drug prescription. The major hindrance in setting up high-risk clinics (as well as in conducting community intervention) was the paucity of trained nutritionists and dietitians in the country. We therefore supported the development of a three-year baccalaureate curriculum in nutrition at the Third Medical Faculty. This curriculum was approved and the first students enrolled in the 1994-95 academic year.
Further, the print and broadcast media were highly receptive to cooperating with us in programs for educating the public about behavioral risk factors and their relation to cardiovascular and cerebrovascular health and disease prevention. Evidence from the MONICA survey data, obtained at IKEM, indicated that blood cholesterol levels were leveling off or falling in most segments of the population, probably due to positive dietary changes induced by lifting of price subsidies from fatty meats and dairy products. It therefore seemed worthwhile to explore means to stimulate the dissemination of information to the public. We developed links with Czech State TV-to disseminate health promotional messages and longer health programs (see Elixir of Life TV Series). We expanded this public education effort during the extension period (see below) to link specific programming to targeted educational activities in regions in which community education and high risk intervention efforts will be under way. The mass media programs were supported by CECHE and at the district level by the Czech Ministry of Health.
Our partnership activities in the first two years began to show not only a positive impact on CVD risk factors, most apparent in the high risk population and beginning to be apparent in the community, but also catalyzed strong commitments from the community, the Czech partners, from the majority of Czech professionals and other participants in our training courses, as well as from the Czech Ministry of Health and their General Health Insurance Co., to support health promotion and disease prevention. This commitment enhanced the overall Czech capacity to absorb and sustain this expanded effort, enabling them to assume sole responsibility in 1998.Nationwide Extension
Beginning in October 1994, we began to extend the experience gained in the two model programs to a regional and national level throughout the Czech Republic. The Czech partners assumed the lead in these efforts.
The model program to date has been extended to various districts throughout the Czech Republic through forming, training, and equipping approximately 35 District Interdisciplinary Teams comprising hygienists-nutritionists and specialist physicians, drawing from personnel at the District Hygiene Stations coronary care units or specialty clinics of district hospitals. The teams were trained by our core CVD Program in Prague in population-based intervention as well as primary and secondary CVD prevention, as well as in to reduce CVD risk factors. Team formation started with a workshop in October 1994 and most teams were operational by September 1995-six months into the extension.
Our aim was to alleviate the underlying causes of CVD through multifaceted community-based and high-risk regional and national, initiatives to improve the Czech diet and other lifestyle factors that are known CVD risk factors. A new element-a mass media campaign-added in 1994 in cooperation with Czech State TV improved public knowledge, attitude, and behavior towards health promotion and CVD risk reduction;
During the extension, we also remedied a deficit of trained dietitians and nutritionists - by launching the first Baccalaureate program ever in the Czech Republic for such training. This enhanced a basic element of the Czech health care system and provided the opportunity for broader use of such trainees in various sectors of society; and we trained the interdisciplinary teams to initiate intervention in schools, thus focusing especially on children and youth, who are most vulnerable to the effects of a poor lifestyle and who provide the best opportunity for instituting long-lasting, positive behavioral change in the population.
The extension also attempted to address the following specific challenges encountered during the model development phase.
A multi-channel mass media campaign was begun in September 1995 and continues today to support and enhance the impact of the community and high-risk activities; inform and educate the Czech public nationwide about CVD risk factors and motivate them to modify their lifestyle to reduce the risk of chronic diseases in general and CVD in particular. The program is based on lessons from the most successful programs for community prevention (e.g., the Stanford Five-City Project and the North Karelia Project in Finland), that demonstrate that a combination of individual and group effort supported and influenced by the mass media creates a synergetic effect in disease prevention and health promotion.
Television: Television programs include short, 30- to 60-second public service announcements (PSAs) as well as longer program focusing on smoking prevention and cessation, nutrition, and exercise to stimulate interest and convey specific practical information and skills (e.g., low-fat cooking and menus to increase vegetable and cereal consumption) (see PSAs).
Radio: NIPH has been using its national network, including the regional stations (Cesky rozhlas, Fekvence 1, Radio Alfa, Radio Golem, Radio Svobodna Evropa, etc.), to integrate materials, information, and programs from the Mass Media Campaign into radio programs. NIPH and NIPH through its radio program continues to give radio interviews with cardiologists and public health specialists.
Print Media: A Scientific Writers Club for Health Promotion was organized under the aegis of IKEM. It consults with the Mass Media Campaign Board and other Czech specialists to obtain information, discuss stories under consideration, and review controversial topics in health promotion and disease prevention. NIPH will also collect and supply relevant print materials from the Healthy Dubec project to support programs for practitioners and other DIT members.
Training in Media: As part of CECHE's ongoing program to train health professionals and journalists and producers from television, print, and radio in effective communications, CECHE committed its own funds to train Czechs for this program. The training, including hands-on experience in U.S. facilities, began in July 1994 under CECHE aegis (see Media Training). A TV producer, Martin Slunecko, and a writer, Renate Cervenkova, were the first trainees.Evaluation
Although the entire program has been evaluated using multiple measures, special attention was focused on evaluation of the effectiveness of community and high-risk intervention in four selected districts-Litomerice, Benesov, Kutna Hora, and Liberec, where teams were formed in October, 1994. High-risk intervention involved the assessment of CVD risk factors (e.g., lipid profiles, body mass index, dietary data, etc.) in high-risk patients prior to and following secondary or primary intervention. These data were compared with the results of high-risk intervention in the two existing model programs. For community intervention, the teams in these four districts performed pre- and post-surveys of randomly selected individuals, consisting of questionnaires measuring knowledge, skills, reported behavior, and other CVD risk factors, and analyze the data.
The mass media campaign facilitated extension of the program on a national basis, because it was directed to the entire Czech population. In general, focus groups were used to select the best approaches to achieve the maximum lasting behavioral change in the public, for example, to lower fat intake or increase vegetable intake. And focus groups were used to track and assess various components of the campaign.
Impact To Date
Impact measures to date indicate, on average, reductions of 25% LDL-cholesterol for high-risk groups, and this alone should reduce new or recurrent coronary events by approximately 50%. Reduction in non-HDL cholesterol has also been observed in the clinic population. A comparison of high-risk intervention in the four selected districts with data from the two initial models will provide further basis for determining the impact of disseminating the high-risk approach nationwide. For the general population, the experience in the Stanford Five-City Project implies that while it would be premature to expect a reduction in mortality over the short duration of this program, a change in coronary risk factors could be anticipated. This was apparent from a follow up community survey in Dubec in October 1994. An improvement in knowledge and attitude toward CVD risk factors has already been observed. The Dubec pre- and post-survey data were used to modify, strengthen, and reinforce components of the community approach in the districts. The mass media campaign involving print and TV is also providing evidence of impact (see A Family Year TV Series; and PSAs).
For more information, also visit the Elixir of Life page. Elixir of Life is a 10-part, magazine-style TV series produced by CECHE in conjunction with its partners in the Czech Republic. The show's emphasis is on tobacco control (and other health issues) for prevention of cardiovascular and other diseases, the leading killers in the CEE-NIS region.
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