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London School of Hygiene & Tropical Medicine
Issues in Public Health 2007 Final Project

Cardiovascular disease is the leading cause of premature death in industrialised countries, although its incidence varies greatly. Death rates are higher in northern than in southern Europe, and are particularly high in eastern Europe. It has, however, been falling rapidly in a number of northern and central European countries in recent years. The task is to develop a strategy to reduce the disease burden attributable to CVD for a selected country in Europe.

Group 1B - Portugal

Last week on Floribella:
Ronaldo suffers a massive heart attack and stroke. He is currently at Lisbon General in a coma, with GCS=7 E2 V2 M3 at 2235. Floribella receives word of this tragic accident and rushes back from her trip to Macedonia. Paolo is recovering from an intense love affair with Dr. Eusebio, while Teresa is up to no good.

Cast of Characters:
Anne Pelet - Floribella
Siddharth Bhatia - Ronaldo Azevedo
Laura Libman - Teresa Pessoa
Gideon Gorit - Paolo Rego
Amina Aitsi-Selmi - Dr. Blanca Eusebio
Sarah Mullan - Public Health (PH) Expert
Lauren Hutchinson - PH Expert
Katarina Widgren - PH Expert
Margaret Chinhoi - PH Expert
Michelle Chaney - PH Expert and Voice-Over Announcer

Music - Cancao do Mar by Madredeus

CVD Areas of Concern-
1) Tobacco
*Rising rates among women and teenagers
*Culture does not recognise rights of non-smokers
*Smoking allowed in work places
*Legislation is inadequate
*Lack of smoking cessation services
*Low price does not discourage consumption

2) Diet
*Considerable shift from a traditional, Southern European to a more Westernised diet
*Trends of diet transition have been observed faster in Portugal than in other Mediterranean countries
*Shift to Western diet -- higher calorie intake -- obesity -- CVD

3) Hypertension (HTN)
*42.1% of the population in Portugal has hypertension
*Only 11% achieved blood pressure control

4) Lack of Excercise
*Fear that as people move into more industrialised areas, they will no longer participate in as much physical activity

5) Underuse of Health Services
*Poorest individuals are the least likely to visit a physician and receive care (inverse care law)
*This is particularly the case in rural areas

Recommendations-
Tobacco: Pioneer a national anti-smoking strategy
*Increase the price of tobacco (through taxation, additional money to be used specifically to implement CVD strategy and smoking cessation program)
*Revise legislation to a more comprehensive smoking ban particularly to include work places, and ensure enforcement.
*Invest in smoking cessation services (improve access, train professionals, provide free nicotine cessation products)
*Target teenagers (girls in particular)

Diet: Preserve a healthy food culture
*Through community based programmes involving families, distributors, manufacturers, and schools to celebrate and promote traditional Portuguese Mediterranean diet
*Using social marketing techniques through effective media campaigns and capitalising on popular festivals and national heritage
*Integrate this with the hypertension reduction strategy

Hypertension:
*Develop a national HTN screening programme based on the WHO pharmacies based HTN management model
*Support pharmacies in HTN screening by providing pharmacies with automatic sphygmomanometers
*Training pharmacy staff to provide basic screening and advice according to national screening guidelines
Work in partnership with family physicians to facilitate a pharmacy to physician referral process
*Legislation to reduce salt content in processed and take away foods.

Physical inactivity:
*Increase recreational spaces for exercise programs
*National campaign where football stars visit schools to promote exercise/healthy life choices
*Implement a health education curricula and instruction to help students maintain physically active lifestyles

Underuse of health services:
*Increase the number of physicians practicing in rural areas by providing them with incentives such as monetary compensation, relocation programs
*Promotion program that targets poorer areas (no out of pocket expense for yearly doctor visit)

Strategy Evaluation-
*Strengthen multilevel health observatories and high quality surveillance systems to monitor epidemiological trends
*Work with independent academic centres including international centres of excellence such as the London School of Hygiene and Tropical Medicine
*Evaluate both the impact of the new strategy and its process
*Use clearly defined outcome measures over 5 years to:
*Reduce the prevalence of smoking by 30%
*Reduce the average population cholesterol level 0.5 mmol/L
*Reduce the population average BMI by 1-2 units
*Increase the number of rural clinics by 25%
*Convene an international conference in 2012 with all partners including grassroots organisations to review achievements

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