17 ANNUAL MEETING OF CINDI PROGRAMME DIRECTORS TH

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17 ^th Annual Meeting of CINDI

Programme Directors

Report on a WHO Meeting

Qawra, Malta 9–10 June 2000

2001

E74080

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REGIONAL OFFICE FOR EUROPE

___________________________

17 ^TH ANNUAL MEETING OF CINDI PROGRAMME DIRECTORS

Report on a WHO meeting Qawra, Malta 9–10 June 2000

SCHERFIGSVEJ 8 DK-2100 COPENHAGEN Ø

DENMARK TEL.: +45 39 17 17 17 TELEFAX: +45 39 17 18 18

TELEX: 12000

E-MAIL: POSTMASTER@WHO.DK

WEB SITE: HTTP://WWW.WHO.DK 2001

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ABSTRACT

The 17^th Annual Meeting was held to discuss the implementation of the countrywide integrated noncommunicable disease intervention (CINDI) programme in the previous year and the plan of work for the coming year.

Reports were presented on the implementation of CINDI in participating countries, and on the activities of the CINDI working groups on monitoring, evaluation and research; smoking; hypertension; the workplace; children and young people; nutrition and elevated blood cholesterol; nursing; diabetes;

physical activity; guidelines and training for preventive practice; and policy development. The discussion on monitoring and evaluation focused on the methodology for surveys and data analysis. The first draft of an analysis of the second CINDI survey on policy development and implementation processes in CINDI country programmes was presented. In addition, the participants discussed networking at the regional and global levels, and a plan was presented to establish a WHO global network on an integrated approach to the prevention and control of noncommunicable diseases.

Keywords

CHRONIC DISEASE – prevention and control HEALTH PLANNING

PUBLIC HEALTH ADMINISTRATION

HEALTH SERVICES – organization and administration PROGRAM EVALUATION

HEALTH CARE SURVEYS EUROPE

EUROPE, EASTERN MALTA

All rights in this document are reserved by the WHO Regional Office for Europe. The document may nevertheless be freely reviewed, abstracted, reproduced or translated into any other language (but not for sale or for use in conjunction with commercial purposes) provided that full acknowledgement is given to the source. For the use of the WHO emblem, permission must be sought from the WHO Regional Office. Any translation should include the words: The translator of this document is responsible for the accuracy of the translation. The Regional Office would appreciate receiving three copies of any translation. Any views expressed by named authors are solely the responsibility of those authors.

This document was text processed in Health Documentation Services WHO Regional Office for Europe, Copenhagen

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Page

1. Introduction...1

1.1 Opening session ...1

1.2 Election of Officers...2

2. CINDI network ...2

2.1 CINDI Joint Annual Progress Report for 1999...2

2.2 Annual Progress reports from new CINDI countries...2

2.3 Second period of cooperation between the WHO Regional Office for Europe and countries in respect of the WHO CINDI Programme ...4

3. Collaboration with headquarters ...4

3.1 WHO global strategy for NCD prevention and control ...4

3.2 Global Forum on NCD prevention and control (GF)...5

4. Collaboration with other WHO Regions...6

4.1 Regional Office for Africa (AFRO)...6

4.2 Regional Office for the Eastern Mediterranean (EMRO)...7

4.3 Pan American Health Organization (PAHO)...7

4.4 Collaboration with CDC ...7

5. Working Groups...8

5.1 Joint report of the CINDI Working Groups...8

5.2 Monitoring, evaluation and research...9

5.3 Smoking...10

5.4 Hypertension...11

5.5 Workplace...12

5.6 Children and Youth...13

5.7 Nutrition and Elevated Blood Cholesterol...13

5.8 CARMEN/CINDI Working Group on Physical Activity ...14

5.9 Nursing ...14

5.10 Diabetes ...14

5.11 Guidelines and Training for Preventive Practice ...14

6. CINDI monitoring and evaluation ...15

6.1 Methodology...15

6.2 CINDI data analysis...18

7. Policy development...20

7.1 Second comparative analysis ...20

7.2 The art and science of implementation in CINDI: lessons for health promotion and disease prevention...21

8. CINDI Winter School ...21

9. CINDI Highlights...21

10. CINDI millennium project ...21

11. CINDI Internet presentations ...22

12. Future meetings...22

13. Conclusions and recommendations...23

13.1 CINDI network ...23

13.2 Collaboration with headquarters...23

13.3 Collaboration with other regions ...23

13.4 Working Groups ...24

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13.7 CINDI Winter School ...29

13.8 CINDI Visibility ...29

13.9 CINDI millennium project: Children’s Internet Forum...30

13.10 Future meetings...30

Annex 1 FINAL PROGRAMME...31

Annex 2 FINAL LIST OF PARTICIPANTS...34

Annex 3 PROGRESS OF CINDI IN 1999: SUMMARY OF THE COUNTRY REPORTS...41

Preface ...42

Programme objectives and documentation ...43

Administration and management ...43

Monitoring, surveys and data collection...45

Intervention...46

Resources and financing ...53

1. Introduction

1.1 Opening session

The aim of the meeting was to discuss progress achieved in programme implementation in countries since the 16^th annual meeting in Dornbirn, Austria, June 1999, as well as the design and implementation of major collaborative CINDI projects and the related plan of work (Annex 1 – Programme of the meeting).

Dr L. Deguara, the Minister of Health of Malta, and Dr R. Busuttil, the Director-General of Health of Malta, welcomed the participants (Annex 2 – Final list of participants) to Malta.

Dr Deguara emphasized that the participation of CINDI-Malta – an active member of the CINDI network for sixteen years – had been strengthened over the past 6–8 years following a reform in the Department of Health Promotion.

As noncommunicable diseases (NCD) account for the vast majority of causes of death in Malta, it was the policy of the present Government to prioritize programmes aimed at their prevention.

The reform had resulted in an infiltration of the CINDI concept into the formulation of the health policy of Malta. NCD prevention and health promotion form the main elements of the Maltese National Health Policy – Health Vision 2000. The priority intervention objectives are: reduction in smoking; reduction in the prevalence of obesity; lowering of blood cholesterol and blood pressure; encouraging a more active lifestyle.

Dr Deguara highlighted the following action taken by the Health Promotion Department, which demonstrates the commitment of the Maltese health authorities to reduce the risk factors for NCD and enhance the provision of health services for their management:

· Expansion of smoking cessation clinics run by health centres to cover worksites.

· Active participation in the Quit and Win smoking cessation competition.

· Introduction of weight reduction programmes in health centres and in the community.

· Ongoing promotion of the healthy Mediterranean diet; active contribution to the formulation of the CINDI food-based dietary guide and to the preparation of the WHO European Food and Nutrition Action Plan.

· Drawing up of a national breastfeeding policy, which was launched in May 2000, and which will be backed by appropriate legislation.

· Participation in the European Network of Health Promoting Schools.

· Improvement in the management of diabetes through the involvement of Maltese diabetologists in the WHO diabetes management programme.

Dr Deguara felt that capacity-building in the area of health promotion and disease prevention, supported by a steadily increasing budgetary allocation for the Health Promotion Department and reinforced human resources, have brought the health promotion and disease prevention strategy adopted by the Ministry of Health in line with the current approach. This approach declared during the 5^th Global Conference on Health Promotion held in Mexico City just prior to the present meeting, urged countries to invest in health through improvement in social and economic structures.

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Dr A. Shatchkute, Regional Adviser, Chronic Disease Prevention, conveyed to the participants the greetings of Dr M. Danzon, Regional Director of the WHO European Office. She thanked Dr Deguara and his team for hosting the meeting and supporting its organization and

acknowledged the very active contribution to the programme made by Dr R. Busuttil during his term as CINDI Programme Director and by Ms M. Ellul since she had taken over this function in 1999.

Dr Shatchkute informed the participants that a reform process had been started in WHO/EURO that provided an opportunity to update and further develop CINDI implementation. She

mentioned that since the last meeting a number of CINDI products had been elaborated (the CINDI food-based dietary guide, the second CINDI survey on policy development, the CINDI database on risk factors). Important items for discussion during the meeting were the WHO global strategy of NCD prevention and control to which CINDI had been contributing and the new WHA Resolution on the prevention and control of NCD adopted by the WHA53 this year.

1.2 Election of Officers

Ms M. Ellul was elected as Chairperson of the meeting; Dr D. Muacevic-Katanec was elected as Co-Chairperson; WHO/EURO would be responsible for the report.

The provisional programme was adopted.

2. CINDI network

2.1 CINDI Joint Annual Progress Report for 1999

Dr T. Laatikainen introduced the main points of the 1999 CINDI joint progress report, which had been compiled from the annual country progress reports (Annex 3). She emphasized that the CINDI network has been further strengthened by the establishment of new demonstration areas and the improved implementation of CINDI experiences at national level in many countries.

Professor P. Puska, Chairman of the CINDI Programme Management Committee, mentioned that the standard of the material presented in the country progress reports still varies somewhat although there is steady improvement. The participants were requested to review the report during the meeting and to let Dr Laatikainen know, in writing, of any changes that should be made, if possible by the end of the meeting but at the latest by 23 June 2000.

In acknowledging the very clear presentation of the report, Professor Glasunov said that reference to international coordination was lacking in the report. In this connection,

Dr Shatchkute encouraged the CINDI Programme Directors to make their publications better known. In the future, a list of publications should be included in the CINDI joint progress report.

2.2 Annual Progress reports from new CINDI countries

Latvia

Dr V. Dzerve presented the CINDI-Latvia programme which has the following sub-components:

1) health promotion and primary prevention; 2) education and training of health professionals; 3) research and monitoring. Priority areas are cardiovascular diseases, cancer, mental disorders and diabetes mellitus with the focus of intervention on tobacco, poor diet and obesity, elevated cholesterol and elevated blood pressure.

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In the demonstration area (Kuldiga), the main activities during the first year of Latvia’s

membership in CINDI were related to the primary prevention of NCD (Quit and Win smoking cessation competition, Healthy Weeks, adaptation and distribution of national guidelines,

training of trainers), research and monitoring (support to the FINBALT survey, population-based risk factor survey, population-based survey to assess health care in the region) and improvement of the quality of health care (improvement of CVD primary and secondary prevention and of the hypertension management skills of primary health care staff through development and

distribution of national guidelines, the development of referral chain guidelines, training of trainers).

A CINDI conference was held and a pharmacy-based hypertension management project launched.

It was noted that good progress had been made in the CINDI-Latvia Programme.

Italy

Professor M.T. Tenconi reminded the meeting that in Italy CINDI is organized in three regional programmes and three local projects.

In 1999 surveys on risk factors for atherosclerosis were carried out in Lombardy, Latina Province, Sardinia and Valle dell’Irno.

In the Region of Lombardia, special units of preventive medicine dedicated to chronic diseases have been organized as part of the Prevention Department of each of the 14 Local Health Agencies. Activities include the promotion of healthy lifestyles (nutrition, smoking, alcohol and drug abuse, and physical activity), screening for and management of risk factors for

cardiovascular diseases and screening campaigns in the at-risk population. The table below gives an overview of the screening activities carried out.

Table 1. Screening activities – CINDI Lombardia

% Units

Children visual defects 28 (6 out of 8) Breast cancer 18 (4 out of 8) Cancer of cervix uteri 18 (4 out of 8)

TBC 14 (3 out of 8)

Odontopathies 10 (2 out of 8)

Auxology 4 (1 out of 8)

Postural defects 4 (1 out of 8) Speech defects 4 (1 out of 8)

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Professor Tenconi reported on the G7/G8 Cardio-ANMCO software developed by the Centre for Cardiovascular Disease Prevention (WHO Collaborating Centre), Udine, for the assessment and monitoring of CVD risk factors.

It was noted that the work being carried out in Italy within CINDI is substantial and it was hoped that Italy could become a full member of the programme within the coming year.

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Romania

Dr M.I. Popa reported that the local CINDI protocol had been finalized and intervention

guidelines prepared. An Operational Committee had been formed in October 1999 to coordinate and implement the programme. The Committee set up a Coordinating Council in February 2000 comprising representatives of ministries and groups involved in CINDI activities. The Council acts as an advisory body.

In Romania, the programme is being implemented in the demonstration area of Pucioasa. Much progress was made during their first year; activities included local health information campaigns, work to involve the local authorities and the training of baseline survey interviewers.

Despite financial and other restraints at national and local levels, it was planned that intervention would start in the demonstration area in the near future. It was envisaged that at least two more demonstration areas would be set up in 2000.

The enthusiasm and effort that has resulted in the good progress made in all three countries in their first year of CINDI membership was appreciated. The intervention projects mentioned by the new CINDI countries could be usefully shared with other countries.

2.3 Second period of cooperation between the WHO Regional Office for Europe and countries in respect of the WHO CINDI Programme

Dr Deguara signed the agreement for the second period of cooperation between the Ministry of Health of Malta and WHO/EURO in respect of the CINDI Programme.

A similar agreement was signed in May 2000 between Lithuania and WHO/EURO at the Ministry of Health of Lithuania.

3. Collaboration with headquarters

3.1 WHO global strategy for NCD prevention and control

Professor V. Grabauskas briefed the participants on the latest development related to the WHO global strategy for NCD prevention and control. He recalled that during the meeting of the Fifty- first World Health Assembly (WHA) in 1998, the very serious attitude of the countries to NCD prevention and control was clearly demonstrated through the adoption of the Resolution WHA 51.18 “Noncommunicable Disease Prevention and Control”.

At the meeting of the WHO Executive Board in January 2000, it was considered timely to formulate a concrete proposal on how to deal with NCD prevention and control. The report of the Director-General of WHO (DG) on NCD prevention and control was prepared.

In May 2000, the Fifty-third WHA was unanimous in its agreement to promote global action against NCD. Resolution WHA 53.17 “Prevention and control of noncommunicable diseases”

was adopted setting up very clear guidelines on how to plan the action to be taken. Many points were along the lines of the CINDI approach. (A copy of the Resolution was distributed at the meeting to all CINDI Programme Directors.)

For the first time in many years, the vast majority of countries recognize the burden of NCD.

NCD prevention and control has been declared a priority even by the developing and low and

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middle income countries. The measures proposed in Resolution WHA 53.17 to deal with these diseases – to take the commonality of the risk factors for major NCD as a major approach in attacking the problem globally – were the same as those used in the CINDI approach.

Professor Puska noted that CINDI had played an active role in the preparation of the Director- General’s report on NCD prevention and control.

In the light of these developments, the CINDI Programme Directors agreed that the time was optimal for them to address the Regional Director of WHO/EURO on the implementation of the WHA Resolution 53.17. A drafting group comprising Ms Ellul, Dr Gaffney, Professor

Grabauskas and Professor Puska was set up to prepare a letter for the signature of the Programme Directors at the meeting (Annex 10).

3.2 Global Forum on NCD prevention and control (GF)

Dr G. Goldstein transmitted the greetings of Dr A. Alwan, Director, NCD/HQ Cluster. He said that the global strategy for NCD prevention and control highlights the role of the WHO in stimulating regional and global networking for the integrated prevention of the major NCD and in strengthening community-based activities, particularly in the developing countries. The strategy recommends the establishment of a global network of national and regional programmes for the prevention and control of NCD in order to facilitate the dissemination of information and exchange of experiences, and to support regional and national initiatives. It provides the vision, principles and framework for the GF.

In connection with the need for practical NCD prevention programmes and better international collaboration, Professor Puska felt that the other WHO Regions might wish to consider adopting the approach being taken by CINDI and CARMEN.¹ The approval of this approach by the WHA gives a formal backing to the work being carried out by these programmes.

Dr Goldstein reported that a meeting on the GF, organized by the WHO headquarters NCD Cluster, was held in Joensuu, Finland, on 2–4 May 2000. With the exception of the Western Pacific Region (WPRO), all the Regions were represented. Discussion centred on the practical steps that would be connected to setting up CINDI and CARMEN-type networks in other Regions, as well as on the establishment and role of the proposed GF (Annex 4) short summary of the meeting).

The current plan of action related to setting up the GF was presented by Dr Goldstein as follows:

1. Endorsement of the report of the Joensuu consultation by the Directors of the WHO

Regional Offices and the Executive Director of the WHO headquarters MNH Cluster (June 2000).

2. Submission of a GF progress report to the CINDI and CARMEN Programme Management Committees (June 2000).

3. Establishment of a GF Steering Committee and organization of the first telephone conference (July 2000).

1 The CARMEN Programme is the WHO Region for the Americas’ programme equivalent to CINDI.

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4. Identification of seed funding for immediate activities, including the preparation of the first meeting in 2001 (July 2000).

5. Preparation of proposals for fund raising (July 2000).

6. Development of regional plans for the establishment of networks (? August 2000).

7. Development of regular interaction between the Regional Offices and the relevant departments of national Ministries of Health in order to strengthen synergism, prevent overlap¸ and maximize joint effort.

8. Preparation of papers on the GF for international fora such as the Fifth Preventive Cardiology Conference, May 2001.

During the ensuing discussion, Dr Busuttil, Professor Grabauskas and Professor Puska supported the idea of a GF. They proposed that, should it be established, representation of the regional programmes be at the level of the international network and not at the level of individual participating countries. It was also proposed that CINDI be represented by the WHO Regional Adviser for NCD Prevention, the Chairman of the CINDI Programme Management Committee and by a CINDI Programme Director elected on a rotational basis.

Dr Goldstein reported that it is yet to be determined whether the GF will absorb

INTERHEALTH. Questions on the future of this programme would be resolved in the coming months.

In Professor Glasunov’s opinion, a GF would help to develop and strengthen CINDI and its position in the Regional Office. It could also be useful for the Regional Office and headquarters together to build opportunities for training; the annual CINDI Winter School, for example, could be used for global purposes. Professor Glasunov pointed out that the development of the

demonstration area was the backbone of the CINDI Programme. He suggested setting up a consultation process to develop a strategy on how to position CINDI in the GF and to determine how CINDI can contribute.

In conclusion, the meeting supported the plans for the establishment of a GF. A consultation process should be launched on how CINDI could participate in the GF.

4. Collaboration with other WHO Regions

4.1 Regional Office for Africa (AFRO)

Dr A. Filipe Junior outlined the structure of the Division of NCD at WHO/AFRO which is relatively new having been created in September 1998.

In Africa there is a heavy burden of communicable diseases, now aggravated by HIV/AIDS, and an increase in NCD such as hypertension, rheumatic heart disease, diabetes and cancer.

Dr Filipe Junior said that there was an increasing awareness of the burden of NCD in Africa and of the way NCD is viewed by health decision-makers.

Dr Filipe Junior explained that they have started gathering data (community-based and hospital- based) on the real situation regarding NCD prevention and control. An Expert Committee has been set up and has prepared a regional strategy for NCD. Another group has made

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recommendations on the management of hypertension. There are guidelines on the management of diabetes. Several training courses have been held. NCD/AFRO is planning to set up a network of 5–10 countries as a demonstration. CINDI will be used as a model.

Professor F. de Padua kindly offered the assistance of CINDI-Portugal in launching CINDI-type programmes in Portuguese speaking communities.

4.2 Regional Office for the Eastern Mediterranean (EMRO)

Owing to other commitments Dr O. Khatib, Acting Regional Adviser, Noncommunicable Diseases, was unable to participate in the meeting.

4.3 Pan American Health Organization (PAHO)

It was noted that CINDI-CARMEN collaboration was very productive. CARMEN participated in the Quit and Win smoking cessation campaign, the second CINDI policy survey and the

CINDI/CARMEN survey on tobacco prevention and control policies. CARMEN chairs the Working Group on Physical Activity.

4.4 Collaboration with CDC

Mr G. Hogelin reported on some of the new activities being carried out at CDC that he felt might be of interest to the CINDI Programme Directors.

In the area of surveillance, comparative behavioural risk factor data on the 50 largest US cities are available. Work has also been carried out on policy development. As part of the CVD prevention programme, data on such process indicators as smoke-free worksites, availability of sidewalks and walking trails, and reduced-fat school lunches will be worked on. Mr Hogelin hoped that these data would be useful to the CINDI Programme Directors.

A second area that CDC has expanded is training. In 1999 they initiated a CVD Institute (a training course) in Black Mountain, Virginia, with international participation (students and faculty). The Institute will be repeated in 2001 and Mr Hogelin hoped that some of the CINDI programmes could be represented.

Another institute initiated is the Evidence-based, Chronic Disease Epidemiology Institute in San Diego, California. Here too international participation has been budgeted for and it was hoped that CINDI could take advantage of this course in the future.

CDC has recently developed a new community-based programme REACH, designed to address health disparities in the US: 32 communities were being funded in 2000 and it was hoped that 15 more could be funded in the near future. From these model projects it was hoped that new ways to approach community health could be found and that these fundings would help researchers such as CINDI programme teams.

Finally Mr Hogelin mentioned the “Prevention Effect” project that is a knowledge management system. This system will compile community-based research findings and look into the

effectiveness of community-based interventions. In the context of populations, it will identify actions taken and the effectiveness of those actions. It will enable practitioners to rapidly identify successful interventions, their settings and populations.

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In summary, CDC has new initiatives in surveillance, model projects, training and knowledge management. Mr Hogelin expressed the hope that these would be of use to CINDI in the future and he invited the participants to take advantage of them.

Dr Hogelin said that CDC was presently supporting the CINDI network with some modest resources and will be offering the same support to the CARMEN network. Should WHO

networks develop, CDC would be happy to extend this support. It was the aim of CDC to further the existing networks so that they may serve their constituents.

Dr Shatchkute expressed her appreciation of CDC’s support to CINDI and reported that the funds already received would be used for CINDI monitoring and evaluation in the countries.

CDC was also invited to participate in CINDI technical projects (e.g. hypertension management, assessing health inequalities).

Dr Shatchkute also mentioned that CINDI might be able to contribute to the CDC knowledge management system by providing programme experience.

Collaboration between CINDI and CDC can be used as an example to demonstrate to the GF how an institution can assist two regional networks and how networks can collaborate.

5. Working Groups

5.1 Joint report of the CINDI Working Groups

The joint report for 1999, containing annual reports from the Working Groups on Policy Development, Smoking, Children and Youth, Hypertension, Guidelines and Training for Preventive Practice, was distributed to all Programme Directors.

Professor Puska reminded the participants that the CINDI Working Groups² had been established so that important priority subject matters could be dealt with by interest groups.

The CINDI Programme Management Committee supervises and evaluates the work of the Groups. The Chair of each Working Group submits an annual report to the Chair of the CINDI Programme Management Committee.

Each Working Group has its own terms of reference and every year presents a plan of work for the approval of the CINDI Programme Directors.

The Working Groups are established for a certain period of time. When its work is completed a Working Group might be terminated or re-established.

The Working Group on Diabetes has completed its work. It is however possible that some issues still need to be addressed.

Concerning physical activity, CINDI will continue to participate in the CARMEN/CINDI Working Group on this topic.

2 Policy development, Monitoring, Evaluation and Research, Nutrition and Elevated Blood Cholesterol, Smoking, Children and Youth, Hypertension, Worksite Programmes, Guidelines and Training for Preventive Practice, Nursing, Diabetes.

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It was concluded that the working group system is useful but that it could be strengthened. Since there are a number of newcomers to CINDI, the time was right to ascertain which countries are interested in which groups. Programme Directors should review the list and let WHO/EURO know in which group(s) they wish to be involved.

5.2 Monitoring, evaluation and research

Future data collection and analysis strategy

The discussion was aimed at further elaborating the policy on access to and use of the CINDI database

At present a dataset resulting from the surveys on risk factors and process evaluation is available at the CINDI Data Management Centre (CDMC) (Annex 6). The Working Group on Monitoring, Evaluation and Research had recommended that the dataset become WHO property when the validity of the country data had been checked and the data incorporated in the database of the CDMC. Therefore it was recommended that a copy of the dataset also be kept in WHO/EURO.

Professor MacLean introduced a draft document regarding the policy on access to and use of the core dataset (risk factors and process evaluation surveys) (Annex 7). Professor Morava

commented that Principle 1 and Principle 3 outlined in the draft should be reworded since they contradicted each other. It was also noted that from the text it was not clear which data – raw or aggregated – were referred to. This should be rectified.

It was concluded that the draft document presented at the meeting is valid as policy document until the final version is elaborated.

It was agreed that any comments on the content of the policy guidelines on access to and use of data should be made to CINDI/EURO within two weeks after the meeting. If no response was received within this time limit, it would be understood that no comments were forthcoming.

At present several databases exist that contain the results of various surveys and to which CINDI Programme Directors have a certain degree of access. Therefore the discussion covered the issue of policy with respect to data collection, the establishment of databases and their storage, access to and use of databases.

It was concluded that the issue of the policy on access to and use of the CINDI data would be included in the agenda for the next meeting of the Working Group on Monitoring, Evaluation and Research.

The terms of reference of the Working Group on Monitoring, Evaluation and Research At its meeting on 17–18 March 2000, the CINDI Programme Management Committee approved the terms of reference of the Working Group on Monitoring, Evaluation and Research. The participants of the meeting discussed these terms of reference and approved them (Annex 8).

The terms of reference of the CINDI Data Management Centre (CDMC)

Professor Nüssel introduced his proposal to update the terms of reference of the CDMC to reflect the new opportunities provided by the development of information technology. Almost all

CINDI centres were able to establish their own databases, perform basic data analysis and send

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their data to the CDMC electronically. Therefore Professor Nüssel suggested that the CDMC should concentrate its efforts on better communication with CINDI centres through a system of error-checking raw data to establish certified data sets. Certified data would be placed on the Internet in such a way that the users could access it. The CDMC would then carry out data analyses as requested by the Working Group on Monitoring, Evaluation and Research or certified users.

Professor Nüssel’s proposal was supported. It was agreed that the terms of reference of the CDMC were to be amended to include reference to the high potential of the CDMC to improve communication among CINDI Centres.

5.3 Smoking

Quit and Win tobacco cessation campaign

Before presenting the experience of the International Quit and Win 2000, Professor Puska introduced the project. Countries participating in the Quit and Win campaign follow jointly agreed rules. Contestants are daily smokers of 18 years of age or older. They are required to abstain from smoking for at least four weeks. This is verified through a cotinine test of the winners. Based on earlier experience, an estimated 20% of the participants are still smoke-free at the one-year follow-up.

The Quit and Win campaign has rapidly grown in popularity as a practical, international smoking cessation intervention. It began in 1994 with the participation of 13 CINDI countries. In 1996, 25 countries took part and in 1998 there were over 200 000 participants involving over 48 countries world wide.

International Quit and Win 2000 – the fourth campaign – arranged in May 2000, set a new world record. About 420 000 smokers world wide were joined across 81 countries in the pursuit of the common goal to give up smoking. The National Public Health Institute (KTL), Finland,

coordinated International Quit and Win 2000, supported by the WHO and two commercial partners: Pharmacia Corporation and Glaxo Wellcome.

According to Professor Puska, the popularity of the campaign is largely due to its unique and positive approach to a problem that is receiving increasing attention world wide as a major health threat. “Contestants may win one of the prizes, but by quitting smoking they win over tobacco and all the harm it causes. Everyone who quits smoking is a winner.”

Dr Deguara, the Minister of Health of Malta, drew the winning lot for the Super prize of the International Quit and Win 2000 as follows:

International super prize: Chile Regional Prizes:

· European Region Russia

· American Region Cuba

· Eastern Mediterranean Region The United Arab Emirates

· South East Asian Region The Maldives

· Western Pacific Region Kiribati

· African Region Kenya

The results of the International Quit and Win 2000 will be presented and discussed at the meeting of the Working Group on Smoking, Copenhagen, 24–25 November 2001.

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Professor Puska proposed that the next Quit and Win campaign be organized in 2002. The

CINDI Programme Directors supported the proposal. They felt that this project is a very practical preventive activity and acknowledged the role of Professor Puska in its success.

It was noted that all promotional material produced in relation to the Quit and Win campaign at international level should include the CINDI logo among the logos of other supporting bodies.

Tobacco policies in CINDI-CARMEN countries

The Working Group on Smoking and the Working Group on Guidelines and Training for Preventive Practice are participating in the work related to the survey on tobacco policies initiated and supported by headquarters (the Tobacco Free Initiative and the CVD programme).

Professor Pardell presented the preliminary results of the survey on tobacco policies in CINDI- CARMEN countries. Almost all CINDI countries and a number of CARMEN countries participated in the survey.

The final report will be presented to WHO headquarters in July 2000. The CINDI Programme Management Committee will decide on the further analysis of the data.

CINDI millennium initiative on smoking prevention and reduction in health professionals Professor Pardell presented the preliminary design of the CINDI millennium initiative on smoking prevention and reduction in health professionals (Annex 11 – minutes of the Informal planning consultation, EURO, 6 April 2000). The project, which will focus on physicians (including students), will be the responsibility of the Working Group on Smoking and the Working Group on Guidelines and Training Preventive Practice and will be implemented in partnership with the WHO/EURO Tobacco or Health programme. Collaboration will also be established with EUROPREV (the European Review Group on Prevention and Health Promotion in General Practice/Family Medicine, Web site at www.europrev.org). Dr M.R. Sammut,

EUROPREV, explained its activities. A survey on the attitudes and knowledge of GPs in relation to disease prevention and health promotion was the current major activity of the Group.

It was agreed that the CINDI-Catalonia team would work in close collaboration with the CINDI- Finland team and the EUROPREV secretariat to collect available information about tobacco use by health professionals, particularly physicians. The CINDI Working Group on Smoking will organize a meeting in Copenhagen on 24–25 November 2000 where the development of this project will be decided.

Those interested in taking part in the project should inform WHO/EURO.

5.4 Hypertension

Pharmacy-based hypertension management project

CINDI and the EuroPharm Forum will run a pilot project on the feasibility of the protocol and guidelines for the project, “Pharmacy-based hypertension management model”. Estonia, Latvia, Lithuania, Portugal, Slovenia and Spain (Catalonia) are involved in the project.

Developments in self-measurement of blood pressure

The document on self-measurement of blood pressure, “Guidelines for the use of self blood pressure monitoring: a summary report of the first international consensus conference” (Journal

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of Hypertension 18: 493–508 (2000)) and the document prepared by the CINDI Working Group on Hypertension on self-measurement of blood pressure (final draft) have been distributed. How these should be recommend for practice in the CINDI countries needs to be discussed.

The CINDI statement on the clinical and epidemiological uses of automatic devices for blood pressure measurement, submitted to and endorsed by the CINDI Programme Directors at the 16^th annual meeting in Dornbirn in 1999, has been distributed to CINDI countries.

Survey on policies regarding hypertension prevention and management

Professor Pardell introduced a proposal to assess the current situation regarding policies on hypertension prevention and management in CINDI countries. It was agreed that the

questionnaire to be used to update the hypertension management survey would be similar to the one used in 1994, with the addition of a few new topics. Some data could be obtained from the CDMC.

The above three topics will be on the agenda of the next meeting of the Working Group on Hypertension which is planned for end 2000.

5.5 Workplace

Professor W. Drygas referred to previous meetings where problems with the Working Group had been discussed. He commented that although there are numerous preventive activities directed to workplace in the countries, little interest in participating had been shown by the countries and no finances were available to support activities of the Working Group. As an example, he referred to the document “Guidelines on improving the physical fitness of employees” produced jointly by the WHO/EURO Occupational Health and CINDI programmes and edited by Mr F. Kelly several years previously. It had not been possible to publish the document owing to lack of funds.

Professor Drygas reported that he had carried out a survey (17 countries responded to the questionnaire) on workplace programmes in CINDI countries. CINDI programmes in Austria, Belarus, Bulgaria, Canada, Croatia, the Czech Republic, Finland, Malta, Poland, Russia, Slovakia had experience in interventions at the workplace. The number of enterprises where health promotion and diseases prevention activities were implemented varied from 1–3

(Bulgaria, Belarus, Russia) to 100 (Canada). In most countries CINDI activities were financed by the enterprises involved. In Belarus, Canada, Croatia, Russia special documents on

interventions at the workplace were produced. Intervention programmes in most countries were focused on smoking, hypertension and obesity.

Professor Drygas proposed combining this Working Group with the Working Group on Physical Activity. He also requested that another Programme Director be nominated as Chair.

The participants thanked Professor Drygas for his report and for the work done. It was concluded that if this Working Group were to continue, resources would need to be found to support it (e.g.

by approaching companies in countries).

It was recommended that the CINDI Programme Management Committee determine whether the Working Group should continue and if so identify a Chair.

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5.6 Children and Youth

Professor Grabauskas outlined the two main activities covered by the Working Group:

(1) drafting of joint publications on: a) the assessment CINDI Children’s component activities in national centres; b) the results of breast-feeding support programmes in CINDI countries;

c) changes in the health behaviour of school-aged children in the CINDI countries (results of 1994 and 1998 cross-national surveys); (2) updating international data files.

It is planned to continue the elaboration of the CINDI document: “Policy guidelines for smoking prevention among children and youth”. At the meeting of the CINDI Working Group on

Children and Youth in Kaunas on 8–9 March 1999, an initiative group comprising

representatives from Estonia, Finland, Lithuania, Russia and Slovakia was identified to elaborate the above-mentioned document. The group was asked to prepare the first proposals for the document by the end of June 2000. It was envisaged that the Working Group on Smoking would collaborate in this work.

The Working Group also plans to be involved in the development of a “Nonsmoking Class Competition” for CINDI countries. An initiative group comprising representatives from Estonia, Finland, Lithuania and Russia was encouraged to elaborate proposals for this project.

5.7 Nutrition and Elevated Blood Cholesterol

Professor MacLean reported that the CINDI dietary guide was finalized. It will be available in English and Russian. Countries were encouraged to translate the document or use it as a background document when preparing national nutrition guides. Professor Glasunov informed the participants that the document had already been successfully used by the CINDI-Russia team in the elaboration of the national healthy nutrition policy in Russia.

Professor MacLean informed the participants that he, as Chair of the CINDI Working Group on Nutrition and Elevated Blood Cholesterol, had participated in the consultation on the

development of the First Food and Nutrition Action Plan for the WHO European Region held in Malta on 8–10 November 1999, organized by the WHO/EURO Programme for Nutrition, Infant Feeding and Food Security. CINDI is one of four WHO/EURO programmes contributing to the elaboration of the Action Plan for Food and Nutrition Policy in the WHO European Region. The CINDI dietary guide is one of the products to be used in the implementation of the Action Plan.

It was agreed that practical use of the CINDI dietary guide in countries, training of health professionals on healthy nutrition and improvement in monitoring nutrition and dietary habits would be CINDI priorities in the Action Plan.

Dr J. Maucec Zakotnik presented a summary of the outcome of the WHO/EURO

multidisciplinary training seminar for policy makers on food and nutrition action plans in Southeast Europe that took place on 1–3 June 2000 in Krajn, Slovenia. CINDI-Slovenia participated actively in the seminar. Its aim was to explore current policies related to food and nutrition, to develop an intersectoral food safety, nutrition and supply chain action plan, and to elaborate a strategy to develop and implement a national food and nutrition action plan. Eight countries participated. The seminar was very useful for strengthening intervention in the field of nutrition.

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5.8 CARMEN/CINDI Working Group on Physical Activity

Interest in participating in the above Working Group was shown by Austria, Canada, Poland, Portugal and Slovenia. It was agreed that Professor MacLean would represent CINDI at the next meeting of the Working Group to be held in Sao Paolo, Brazil, in October 2000.

5.9 Nursing

The Chair of the Working Group on Nursing had resigned. It was noted that over the last two years the Working Group had not been functioning.

It was the general consensus that the area of nursing is important in CINDI. Therefore those CINDI Programme Directors that were interested in forming a new group should send the name of their programme representative to EURO. It was agreed that if the group were to be set up, Professor A. Nissinen would be asked to act as Chair.

5.10 Diabetes

On behalf of Professor Z. Metelko, Dr D. Muacevic-Katanec demonstrated the Croatian Diabetes register and proposed that links with the diabetes databases of other CINDI countries be

established to enhance prevention of CVD in persons with diabetes. It was agreed that the CINDI Programme Management Committee would revise the terms of reference of this Working Group.

5.11 Guidelines and Training for Preventive Practice

Continuing Medical Education (CME)

Dr Sammut, representative of EUROPREV, explained the main objectives of that Organization.

These were mainly centred on antismoking initiatives and other preventive practices. The collaboration of EUROPREV with CINDI was acknowledged and strongly supported.

A short report of the WORKING GROUP meeting (Barcelona, November 1999) was presented.

The meeting was held at the WHO European Centre for Integrated Health Care Services in Barcelona (Dr M. Garcia-Barbero) with the participation of Dr J.R. Eskerud, Dr M. Garcia- Barbero, Professor V. Grabauskas, Dr A. Oriol-Bosch, Professor Pardell, Dr Shatchkute, Dr Tresserras as well as local observers and experts.

In accordance with the main conclusions and recommendations of the Barcelona meeting, a survey on the current situation regarding CME and needs assessment in CINDI countries was carried out in the months prior to the present meeting. The response rate was very low.

Following the suggestions made at the UEMS (Union Européenne de Médecins Spécialistes) meeting “Consensus on CME of the European Accreditation Council for CME”, Brussels, 12 May 2000, in which Professor Pardell represented CINDI, the Programme Directors encouraged the Working Group to further explore possibilities of implementing a pilot project related to a CME accreditation system in the CINDI context.

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CINDI masters in population health

Professor Grabauskas gave a very brief résumé of the history of this initiative:

· The faculty of the CINDI Winter School identified a need for extended training in public health, based on the CINDI concepts.

· Two small-scale consultations were held to discuss the process of establishing such training.

· A master collaborative project design was presented to EURO; CINDI Programmes in Canada, Finland, Lithuania, Russia and Spain (Catalonia) agreed to participate.

Since it had been not possible to further develop the project owing to shortage of funds in EURO, it was proposed that possibilities of collaboration among the above-mentioned CINDI programmes be explored so that those interested in a CINDI-MPH degree could start collecting credits. Two CINDI centres offered courses from January 2001: Finland (a one-credit course through the North Karelia Visitors Programme) and Lithuania (a two-credit course on

“Epidemiological foundations for the integrated prevention of noncommunicable diseases”).

It was agreed that one credit could be awarded for participation in the CINDI Winter School (40 hours’ student time per week).

Dr Shatchkute commented that an application for USD 400 000 from WHO headquarters efficiency funds had been made for this initiative. A response was awaited.

6. CINDI monitoring and evaluation

6.1 Methodology

Manual of operation – Monitoring and evaluation: CINDI Programme

Professor MacLean summarized the content of the second draft of the document “Manual of operation – Monitoring and evaluation: CINDI Programme” which had been sent to all

Programme Directors. It was compiled from the CINDI Protocol and Guidelines issued in 1987 and updated in 1996 and various CINDI survey questionnaires. The document also contains instructions regarding transfer of risk factor data to the CDMC using a data transfer format.

It was proposed that the process evaluation questionnaire contained in the second draft be replaced by a questionnaire on health behaviour and lifestyle-related risk factors. The smoking questionnaire recommended for use in the risk factor surveys differs from the smoking

questionnaire currently recommended by WHO headquarters. The Working Group on

Monitoring, Evaluation and Research and the CINDI Management Committee should determine which smoking-related questionnaire is to be used in CINDI surveys.

The participants were asked to review the document, paying special attention to the part on the methodology and system of CINDI core data collection and analysis (mainly risk factor surveys).

This area could be more clearly described and proposals to this end were requested. Comments on the manual of operation are to be sent to WHO/EURO within one month after the meeting.

It was noted that, from the data collected during risk factor surveys, it is difficult to calculate the proportion of hypertensives in CINDI countries since the relevant questionnaire does not seek

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information on people undergoing treatment. Therefore, when preparing the new questionnaire, the question “Are you taking drugs for high blood pressure?” will be included. The same applies to the issue of high cholesterol.

Dr V. Moltchanov will modify the data transfer format to include questions regarding treatment for hypertension and hypercholesterolemia.

CINDI process evaluation

The principles of common process evaluation in CINDI were agreed already some 10 years previously when a common questionnaire for this evaluation was prepared.

Professor MacLean reported that the process evaluation surveys carried out in countries indicated that the process evaluation questionnaire was not very useful for monitoring health behaviour and that some questions were ambiguous. Therefore a recommendation had been made by the CINDI Working Group on Monitoring, Evaluation and Research to replace this questionnaire with a new questionnaire.

Professor Puska explained that the FINBALT study group and the Working Group on Monitoring, Evaluation and Research, together with WHO/EURO, had elaborated the new questionnaire (Annex 5). It is aimed at monitoring risk factors and lifestyle-related health

behaviour at the community level and is based on the questionnaire used in the FINBALT Health Monitor survey. It includes most of the questions contained in the old process evaluation survey.

It was noted that Estonia, Finland, Latvia, and Lithuania were participating in the FINBALT project. These countries have very good experience in carrying out these surveys and it has been shown that the results and data are very useful for various purposes.

The new questionnaire was briefly discussed. The Programme Directors agreed on the proposed replacement. Since the survey will reflect mainly health behaviour and lifestyle-related risk factors, it was agreed to refer to it as the “CINDI health monitor survey” rather than the “process evaluation survey”.

It was noted that CINDI process evaluation should be intensified. The methodology described in the CINDI Handbook for Process Evaluation in Noncommunicable Disease Prevention should be used for this purpose.

Dr Laatikainen introduced the methodology of the CINDI health monitor survey. It was recommended that the survey be carried out either in the demonstration area(s) or nationwide.

Since the ultimate goal of CINDI is to implement the programme at national level, it was agreed that the survey could be conducted at national level as a random sample survey. It was also recommended that an independent additional sample survey be conducted in the same demonstration area(s) as the risk factor surveys. If it is not feasible to conduct the survey at national level, it could be carried out in the demonstration area(s) only.

The sample should be of at least 1500 persons and the core age group between 25 and 64 years.

Each country will be free to have additional samples from younger or older age groups.

The survey questionnaire includes two categories of questions: (1) an obligatory survey question;

(2) a highly recommended survey question. It was noted that when countries run the survey, additional questions could be added to serve local needs.

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Countries can choose their own methods of data collection according to their possibilities and situation. Data can be collected by mail, by telephone interview or by personal interview. The survey should be carried out twice in a five-year period.

It was emphasized that, in order to be able to assess the trends, countries shall use the same survey methodology every time. It was noted that to have comparable data and establish a data archive of good quality, every survey should contain details on the survey area and method of data collection, as well as contacting information in respect of those charge of the study.

It was agreed that in 2000–2001, a pilot round of CINDI health monitor surveys would be carried out in as many countries as possible (Table 2). Raw data from these surveys will not be gathered centrally. Each country will process its own data. Data could be then analysed for specific purposes in one centre (e.g. data could be sent in table format to CINDI-Finland for elaboration of a report).

It was recommended that a training seminar on the methodology and procedures of the CINDI health monitor be organized. Professor Puska kindly agreed to support a training seminar in Helsinki in autumn 2000.

The support received from CDC for the CINDI monitoring and evaluation component was appreciated very much.

Table 2

Country Process evaluation surveys already carried out Interest in carrying out the proposed CINDI Health

Monitor Survey Bulgaria No earlier studies Interested in carrying out

survey in demonstration area Canada Health and lifestyle survey carried out annually

Croatia Survey carried out in 1995 Interested in carrying out the survey

Comment: New questionnaire needs to be discussed Estonia FINBALT Health Monitor Survey carried out every

second year

Will continue the FINBALT surveys

Finland Health behaviour survey carried out annually

Hungary Health behaviour survey carried out in 1996. Interested in carrying out the survey

Italy No process evaluation surveys carried out Survey could be done in demonstration areas NB: Mail questionnaire not possible

Latvia Participation in FINBALT Lithuania FINBALT Health Monitor Survey carried out every

second year

Questionnaire includes additional questions to back up national policy

Will continue the FINBALT surveys

Romania No earlier process evaluation surveys Interested in carrying out the survey in 2000–2001 Turkmenistan No earlier process evaluation surveys

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6.2 CINDI data analysis

Mortality trends in CINDI countries

Professor Grabauskas introduced the results of the further mortality trends analysis at national level. He said that the question of types of mortality data analyses had been discussed on several occasions. For the present meeting, the data on mortality trends had been analysed as proposed by the CINDI Working Group on Monitoring, Evaluation and Research and approved by the CINDI Programme Management Committee in 1999.

The data analysed are from the WHO HFA database and include data on mortality from all causes, cancer, CVD and coronary heart disease. Data are presented by five-year age groups within the 25–64 years age group, for males and females.

Professor Grabauskas commented that the Working Group on Monitoring, Evaluation and Research had recommended that the starting point for analysis be 1985. The current analysis was carried out by analysing trends and then grouping countries according to trends (increasing, decreasing, and stable). The results of the analysis were presented in graphics. Professor Grabauskas noted that it is also possible to demonstrate the results using a map. This technique makes country grouping clearer. However, since 1991, a number of countries in central and eastern Europe have experienced a sharp increase followed by a decreasing trend in all causes and CVD mortality and it is not possible to reflect this aspect on a map. Therefore, Professor Grabauskas proposed that other types of data analysis be considered, e.g. taking 1991–92 as a second starting point for data analysis.

It was concluded that the data analysis will be finalized and the trends presented in tables and graphics. Further consideration will need to be given to how country groupings can be presented.

The results of the analysis will be sent to WHO/EURO for entry into the CINDI website.

Countries were encouraged to collect mortality data at demonstration area level also.

Introduction of the databook on risk factors

Professor Nüssel presented the structure and content of the databook (in accordance with the recommendations of the meeting of the Working Group on Monitoring, Evaluation and

Research, Heidelberg, 1–2 October 1999). It is now available on the Internet (CDMC website).

The CINDI/EURO homepage and the CDMC homepage were demonstrated.

It was recommended that countries check the data presented. It was concluded that for the purpose of data analysis, it was necessary to know whether risk factor surveys had been carried out according to the CINDI Protocol and Guidelines.

It was very much appreciated that the databook on risk factors is now on the Internet and accessible. Those Programme Directors who do not have a password should contact Professor Nüssel (either before the end of the meeting or by mail after the meeting).

Analysis of risk factors surveys data

Professor Puska reported that the data was in the process of being analysed; no draft was yet available.

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Alcohol data analysis

In 1999, the Working Group on Monitoring, Evaluation and Research proposed that an analysis of data on alcohol and physical activity be initiated. At the 16^th annual meeting of the CINDI Programme Directors in Dornbirn in June 1999, Professor Grabauskas presented a possible method of analysing the alcohol data using the alcohol questionnaire contained in Annex 9 of the CINDI Protocol and Guidelines. CINDI-Lithuania was charged with assisting the CDMC in checking the availability of data on alcohol use for comparative analysis and was granted access to the data available at the CDMC. It was found that eight countries had submitted data on alcohol. However, for technical reasons, several of the data files were inaccessible. Recently several countries had sent new data, which would seem to indicate that more data were available.

The analysis of the data to hand (Annex 9) indicated that each country had used its own set of survey questions thus making a common analysis impossible.

Professor Grabauskas concluded that the results of this analysis showed that it was not clear how many countries have data on alcohol. A decision was needed on which questionnaire should be used in order to allow a standardized presentation of the data.

In the ensuing discussion, Dr Gaffney, Dr Moltchanov and Professor Puska stressed the importance of adhering to the methodology defined in the CINDI Protocol and Guidelines.

Professor Morava commented that even if only one of the questions were common to all

questionnaires used in an alcohol survey, the answer would depend on the culture of the country.

He felt that, since alcohol was such an important lifestyle component, whatever data were

available should be used for comparison. Ms M. Ellul commented that the surveys on alcohol use should reflect the various age groups of the population.

It was agreed that attempts to analyse alcohol use should be continued. In order to assess the comparability of the data already collected, the Programme Directors – by the end of the meeting if possible – would reply to the following questions: Which data on alcohol did your country programme submit to the CDMC? Which questions were used in your country?

It was concluded that if it were not possible to pool the data, countries would be encouraged to prepare case studies.

It was reconfirmed that the questions on alcohol consumption as defined in Annex 6 of the CINDI Protocol and Guidelines are obligatory in risk factor surveys. Countries were encouraged to use additional questions that would allow them to determine the trends in their countries.

CVD in women

Professor MacLean reported that all the CINDI countries had been contacted with the proposal to participate in a study on CVD in women. A data template (for data on CVD mortality and the level of risk factors) was made available in case of interest. There were two requirements for participation: 1) that countries were able to analyse their own data; 2) that the data were at least from 1995. Six countries had completed the data template and another six had agreed to

participate. Other countries with data they can analyse themselves can be included.

The results of the analysis were presented at the First International Conference on Women, Heart Disease and Stroke, Victoria, British Columbia, Canada, 7–10 May 2000, and will also be

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presented at the IEA European Regional Meeting “From Molecules to Public Health”, Kaunas, Lithuania, 24–26 August 2000.

7. Policy development

7.1 Second comparative analysis

In the absence of Dr A. Petrasovits, progress achieved in the second comparative analysis of policy development and implementation processes in CINDI programmes was reported by Professor I. Glasunov, Co-chair of the Working Group on Policy Development.

Professor Glasunov reminded the participants that the CINDI Working Group on Policy Development initiated the study in November 1998. A questionnaire had been elaborated and distributed to CINDI and CARMEN participating countries. All CINDI countries and three CARMEN countries participated in the survey. One country, in addition to information on policy issues at national level, also sent information on policy development and implementation

processes in eight CINDI participating regions of the country.

An Ad Hoc Working Group³ met in L’Esterel, Canada, in January 2000 to review the completed questionnaires and advise on possible ways of analysing the data. A preliminary database was set up with the support of the Memorial University, Newfoundland, Canada, under the leadership of Dr A. Petrasovits. Data from the first CINDI policy survey will be added to the database in the future.

The Co-Chairs met in Montreal in April 2000 to specify the content of the database, determine priorities for analysis and attempt to prepare some basic tables. A preliminary report on the survey was elaborated. The report was presented and discussed at a meeting of the Ad Hoc Working Group on 8 June in Malta. Professor Glasunov summarized the outcome of the

Montreal meeting, the report of which was distributed to all participants in the present meeting.

It was noted that interest in prevention by the health care systems, the role of primary health care in CINDI implementation, and the possibility of linking primary health care and public health were rated as the highest strategic issues facing CINDI in the future.

The work done by the Working Group on Policy Development and the Ad Hoc Group on the survey analysis was appreciated.

It was concluded that the analysis of the data resulting from the second CINDI policy survey should be continued and a report prepared. It was proposed that the results be submitted to a journal for publication. Although some countries submitted both national and demonstration area information, it was agreed that only national data would be used in the analysis. Data from demonstration areas can be analysed separately but in this case it will be necessary to have data from all demonstration areas.

It was agreed that in the meantime the countries should verify the country data included in the database. Countries wishing to use the data shall seek permission to do so from the country that owns the data.

3 Dr B. Gaffney, Professor I. Glasunov (Co-Chair), Dr G. Hogelin, Professor I. Miseviciene, Dr V. Molchanov, Professor H. Pardell, Dr A. Petrasovits (Chair), Dr A. Peruga, Dr A. Shatchkute, Dr S. Stachenko, Dr R. Tresseras.