An information theory based framework for the measurement of population health

This paper proposes a new framework for the measurement of population health and the ranking of the health of different geographies. Since population health is a latent variable, studies which measure and rank the health of different geographies must aggregate observable health attributes into one summary measure. We show that the methods used in nearly all the literature to date implicitly assume that all attributes are infinitely substitutable. Our method, based on the measurement of multidimensional welfare and inequality, minimizes the entropic distance between the summary measure of population health and the distribution of the underlying attributes. This summary function coincides with the constant elasticity of substitution and Cobb–Douglas production functions and naturally allows different assumptions regarding attribute substitutability or complementarity. To compare methodologies, we examine a well-known ranking of the population health of U.S. states, America's Health Rankings. We find that states’ rankings are somewhat sensitive to changes in the weight given to each attribute, but very sensitive to changes in aggregation methodology. Our results have broad implications for well-known health rankings such as the 2000 World Health Report, as well as other measurements of population and individual health levels and the measurement and decomposition of health inequality.     

Heart Failure Care in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Background

Heart failure places a significant burden on patients and health systems in high-income countries. However, information about its burden in low- and middle-income countries (LMICs) is scant. We thus set out to review both published and unpublished information on the presentation, causes, management, and outcomes of heart failure in LMICs.

Methods and Findings

Medline, Embase, Global Health Database, and World Health Organization regional databases were searched for studies from LMICs published between 1 January 1995 and 30 March 2014. Additional unpublished data were requested from investigators and international heart failure experts. We identified 42 studies that provided relevant information on acute hospital care (25 LMICs; 232,550 patients) and 11 studies on the management of chronic heart failure in primary care or outpatient settings (14 LMICs; 5,358 patients). The mean age of patients studied ranged from 42 y in Cameroon and Ghana to 75 y in Argentina, and mean age in studies largely correlated with the human development index of the country in which they were conducted (r = 0.71, p<0.001). Overall, ischaemic heart disease was the main reported cause of heart failure in all regions except Africa and the Americas, where hypertension was predominant. Taking both those managed acutely in hospital and those in non-acute outpatient or community settings together, 57% (95% confidence interval [CI]: 49%–64%) of patients were treated with angiotensin-converting enzyme inhibitors, 34% (95% CI: 28%–41%) with beta-blockers, and 32% (95% CI: 25%–39%) with mineralocorticoid receptor antagonists. Mean inpatient stay was 10 d, ranging from 3 d in India to 23 d in China. Acute heart failure accounted for 2.2% (range: 0.3%–7.7%) of total hospital admissions, and mean in-hospital mortality was 8% (95% CI: 6%–10%). There was substantial variation between studies (p<0.001 across all variables), and most data were from urban tertiary referral centres. Only one population-based study assessing incidence and/or prevalence of heart failure was identified.

Conclusions

The presentation, underlying causes, management, and outcomes of heart failure vary substantially across LMICs. On average, the use of evidence-based medications tends to be suboptimal. Better strategies for heart failure surveillance and management in LMICs are needed. Please see later in the article for the Editors'' Summary     

The Matthew effect in health development.

A study was conducted examining the paradox that populations with a poor standard of health seem to achieve only meagre improvements over time, whereas those with a good standard of health seem to show continual, substantial improvement. The health states of 122 nations were measured by reference to their infant mortality in 1965 and the changes that occurred over the next 20 years. Countries with low infant mortality in 1965 (for example, Japan and East Germany) achieved substantial, further declines over the 20 years, whereas in countries such as Rwanda and Ethiopia infant mortality hardly declined at all or even increased (Ethiopia 165/1000 to 168/1000). In 48 countries for which data were available there was a close link between the change in health state of a people and the ratio of government expenditure on health and defence. As the ratio increased in favour of defence, so the improvement in health state of a people declined; the reverse was also true. At the primary care level disparity in uptake of care both among and within communities was associated with literacy and socioeconomic state, services inadvertently being aimed at those sections most likely to benefit. The forces that act to produce this setting of unequal care must be checked at both national and primary levels if we are to have "Health for All by the Year 2000."     

Excess Mortality in Patients with Severe Mental Disorders in 1996-2010 in Finland

Unselected population-based nationwide studies on the excess mortality of individuals with severe mental disorders are scarce with regard to several important causes of death. Using comprehensive register data, we set out to examine excess mortality and its trends among patients with severe mental disorders compared to the total population. Patients aged 25–74 and hospitalised with severe mental disorders in 1990–2010 in Finland were identified using the national hospital discharge register and linked individually to population register data on mortality and demographics. We studied mortality in the period 1996–2010 among patients with psychotic disorders, psychoactive substance use disorders, and mood disorders by several causes of death. In addition to all-cause mortality, we examined mortality amenable to health care interventions, ischaemic heart disease mortality, disease mortality, and alcohol-related mortality. Patients with severe mental disorders had a clearly higher mortality rate than the total population throughout the study period regardless of cause of death, with the exception of alcohol-related mortality among male patients with psychotic disorders without comorbidity with substance use disorders. The all-cause mortality rate ratio of patients with psychotic disorders compared to the total population was 3.48 (95% confidence interval 2.98–4.06) among men and 3.75 (95% CI 3.08–4.55) among women in the period 2008–10. The corresponding rate ratio of patients with psychoactive substance use disorders was 5.33 (95% CI 4.87–5.82) among men and 7.54 (95% CI 6.30–9.03) among women. Overall, the mortality of the total population and patients with severe mental disorders decreased between 1996 and 2010. However, the mortality rate ratio of patients with psychotic disorders and patients with psychoactive substance use disorders compared to the total population increased in general during the study period. Exceptions were alcohol-related mortality among patients with psychoactive substance use disorders and female patients with psychotic disorders, as well as amenable mortality among male patients with psychotic disorders. The mortality rate ratio of persons with mood disorders compared to the total population decreased. The markedly high mortality amenable to health care intervention among patients with severe mental disorders found in our study suggests indirectly that they may receive poorer quality somatic care. The results highlight the challenges in co-ordinating mental and somatic health services.     

Dietary habits and mortality in 11,000 vegetarians and health conscious people: results of a 17 year follow up.

OBJECTIVE: To investigate the association of dietary habits with mortality in a cohort of vegetarians and other health conscious people. DESIGN: Observational study. SETTING: United Kingdom. SUBJECTS: 4336 men and 6435 women recruited through health food shops, vegetarian societies, and magazines. MAIN OUTCOME MEASURES: Mortality ratios for vegetarianism and for daily versus less than daily consumption of wholemeal bread, bran cereals, nuts or dried fruit, fresh fruit, and raw salad in relation to all cause mortality and mortality from ischaemic heart disease, cerebrovascular disease, all malignant neoplasms, lung cancer, colorectal cancer, and breast cancer. RESULTS: 2064 (19%) subjects smoked, 4627 (43%) were vegetarian, 6699 (62%) ate wholemeal bread daily, 2948 (27%) ate bran cereals daily, 4091 (38%) ate nuts or dried fruit daily, 8304 (77%) ate fresh fruit daily, and 4105 (38%) ate raw salad daily. After a mean of 16.8 years follow up there were 1343 deaths before age 80. Overall the cohort had a mortality about half that of the general population. Within the cohort, daily consumption of fresh fruit was associated with significantly reduced mortality from ischaemic heart disease (rate ratio adjusted for smoking 0.76 (95% confidence interval 0.60 to 0.97)), cerebrovascular disease (0.68 (0.47 to 0.98)), and for all causes combined (0.79 (0.70 to 0.90)). CONCLUSIONS: In this cohort of health conscious individuals, daily consumption of fresh fruit is associated with a reduced mortality from ischaemic heart disease, cerebrovascular disease, and all causes combined.     

Drug control: a prerequisite for health

The purchase of drugs employs an increasingly large part of the health budget of many Third World countries. Like health care expenditure as a whole, drug spending is heavily biased in favour of urban hospitals, often for expensive proprietary drugs that offer little benefit over cheaper preparations. As a result, because limited funds are available, vaccines and drugs for prevention and primary care are sometimes unavailable, especially in rural areas. The World Health Organization and many individual countries have responded to the problem of drug costs by creating a limited list of drugs considered essential for health care needs. Other methods of curtailing spending on drugs have included tendering for supplies and the establishment of plants to manufacture and formulate drugs. Controls of this type meet enormous resistance from doctors and pharmaceutical manufacturers, but are vital for the implementation of policies for appropriate health care.     

Severe imported falciparum malaria: a cohort study in 400 critically ill adults

Background

Large studies on severe imported malaria in non-endemic industrialized countries are lacking. We sought to describe the clinical spectrum of severe imported malaria in French adults and to identify risk factors for mortality at admission to the intensive care unit.

Methodology and Principal Findings

Retrospective review of severe Plasmodium falciparum malaria episodes according to the 2000 World Health Organization definition and requiring admission to the intensive care unit. Data were collected from medical charts using standardised case-report forms, in 45 French intensive care units in 2000–2006. Risk factors for in-hospital mortality were identified by univariate and multivariate analyses.Data from 400 adults admitted to the intensive care unit were analysed, representing the largest series of severe imported malaria to date. Median age was 45 years; 60% of patients were white, 96% acquired the disease in sub-Saharan Africa, and 65% had not taken antimalarial chemoprophylaxis. Curative quinine treatment was used in 97% of patients. Intensive care unit mortality was 10.5% (42 deaths). By multivariate analysis, three variables at intensive care unit admission were independently associated with hospital death: older age (per 10-year increment, odds ratio [OR], 1.72; 95% confidence interval [95%CI], 1.28–2.32; P = 0.0004), Glasgow Coma Scale score (per 1-point decrease, OR, 1.32; 95%CI, 1.20–1.45; P<0.0001), and higher parasitemia (per 5% increment, OR, 1.41; 95%CI, 1.22–1.62; P<0.0001).

Conclusions and Significance

In a large population of adults treated in a non-endemic industrialized country, severe malaria still carried a high mortality rate. Our data, including predictors of death, can probably be generalized to other non-endemic countries where high-quality healthcare is available.     

Gestational age patterns of fetal and neonatal mortality in Europe: results from the Euro-Peristat project

Background

The first European Perinatal Health Report showed wide variability between European countries in fetal (2.6–9.1‰) and neonatal (1.6–5.7‰) mortality rates in 2004. We investigated gestational age patterns of fetal and neonatal mortality to improve our understanding of the differences between countries with low and high mortality.

Methodology/Principal Findings

Data on 29 countries/regions participating in the Euro-Peristat project were analyzed. Most European countries had no limits for the registration of live births, but substantial variations in limits for registration of stillbirths before 28 weeks of gestation existed. Country rankings changed markedly after excluding deaths most likely to be affected by registration differences (22–23 weeks for neonatal mortality and 22–27 weeks for fetal mortality). Countries with high fetal mortality ≥28 weeks had on average higher proportions of fetal deaths at and near term (≥37 weeks), while proportions of fetal deaths at earlier gestational ages (28–31 and 32–36 weeks) were higher in low fetal mortality countries. Countries with high neonatal mortality rates ≥24 weeks, all new member states of the European Union, had high gestational age-specific neonatal mortality rates for all gestational-age subgroups; they also had high fetal mortality, as well as high early and late neonatal mortality. In contrast, other countries with similar levels of neonatal mortality had varying levels of fetal mortality, and among these countries early and late neonatal mortality were negatively correlated.

Conclusions

For valid European comparisons, all countries should register births and deaths from at least 22 weeks of gestation and should be able to distinguish late terminations of pregnancy from stillbirths. After excluding deaths most likely to be influenced by existing registration differences, important variations in both levels and patterns of fetal and neonatal mortality rates were found. These disparities raise questions for future research about the effectiveness of medical policies and care in European countries.     

Examining the Ugandan health system’s readiness to deliver rheumatic heart disease-related services

BackgroundIn 2018, the World Health Assembly mandated Member States to take action on rheumatic heart disease (RHD), which persists in countries with weak health systems. We conducted an assessment of the current state of RHD-related healthcare in Uganda.Methodology/Principal findingsThis was a mixed-methods, deductive simultaneous design study conducted in four districts of Uganda. Using census sampling, we surveyed health facilities in each district using an RHD survey instrument that was modeled after the WHO SARA tool. We interviewed health workers with experience managing RHD, purposively sampling to ensure a range of qualification and geographic variation. Our final sample included 402 facilities and 36 health workers. We found major gaps in knowledge of clinical guidelines and availability of diagnostic tests. Antibiotics used in RHD prevention were widely available, but cardiovascular medications were scarce. Higher levels of service readiness were found among facilities in the western region (Mbarara district) and private facilities. Level III health centers were the most prepared for delivering secondary prevention. Health worker interviews revealed that limited awareness of RHD at the district level, lack of diagnostic tests and case management registries, and absence of clearly articulated RHD policies and budget prioritization were the main barriers to providing RHD-related healthcare.Conclusions/SignificanceUganda’s readiness to implement the World Health Assembly RHD Resolution is low. The forthcoming national RHD strategy must focus on decentralizing RHD diagnosis and prevention to the district level, emphasizing specialized training of the primary healthcare workforce and strengthening supply chains of diagnostics and essential medicines.     

Multidimensional Profiles of Health Status: An Application of the Grade of Membership Model to the World Health Survey

Background

The World Health Organization (WHO) conducted the World Health Survey (WHS) between 2002 and 2004 in 70 countries to provide cross-population comparable data on health, health-related outcomes and risk factors. The aim of this study was to apply Grade of Membership (GoM) modelling as a means to condense extensive health information from the WHS into a set of easily understandable health profiles and to assign the degree to which an individual belongs to each profile.

Principal Findings

This paper described the application of the GoM models to summarize population health status using World Health Survey data. Grade of Membership analysis is a flexible, non-parametric, multivariate method, used to calculate health profiles from WHS self-reported health state and health conditions. The WHS dataset was divided into four country economic categories based on the World Bank economic groupings (high, upper-middle, lower-middle and low income economies) for separate GoM analysis. Three main health profiles were produced for each of the four areas: I. Robust; II. Intermediate; III. Frail; moreover population health, wealth and inequalities are defined for countries in each economic area as a means to put the health results into perspective.

Conclusions

These analyses have provided a robust method to better understand health profiles and the components which can help to identify healthy and non-healthy individuals. The obtained profiles have described concrete levels of health and have clearly delineated characteristics of healthy and non-healthy respondents. The GoM results provided both a useable way of summarising complex individual health information and a selection of intermediate determinants which can be targeted for interventions to improve health. As populations'' age, and with limited budgets for additional costs for health care and social services, applying the GoM methods may assist with identifying higher risk profiles for decision-making and resource allocations.     

Health Gain by Salt Reduction in Europe: A Modelling Study

Excessive salt intake is associated with hypertension and cardiovascular diseases. Salt intake exceeds the World Health Organization population nutrition goal of 5 grams per day in the European region. We assessed the health impact of salt reduction in nine European countries (Finland, France, Ireland, Italy, Netherlands, Poland, Spain, Sweden and United Kingdom). Through literature research we obtained current salt intake and systolic blood pressure levels of the nine countries. The population health modeling tool DYNAMO-HIA including country-specific disease data was used to predict the changes in prevalence of ischemic heart disease and stroke for each country estimating the effect of salt reduction through its effect on blood pressure levels. A 30% salt reduction would reduce the prevalence of stroke by 6.4% in Finland to 13.5% in Poland. Ischemic heart disease would be decreased by 4.1% in Finland to 8.9% in Poland. When salt intake is reduced to the WHO population nutrient goal, it would reduce the prevalence of stroke from 10.1% in Finland to 23.1% in Poland. Ischemic heart disease would decrease by 6.6% in Finland to 15.5% in Poland. The number of postponed deaths would be 102,100 (0.9%) in France, and 191,300 (2.3%) in Poland. A reduction of salt intake to 5 grams per day is expected to substantially reduce the burden of cardiovascular disease and mortality in several European countries.     

Drivers of Inequality in Millennium Development Goal Progress: A Statistical Analysis

Background

Many low- and middle-income countries are not on track to reach the public health targets set out in the Millennium Development Goals (MDGs). We evaluated whether differential progress towards health MDGs was associated with economic development, public health funding (both overall and as percentage of available domestic funds), or health system infrastructure. We also examined the impact of joint epidemics of HIV/AIDS and noncommunicable diseases (NCDs), which may limit the ability of households to address child mortality and increase risks of infectious diseases.

Methods and Findings

We calculated each country''s distance from its MDG goals for HIV/AIDS, tuberculosis, and infant and child mortality targets for the year 2005 using the United Nations MDG database for 227 countries from 1990 to the present. We studied the association of economic development (gross domestic product [GDP] per capita in purchasing-power-parity), the relative priority placed on health (health spending as a percentage of GDP), real health spending (health system expenditures in purchasing-power-parity), HIV/AIDS burden (prevalence rates among ages 15–49 y), and NCD burden (age-standardised chronic disease mortality rates), with measures of distance from attainment of health MDGs. To avoid spurious correlations that may exist simply because countries with high disease burdens would be expected to have low MDG progress, and to adjust for potential confounding arising from differences in countries'' initial disease burdens, we analysed the variations in rates of change in MDG progress versus expected rates for each country. While economic development, health priority, health spending, and health infrastructure did not explain more than one-fifth of the differences in progress to health MDGs among countries, burdens of HIV and NCDs explained more than half of between-country inequalities in child mortality progress (R ²-infant mortality  = 0.57, R ²-under 5 mortality  = 0.54). HIV/AIDS and NCD burdens were also the strongest correlates of unequal progress towards tuberculosis goals (R ² = 0.57), with NCDs having an effect independent of HIV/AIDS, consistent with micro-level studies of the influence of tobacco and diabetes on tuberculosis risks. Even after correcting for health system variables, initial child mortality, and tuberculosis diseases, we found that lower burdens of HIV/AIDS and NCDs were associated with much greater progress towards attainment of child mortality and tuberculosis MDGs than were gains in GDP. An estimated 1% lower HIV prevalence or 10% lower mortality rate from NCDs would have a similar impact on progress towards the tuberculosis MDG as an 80% or greater rise in GDP, corresponding to at least a decade of economic growth in low-income countries.

Conclusions

Unequal progress in health MDGs in low-income countries appears significantly related to burdens of HIV and NCDs in a population, after correcting for potentially confounding socioeconomic, disease burden, political, and health system variables. The common separation between NCDs, child mortality, and infectious syndromes among development programs may obscure interrelationships of illness affecting those living in poor households—whether economic (e.g., as money spent on tobacco is lost from child health expenditures) or biological (e.g., as diabetes or HIV enhance the risk of tuberculosis). Please see later in the article for the Editors'' Summary     

Inequalities in health within the health sector.

Mortality among men employed in the health sector was examined using data surrounding the 1971 (1970-2) and 1981 (1979-83) censuses to assess the differences between social classes in the health service and to study changes over a decade. Relative to men in England and Wales, mortality in the 1980s was significantly lower among dentists (standardised mortality ratio 66), doctors (69), opticians (72), and physiotherapists (79) and significantly higher among hospital porters (151), male nurses (118), and ambulancemen (109). Mortality from lung cancer among hospital porters (185) was more than fivefold that seen in doctors (33) and dentists (37). Ischaemic heart disease varied twofold, being lowest in dentists (60) and doctors (70) and highest in hospital porters (138). Over the decade mortality from lung cancer and ischaemic heart disease declined in all groups except hospital porters, ambulancemen, and orderlies. Most groups showed excess deaths from suicides and cirrhosis of the liver. Differences in mortality between health workers in social class I and those in social class IV widened between the 1970s and 1980s and to a greater extent than among the general population. The high mortality of some groups within the NHS, and the fact that differentials between social classes have widened more than in the general population, suggest that the NHS needs to pay more attention to the health of its own staff.     

Lymphatic Filariasis (Elephantiasis) Elimination: A public health success and development opportunity

BACKGROUND: The Global Programme to Eliminate Lymphatic Filariasis, launched following World Health Assembly Resolution 50.29 (WHA 50.29), has been facilitated in its progress by new research findings, drug donations, the availability of diagnostic tools, disability management strategies to help those already suffering and the development of partnerships. The strategy recommended by the World Health Organization of annual treatment with a two-drug combination has proved safe. DISCUSSION: Using different approaches in several countries the elimination of lymphatic filariasis (LF) has been demonstrated to be feasible during earlier decades. These successes have been largely overlooked. However, the programme progress since 2000 has been remarkable - upscaling rapidly from 2 million treatments in 2000 to approximately 60 million in 2002. Around 34 countries had active programmes at the end of 2002. It is anticipated that there will be further expansion - but this will be dependent on additional resources becoming available. The programme also provides significant opportunities for other disease control programmes to deliver public health benefits on a large scale. Few public health programmes have upscaled so rapidly and so cost-effectively (<$0.03/treatment in some Asian settings) - one country treating 9-10 million people in a day (Sri Lanka). The LF programme is arguably the most effective pro-poor public health programme currently operating which is based on country commitment and partnerships supported by a global programme and alliance. Tables are provided to summarize programme characteristics, the benefits of LF elimination, opportunities for integration with other programmes and relevance to the Millennium Development Goals. SUMMARY: Lymphatic filariasis elimination is an "easy-to-do" inexpensive health intervention that provides considerable "beyond filariasis" benefits, exemplifies partnership and is easily evaluated. The success in global health action documented in this paper requires and deserves further support to bring to fruition elimination of lymphatic filariasis as a public health problem and health benefits to poor people. A future free of lymphatic filariasis will reduce poverty and bring better health to poor people, prevent disability, strengthen health systems and build partnerships.     

World Health Organization's programme on the prevention of blindness

The WHO Programme for the Prevention of Blindness was established in 1978, reflecting the need for action against the burden of avoidable blindness, which constitutes an increasingly serious socioeconomic problem in many countries. A vast majority of the world's blind live in developing countries, where unoperated cataract, trachoma, xerophthalmia and onchocerciasis are the main causes of visual loss. Thus, more than two-thirds of blindness encountered in such areas is either preventable or curable. The objectives of the WHO Programme for the Prevention of Blindness are to reduce the amount of avoidable blindness in developing countries, and to make essential eye care available to all. In order to achieve this, blindness prevention must form part of primary health care, which is the basic strategy of the World Health Organization to attain the overall goal of "Health for All by the Year 2000". Emphasis is placed on the establishment of national programmes for the prevention of blindness, geared to local needs and resources. This implies a need for a careful programming process, in relation to the general provision of health services.     

Attention to Local Health Burden and the Global Disparity of Health Research

Most studies on global health inequality consider unequal health care and socio-economic conditions but neglect inequality in the production of health knowledge relevant to addressing disease burden. We demonstrate this inequality and identify likely causes. Using disability-adjusted life years (DALYs) for 111 prominent medical conditions, assessed globally and nationally by the World Health Organization, we linked DALYs with MEDLINE articles for each condition to assess the influence of DALY-based global disease burden, compared to the global market for treatment, on the production of relevant MEDLINE articles, systematic reviews, clinical trials and research using animal models vs. humans. We then explored how DALYs, wealth, and the production of research within countries correlate with this global pattern. We show that global DALYs for each condition had a small, significant negative relationship with the production of each type of MEDLINE articles for that condition. Local processes of health research appear to be behind this. Clinical trials and animal studies but not systematic reviews produced within countries were strongly guided by local DALYs. More and less developed countries had very different disease profiles and rich countries publish much more than poor countries. Accordingly, conditions common to developed countries garnered more clinical research than those common to less developed countries. Many of the health needs in less developed countries do not attract attention among developed country researchers who produce the vast majority of global health knowledge—including clinical trials—in response to their own local needs. This raises concern about the amount of knowledge relevant to poor populations deficient in their own research infrastructure. We recommend measures to address this critical dimension of global health inequality.     

The future of the management of ischaemic heart disease.

Ischaemic heart disease will kill over 150,000 people in the next year in Britain, more than any other single disease process, and cost more than 1.4bn pounds in health care alone. Faced with the continuing problems arising from ischaemic heart disease cardiological clinician scientists are moving from technology based solutions to basic sciences. This article explains how basic science may contribute to new understanding and treatments for patients with ischaemic heart disease. Highlighted are three problems which face any clinical cardiologist on a daily basis and for which basic science may provide solutions: the uncertainty of plaque stability in coronary disease; restenosis after percutaneous transluminal angioplasty; and the shortage of organs for cardiac transplant programmes for patients with heart failure.     

Regional variations and trends in mortality from cardiovascular diseases in population aged 0-64 in Dalmatia and Slavonia, 1998-2009

The aim of this paper was to analyse the regional variations and trends in mortality from cardiovascular diseases in the population aged 0-64 years in Dalmatia and Slavonia, over the period 1998 to 2009. Mortality data were derived from Central Bureau of Statistics. The results show that age-standardized mortality rates from total cardiovascular diseases, ischaemic heart diseases and cerebrovascular diseases were lower in Dalmatia than rates for Slavonia, for both genders. All mortality rates, except rates for ischaemic heart diseases mortality for men in both regions, showed the trend of decline. Dalmatia has a more protective factors in pattern of Mediterranean diet. The improvement of cardiovascular health and reduction of premature mortality from cardiovascular diseases requires a system and comprehensive intervention approach at all levels of health care and multisectorial coordination.     

A conceptual framework for the revision of the ICD-10 classification of mental and behavioural disorders

The World Health Organization (WHO) is revising the ICD-10 classification of mental and behavioural disorders, under the leadership of the Department of Mental Health and Substance Abuse and within the framework of the overall revision framework as directed by the World Health Assembly. This article describes WHO’s perspective and priorities for mental and behavioural disorders classification in ICD-11, based on the recommendations of the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders. The WHO considers that the classification should be developed in consultation with stakeholders, which include WHO member countries, multidisciplinary health professionals, and users of mental health services and their families. Attention to the cultural framework must be a key element in defining future classification concepts. Uses of the ICD that must be considered include clinical applications, research, teaching and training, health statistics, and public health. The Advisory Group has determined that the current revision represents a particular opportunity to improve the classification’s clinical utility, particularly in global primary care settings where there is the greatest opportunity to identify people who need mental health treatment. Based on WHO’s mission and constitution, the usefulness of the classification in helping WHO member countries, particularly low- and middle-income countries, to reduce the disease burden associated with mental disorders is among the highest priorities for the revision. This article describes the foundation provided by the recommendations of the Advisory Group for the current phase of work.