The European Journal of Public Health Advance Access originally published online on May 12, 2006
The European Journal of Public Health 2007 17(1):75-79; doi:10.1093/eurpub/ckl066
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International perspectives |
Cardiovascular Risk Factors in the Federation of Bosnia and Herzegovina
Aida Pilav1, Aulikki Nissinen2, Ari Haukkala3, Dragana Nik
i
4 and
Tiina Laatikainen2
1 Department of Health statistics and informatics, Federal Public Health Institute Sarajevo, Bosnia and Herzegovina
2 Department of Health Promotion and Chronic Disease Prevention, National Public Health Institute Helsinki, Finland
3 Department of Social Psychology, University of Helsinki Helsinki, Finland
4 Institute for Social Medicine and Organization of Health, Medical Faculty Sarajevo, Bosnia and Herzegovina
Correspondence: Aida Pilav, MD MSci, Department of Health statistics and informatics, Federal Public Health Institute, Titova 9, 71 000 Sarajevo, Bosnia and Herzegovina, tel: +387 33 663 941, fax: +387 33 220 548, e-mail: idanap{at}bih.net.ba
Received March 20, 2006, accepted April 6, 2006
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Abstract |
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Background: Federation of Bosnia and Herzegovina (FBiH) has high cardiovascular disease mortality as other countries in Eastern Europe and situation has even deteriorated in the post war period. Reliable information on risk factor levels and patterns needed in prevention planning and disease management has been lacking. Methods: A cross sectional population survey was conducted in the FBiH in autumn 2002. A random sample of population, aged 25–64 years, was taken using a three stage stratified sampling methodology. Altogether, 2750 persons participated in the survey (1121 men and 1629 women). The survey was done according to internationally established standards and protocols. Results: The mean systolic blood pressure was 132 mmHg among men and 135 mmHg among women. The mean diastolic blood pressure was 84 mmHg in both genders. Almost 40% of the participants were recognized as hypertensive (blood pressure level over 140/90 mmHg). The prevalence of hypertension among men was 36% and among women 45%. The mean Body Mass Index (BMI) was 26.5 kg/m2 among males and 27.0 kg/m2 among females. About 75% of both men and women were overweight (BMI > 25 kg/m2) and 16% of men and 20% of women were obese (BMI > 30 kg/m2). About 50% of men and 30% of women reported to be daily smokers. Conclusions: As a whole the non-communicable disease risk factor levels in the FBiH seems to be relatively high. The data can be utilized in health promotion planning and as a baseline for future monitoring activities with possibility of international comparison of results.
Keywords: cardiovascular risk factors, Bosnia and Herzegovina, smoking, obesity, blood pressure
Non-communicable diseases exceed communicable diseases in causing mortality and disability in most countries. In 2000, they contributed to 
60% of the deaths worldwide. The WHO Global Strategy of 2000 addresses the critical role of physiological and behavioral risk factors as causes of non-communicable diseases. The highest priority in prevention should be given to risk factors that create the highest risk of disease and are the most prevalent in the population. Continuing to monitor the levels and patterns of risk factors is of fundamental importance to planning and evaluating preventive activities.1–3
The increase in non-communicable diseases is a major public health concern in many developing countries as well as in the Federation of Bosnia and Herzegovina (FBiH). In April 1992, Bosnia and Herzegovina (BiH) was internationally recognized as a new independent country and became a member of the United Nations. War broke out in 1992 and ended with the signing of the Dayton Peace agreement in December 1995. The Peace Agreement established BiH as a country of two entities and one district—the FBiH, Republika Srpska and District Brcko. The war of 1992–1995 had a disastrous impact on the demographics and epidemiology of BiH.4
In the post-war period, great steps have been taken towards economic revival. This economic transition is strongly associated with the epidemiological transition caused by the poor economic situation, unemployment, unhealthy and unsafe food, and an increasing trend towards smoking and unhealthy life styles. The after effects of the war include high levels of physical and mental disability.5,6 The health profile of the population reflects many of the trends of South-East Europe, including high morbidity and mortality due to cardiovascular disease and cancer. The FBiH mortality statistics, in the 5-year period from 1998 to 2002 indicated that cardiovascular diseases caused 50% of deaths with an average mortality rate of 390–100 000 population (unstandardized rate).6 There is no existing data on specific mortality rate by gender. For an assessment of disease prevalence limited information can be obtained from the morbidity data of the routine outpatients health statistics report.
The reorganization of the health sector is progressing and is supported by entity laws on health care and health insurance. One of the main initiatives was to re-establish population health monitoring activities. The first cross sectional population health survey, in the post-war period, was made in the FBiH in order to provide reliable information on the cardiovascular risk factor profile in adult populations. The survey was made according to internationally established standards and protocols.
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Methods |
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A cross sectional population survey was conducted in the FBiH from September to December 2002. The target population was all adults aged 25–64 years living in the FBiH. Permission for the implementation of the survey was received from the Ministry of Health and the Public Health Institute of the FBiH. Special ethics approval was not needed.
Sampling was designed and carried out by the Statistical Institute of the FBiH. A stratified random sample was drawn using a three-stage stratified sampling methodology. At the first stage, the urban and rural strata were defined in each of the 79 municipalities in the FBiH. Strata were divided into segments with an approximately equal number of inhabitants. A random selection of 151 segments was drawn. At the second stage, the interviewers visited the mapped areas of the selected segments and made a list of the households in each segment (‘ad hoc’ census). Households were listed up to 100 households. From each segment 20 households were randomly selected using a random number method. At the third stage, the survey team visited the selected households and listed all the persons aged 25–64 years living in the household. The survey subject was then randomly selected amongst these eligible persons living in the household. The original sample included 3020 persons. Altogether, 2750 persons participated in the survey resulting in a participation rate of 91.5%. Substitution of non-participants was not permitted (table 1).
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The survey methodology followed closely the WHO MONICA protocol and the latest recommendations of the European Health Risk Monitoring Project.7,8 The survey included an interview, based on a structured questionnaire, and physical measurements.
The survey questionnaire was based on the WHO CINDI Health Monitor Survey9 including questions on socioeconomic status, symptoms, disease and health behavior. Additional questions on risk factors, diseases, and treatments were included from the EHRM protocol8 as well as from the WHO MONICA questionnaire.7 The questionnaire was translated into the local language and was pre-tested during the summer of 2002.
The questionnaire was completed at the participant's home, by the interviewer. The height, weight and blood pressure of the participant were also measured and recorded at his/her home.
Weight was measured by a digital scale and height by a stadiometer, which was attached either to a wall or to a separate lath. The height and weight of the participant were used to calculate his body mass index (BMI in kg/m2). The cutoff points of 25 and 30 kg/m2 were used to determine the overweight and obese subjects.
Blood pressure was measured with a mercury sphygmomanometer on the patient's right arm when they were in a sitting position and had at least 5 min rest. Two measurements were taken one minute apart. The first appearance of a clear, repetitive tapping sound (Korotkoff Phase 1) was recorded as systolic blood pressure. The disappearance of the repetitive sounds (Phase 5) was recorded as diastolic blood pressure. The blood pressure value was recorded to the nearest 2 mm Hg. The mean of the two measurements was used in the analysis. For the analysis, the subjects were classified as having hypertension if their systolic blood pressure was over 140 mm Hg and/or the diastolic blood pressure over 90 mm Hg and/or if they were being treated with antihypertensive drugs.
Smoking status was assessed using a standard set of questions following the European Health Risk Monitoring project protocol. Based on the responses, the participants were classified into three categories: daily smokers, ex-smokers and never smokers.
Leisure time physical activity was based on the question of how often the respondents did physical exercise that made them at least mildly short of breath. Answers were given with eight alternatives starting from daily exercise to the situation where respondents reported that they could not exercise. In the analyses those who reported that they did physical exercises at least twice a week were compared with the others.
The field work of the survey was planned and organized by the Federal Public Health Institute in BiH in consultation with the National Public Health Institute in Finland. The field work was carried out by ten teams. Each team consisted of two nurses or physicians, who were specially trained for this task. A pilot survey was done with both sampling and data collection procedures prior to the actual survey implementation.
Data was analysed using the SPSS for Windows, version 10.0. The analysis of variance was used for comparing the mean values of continuous variables (systolic blood pressure, diastolic blood pressure and BMI) by gender and age groups. The differences in obesity and hypertension prevalence and smoking status and interaction effects between age groups and gender were examined with a log–linear model. The differences in the linear associations between continuous variables were examined among men and women using a linear regression model. The significance of the interaction terms between gender and other continuous variables after the main effects was tested. Significant interactions indicate different associations among men and women between two continuous variables.
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Blood pressure
The mean systolic blood pressure was 132 mm Hg among men and 135 mm Hg among women, and the gender difference was statistically significant (P < 0.001). The mean values of systolic blood pressure increased significantly with age. Younger men (25–44 years of age) had slightly higher systolic blood pressure compared with younger women, whereas in the older age groups (45–64 years of age), women had higher systolic blood pressure than men. The variance of systolic blood pressure increased by age group, especially among women, so the Levene's test of equal error variances between age groups was rejected (P < 0.001).
The mean diastolic blood pressure was 84 mmHg in both genders. Again, the mean values of diastolic blood pressure increased with age in both genders. Younger men (25–44 years of age) had slightly higher diastolic blood pressure whereas in the older age groups (45–64 years of age) women had slightly higher diastolic blood pressure. The variance of diastolic blood pressure was greater among older age groups than among younger age groups(Levene's test P < 0. 001 among both genders) (table 2).
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The prevalence of hypertension among men was 36% and among women 45%. The proportion of subjects with hypertension increased considerably with age in both genders. There was an interaction in the prevalence of hypertension between gender and age groups indicating a steeper increase in the prevalence of hypertension with age for women than for men (table 2).
Body mass index and leisure time physical activity
The mean BMI was 26.5 among men and 27.0 among women (P = 0.005). BMI increased with age for men and women, but the increase was more pronounced in women. The prevalence of obesity (BMI > 30 kg/m2) was 17% for men and 25% for women and significantly increased with age for both genders. There was an interaction in obesity prevalence between gender and age groups showing steeper increase of obesity among women (table 3). The prevalence of those who reported to be physically active at leisure at least twice a week was 20% among males and 12% among females.
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Smoking
In the FBiH, 49% of men and 30% of women were reported to be daily smokers. The prevalence of daily smoking increased with age for both men and women, but it was lower among women in all age groups. There were more ex-smokers among older men (55–64 years of age) compared with younger men. There were more women in the older age groups who had never smoked, compared with younger women. The prevalence of men who never smoked was similar for all age groups (table 4). Nearly 60% of female daily smokers wanted to quit smoking compared with 42% of male daily smokers. Only one-third of the daily smokers in both genders reported that they ever tried seriously to quit smoking.
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Correlations between risk factors
Table 5 displays the bivariate correlations among men (below diagonal) and women (above diagonal). When comparing the correlations among males and females, education was more correlated on systolic blood pressure and diastolic blood pressure, BMI and daily smoking among women (P < 0.001 for interaction). Systolic and diastolic blood pressure and BMI decrease with higher education especially among women. Also more educated females were more likely to be daily smokers whereas among males education did not relate to daily smoking. Furthermore, BMI and smoking had higher correlations to both systolic and diastolic blood pressure among females than males (P < 0.001 for interaction). More frequent leisure-time physical activity was related to lower blood pressure and BMI in both genders.
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Discussion |
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The assessment of the prevalence of cardiovascular risk factors in the adult population in the FBIH was made through a cross sectional population survey for the first time since the war ended in 1995. The emphasis was on the major cardiovascular disease risk factors—hypertension, obesity, and smoking. Measurement of cholesterol would have been of importance, but it was not feasible in the context of this household study.
Data on the rates of cardiovascular and other noncommunicable diseases, that is usually available from routine health service records, is limited in the FBiH and can only be used for identifying morbidity and mortality patterns. Unfortunately, there is no data on the incidence of noncommunicable diseases. The available data does show some increase in cardiovascular disease mortality in the recent post-war period. This could be an indicator of the wider public health implication of accepting the unhealthy life style in FBiH. The results of the health interview survey recently carried out in one part of the FBiH showed rather high levels of behavioral and self-reported cardiovascular risk factors.10 Thus, the conducting of the cross sectional population survey was of great interest in getting reliable information on the cardiovascular risk factor profile of the adult population in FBiH.
A major strength of the survey was the high response rate (91.5%) and the results could be seen as representative for the adult population in the FBiH. The study sample of 2750 respondents was characterized by an excess of women (59%). The proportion of participants was lower in the youngest age group (25–34 years of age) for both men and women. This could be explained by the fact that there was a significant demographic transition caused by war where many younger people emigrated. This finding is in line with the official demographic data on population size and distrubution by age groups, estimated by the Statistical Institute of the Federation of Bosnia and Herzegovina. According to the estimates of the Statistical Institute in the FBiH in 2001, there were 2.3 million inhabitants in the Federation, 51% being women.5,6
The results of the study showed reasonably favourable values in mean systolic and diastolic blood pressure levels in both genders. The mean systolic blood pressure was still <140 mm Hg for both men and women, but the mean diastolic blood pressure was >80 mm Hg for both genders. The observed values of systolic and diastolic blood pressure were higher among women. The blood pressure levels, even among women, were lower compared with the results from most of the European countries.11,12 Overall, 41% of all participants were recognized as hypertensive. The prevalence of hypertension seems to be higher here than in some other countries from this part of Europe, such as Albania and Hungary.13,14 The cross sectional survey conducted in Albania and Hungary in the recent period showed much lower hypertension prevalence, 32% in Albania and 37% in Hungary. Both the primary prevention and good management of hypertension will be a future challenge in the FBiH as some of the contributing factors such as obesity are likely to continue to increase in the post-war period.
The observed mean values of BMI were >25 kg/m2 for both genders. Prevalence of obesity increased with age. The WHO MONICA project reported very similar BMI levels and prevalence of obesity in the same region in the mid-1990s.15,16 More recently, Kern et al. have reported obesity levels in Croatia that are in line with our findings.17 The high prevalence of obesity, low physical activity and accumulation of other cardiovascular risk factors in the mid- and older age groups are likely to increase the future burden of cardiovascular disease and diabetes in the near future. In addition, increasing economy and availability of food products that were scarce during the war and post-war period can increase the obesity levels in future.16
Numerous epidemiological studies have identified smoking as one the most important risk factors for non-communicable diseases:cardiovascular diseases and cancer. Prevention of smoking is one of the main targets of common health promotion recommendations. The prevalence of smoking in the FBiH is rather high. Almost 50% of males and 30% of females are daily smokers. In the WHO MONICA project similar smoking rates were reported from former Yugoslavia in the mid- 1990's.15
The finding that smoking is most prevalent in younger age groups, especially among women, might reflect the continuous increase in smoking in the FBiH. Higher smoking prevalence among young and more educated women can indicate the acceptance of smoking among women as a socially accepted behavior. This phenomenon is in accordance with the theoretical concept about three phases existing in the development of smoking patterns in industrialized countries. The theory describes that in the second phase a predictable increase in smoking prevalence is seen among women and gradually the rates of women reach the rates of men.18,19 The high prevalence of smoking among younger and more educated women indicate that prevention of smoking among girls will be an important and challenging task in future. At the same time the tobacco policy should include attempts to increase actual smoking cessation attempts among the adult population as only one-third of the smokers report any serious attemptat quitting.
In conclusion, the observed values for the major cardiovascular risk factors in the FBiH seem to be relatively high. The major cardiovascular risk factors increase with age, with women at greater risk than men. Powles et al. have demonstrated that in Europe the east–west differences in mortality are most marked for deaths from vascular diseases and from injuries.20 The most dominant contributors to this difference are blood pressure, cholesterol concentration, BMI, physical inactivity, diet, smoking and alcohol abuse. To avoid excess health losses in the east of Europe favourable shifts in vascular risk factors are needed. This requires population-wide measures and intensified tobacco and alcohol control strategies.
There is an urgent need for preventive action. The model of integrated management of cardiovascular risk factors as a comprehensive population-based, well-planned and well-coordinated programme should be established as a part of the primary health care reforms in the FBiH. The programme should be directed primarily to general life style modification and integrated closely to the primary health care settings.21–24
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Acknowledgments |
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The authors would like to acknowledge the contributions of Dr Jasna Omanic, Dr Jelena Ravlija, Dr Aida Filipovic-Hadziomeragic, Dr Maria Zeljko, Dr Mirsada Mulamerovic, Dr Aida Vilic-Svraka and Dr Pekka Jousilahti in conducting the survey. The survey was made as a part of a larger development project of the Public Health Institute of FBiH as a part of the Basic Health Project in Bosnia and Herzegovina, funded by a World Bank loan.
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