Geneva Health Forum Archive

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The Gait and Balance of Patients with Diabetes Can Be Improved: A Randomised Controlled Trial in Switzerland

Author(s): Lara Allet1, R. A. de Bie1, S. Armand2, A. Golay1
Affiliation(s): 1Geneva University Hospital and University of Geneva, Maastricht University and  Caphri Research School, Maastricht, the Netherlands
1st country of focus: Switzerland
Relevant to the conference theme: Communicable chronic diseases
Summary (max 100 words): This randomised controlled trial evaluates the effect of a specific training programme on gait and balance of diabetic patients. A group of 71 diabetic patients was recruited and randomly assigned to an intervention (n=35) or a control group (n=36). The intervention consisted of physiotherapeutic group training including gait and balance exercises with function orientated strengthening (twice weekly over 12 weeks). The control group received no treatment. The authors conclude that specific training can improve gait speed, balance, muscle strength and joint mobility in diabetic patients.
Background (max 200 words): Type 2 diabetes mellitus and its common complication, peripheral neuropathy, affect a large population. Peripheral neuropathy leads to sensory and motor deficits, which often results in mobility-related dysfunction, alterations in gait characteristics and balance impairments. Diabetic patients with peripheral neuropathy have lower gait velocity, decreased cadence, shorter stride length, increased stance time and higher step to step variability compared with healthy controls. These gait alterations increase on irregular surfaces. In addition, diabetic patients are known to suffer from increased risk of injurious falls. Fall-related injuries are often assumed to trigger a vicious circle because of their potentially detrimental influence on the physical activity levels of affected patients. Public Health guidelines for diabetes management recommend that patients perform at least 30 min of physical activity a day six times a week, requiring adequate gait security and balance. However, little is known about treatment strategies that could improve patients’ gait and balance, thereby also reducing the risk of falls.
Objectives (max 100 words): This study evaluates the effect of specific training programme on gait and balance of diabetic patients.
Methodology (max 400 words): This was a randomised controlled trial (n=71) with an intervention (n=35) and control group (n=36). The intervention consisted of physiotherapeutic group training including gait and balance exercises with function orientated strengthening (twice weekly over 12 weeks). Controls received no treatment. Individuals were allocated to the groups in a central office. Gait, balance, fear of falls, muscle strength and joint mobility were measured at baseline, after intervention and at 6-month follow-up.
Results (max 400 words): After training, the intervention group increased habitual walking speed by 0.149 m/s (p<0.001) compared with the control group. Patients in the intervention group also significantly improved their balance (time to walk over a beam, balance index recorded on Biodex balance system), their performance-oriented mobility, their degree of concern about falling, their hip and ankle plantar flexor strength, and their hip flexion mobility compared with the control group. After 6 months, all these variables remained significant except for the Biodex sway index and ankle plantar flexor strength.
Conclusion (max 400 words): Although our study showed positive results, clinicians should be aware of possible adverse events. Two patients developed pain in their Achilles tendon, obliging us to slow down the progression for ‘toe walking’ and ‘one leg stance’exercises. More moderate progression and a longer warm up could possibly avoid such incidents. To the best of our knowledge, this is one of the first randomised controlled trials to describe an effective physiotherapy training programme geared to concurrently improve the balance and gait of diabetic patients. Future studies should examine the effect of exercise regimens on patient groups differentiated by neuropathy status (patients without, with mild or with severe peripheral neuropathy, identified by a more complex instrument for peripheral neuropathy screening). In addition, outcomes such as functional capacity, the number of falls or physical activity level should be considered in order to draw meaningful conclusions about exercise efficacy among patients with diabetes, thereby facilitating medical and clinical decision-making. Overall we can conclude that specific training can improve gait speed, balance, muscle strength and joint mobility in diabetic patients.

Sex Differences in the Association between Serum Uric Acid and Adiposity Markers in the Population-Based CoLaus Study

Author(s): Tanica Lyngdoh1, Pascal Bovet1, Pedro Marques-Vidal1, Gerard Waeber1, Peter Vollenweider1, Murielle Bochud1
Affiliation(s): Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
1st country of focus: Switzerland
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): Women and men differ in their serum uric acid (SUA) levels and fat distribution. As very few large scale population-based studies have systematically assessed sex differences in the relationship between SUA and markers of adiposity, we explored these associations in the CoLaus study. Our study supports previous findings that an elevated serum uric acid is closely associated with measures of adiposity. We present additional information on the differential effects of sex on the relationship. Our findings seem to suggest that the observed sex-differences are, in large part, explained by leptin.
Background (max 200 words): High serum uric acid (SUA) is known to co-exist with the different components of metabolic syndrome including obesity. Epidemiological and clinical studies have established positive associations between SUA and different adiposity markers including waist circumference, body mass index, waist-hip ratio, visceral fat, subcutaneous fat and total body fat. Sex is an important determinant underlying the relationship between SUA and metabolic syndrome. This is evident by the finding that the association is stronger in females than in males. Furthermore, recent findings suggest the role of leptin as a plausible explanation for the sex differences observed in the metabolic pathways involved in metabolic syndrome. Although SUA concentrations, serum leptin, and body fat distribution show obvious sex differences, very few studies have tried to systematically assess sex-differences in the relationship between serum uric acid and the different markers of adiposity.
Objectives (max 100 words): The objective of the current study was to explore sex differences in the relationship of serum uric acid with markers of adiposity and to assess if leptin could be a factor underlying the relationship between serum uric acid and adiposity.
Methodology (max 400 words): In 6184 participants aged 35 to 75 years randomly selected from the general population in Lausanne, we measured SUA, leptin and anthropometric variables including weight, height, body mass index (BMI),  waist circumference (WC), and fat and lean mass (using bioimpedance), and assessed lifestyle behaviors using a questionnaire. Fasting venous blood were collected after an overnight fasting.  Uric acid was measured by uricase-PAP and leptin by ELISA. Multiple median regressions were used to test the association of SUA with the different adiposity markers (as dependent variable) one at a time. We tested the interaction of SUA with sex by adding a multiplicative interaction term in the model.
Results (max 400 words): Mean SUA was higher in men (361.1 ± 75.7 µmol/L) than in women (270.6 ± 67.2 µmol/L). Men had higher mean weight, height, BMI and WC, while women had higher fat mass (p values <0.0001 for all). Positive correlations of SUA with weight, BMI, WC, and fat mass were stronger in women than in men (Spearman r:  0.35, 0.37, 0.40, and 0.41 in women, and 0.26, 0.30, 0.31, and 0.30 in men, respectively, p<0.0001 for all). In univariate analysis, SUA was strongly associated with weight, BMI, WC and fat mass in both men and women and the regression coefficients were almost twice as large in women than in men (p<0.001 for all associations). The associations remained significant upon adjustment for age, alcohol intake, smoking, Modification of the diet in Renal Disease (MDRD), diabetes, hypertension and the use of diuretics (regression coefficients ±SE for weight, BMI, WC and fat mass was 3.35 ±0.38; 1.25±0.10; 3.43±0.30; 2.00±0.15 in men and 5.61±0.38; 2.18±0.13; 6.21±0.32; 4.13±0.22 in women respectively, p<0.001 for all). In models including men and women together, there was a statistically significantly interaction by sex for all the associations between SUA and adiposity markers (p<0.001 for all). The interaction by sex was unaltered upon adjustment for insulin but was no longer significant upon adjustment for leptin.
Conclusion (max 400 words): In this population-based study of Caucasians aged 35 to 75 years, we found a strong association between SUA and markers of adiposity, with women showing stronger associations than men. We observe the sex difference to be largely explained by leptin, consistent with a leptin resistance in maintaining higher fat mass in women.

Effects of Particulate Matters on Inflammatory Markers in the General Adult Population

Author(s): Dai-Hua Tsai1,2, Nadia Amyai3, Pedro Marques-Vidal1, Jia-Lin Wang2, Michael Riediker4, Vincent Mooser5, Fred Paccaud1, Gerard Waeber3, Peter Vollenweider3, Murielle Bochud1
Affiliation(s): 1Institute of Social and Preventive Medicine, Lausanne University Hospital, Epalinges, Switzerland, 2Department of Chemistry, National Central University, Taoyuan County, Taiwan,  3Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland, 4 Institute for Work and
Health (IST), Lausanne, Switzerland, 5 Department of Genetics, GlaxoSmithKline, Philadelphia, PA, USA
1st country of focus: Switzerland
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): Particulate air pollution is associated with increased cardiovascular risk. The induction of systemic inflammation following particle inhalation represents a plausible mechanistic pathway. The purpose of this study was to assess the associations of short-term exposure to ambient particulate matters of aerodynamic diameter less than 10 μm (PM10) with circulating inflammatory markers in 6183 adults in Lausanne, Switzerland. The results show that short-term exposure to PM10 was associated with higher levels of circulating IL-6 and TNF-α. The positive association of PM10 with markers of systemic inflammation materializes the link between air pollution and cardiovascular risk.
Background (max 200 words): Variations in short-term exposure to particulate matters (PM) have been repeatedly associated with daily all-cause mortality. Particle-induced inflammation has been postulated to be one of the important mechanisms for increased cardiovascular risk. Experimental in-vitro, in-vivo and controlled human studies suggest that interleukin 6 (IL-6) and tumor-necrosis-factor alpha (TNF-α) could represent key mediators of the inflammatory response to PM. The associations of short-term exposure to ambient PM with circulating inflammatory markers have been inconsistent in studies including specific subgroups so far. The epidemiological evidence linking short-term exposure to ambient PM and systemic inflammation in the general population is scarce. So far, large-scale population-based studies have not explored important inflammatory markers such as IL-6, IL-1β or TNF-α. We therefore analyzed the associations between short-term exposure to ambient PM10 and circulating levels of high-sensitive CRP (hs-CRP), IL-6, IL-1β and TNF-α in the population-based CoLaus study.
Objectives (max 100 words): To assess the associations of short-term exposure to ambient particulate matters of aerodynamic diameter less than 10 μm (PM10) with circulating inflammatory markers, including hs-CRP, IL-6, IL-1β and TNF-α, in adults aged 35 to 75 years from the general population.
Methodology (max 400 words): All study subjects were participants to the CoLaus study (www.colaus.ch) and the baseline examination was carried out from 2003 to 2006. Overall, 6184 participants were included. For the present analysis, 6183 participants had data on at least one of the four measured circulating inflammatory markers.  The monitoring data was obtained from the website of Swiss National Air Pollution Monitoring Network (NABEL). We analyzed data on PM10 as well as outside air temperature, pressure and humidity. Hourly concentrations of PM10 were collected from 1 January 2003 to 31 December 2006.   Robust linear regression (PROC ROBUSTREG) was used to evaluate the relationship between cytokine inflammatory and PM10. We adjusted all analyses for age, sex, body mass index, smoking status, alcohol consumption, diabetes status, hypertension status, education levels, zip code, and statin intake. All data were adjusted for the effects of weather by including temperature, barometric pressure, and season as covariates in the adjusted models. We performed simple and multiple logistic regression analyses. Descriptive statistical analysis used the Wilcoxon rank sum test (for medians). All data analyses were performed using SAS software (version 9.2; SAS Institute Inc., Cary, NC, USA), and a two-sided significance level of 5% was used.
Results (max 400 words): PM10 levels averaged over 24 hours were significantly and positively associated with continuous IL-6 and TNF-α levels, in the whole study population both in unadjusted and adjusted analyses. For each cytokine, there was a similar seasonal pattern, with wider confidence intervals in summer than during the other seasons, which might partly be due to the smaller number of participants examined in summer. The associations of PM10 with IL-6 and TNF-α were also found after having dichotomized these cytokines into high versus low levels, which suggests that the associations of PM10 with the continuous cytokine levels are very robust to any distributional assumption and to potential outlier values. In contrast with what we observed for continuous IL-1β levels, high PM10 levels were significantly associated with high IL-1β. PM10 was significantly associated with IL-6 and TNF-α in men, but with TNF-α only in women. However, there was no significant statistical interaction between PM10 and sex. For IL-6 and TNF-α, the associations tended to be stronger in younger people, with a significant interaction between PM10 and age groups for IL-6. PM10 was significantly associated with IL-6 and TNF-α in the healthy group and also in the “non-healthy” group, although the statistical interaction between healthy status and PM10 was not significant.
Conclusion (max 400 words): In summary, we found significant independent positive associations of short-term exposure to PM10 with circulating levels of IL-6 and TNF-α in the adult population of Lausanne. Our findings strongly support the idea that short-term exposure to PM10 is sufficient to induce systemic inflammation on a broad scale in the general population. From a public health perspective, the reported association of elevated inflammatory cytokines with short-term exposure to PM10 in a city with relatively clean air such as Lausanne supports the importance of limiting urban air pollution levels.

Nutrition-Related Lifestyle Practices, Dietary Pattern, Nutrient Intake and Nutritional Status of Selected Call Center Agents

First: Hannah Yvette
Last: Salimpade
1st country of focus: Philippines
Relevant to the conference theme: Research and education
Summary (max 100 words): The study aimed to determine association of nutritional status with nutrition-related lifestyle practices, dietary pattern and nutrient intake among selected call center agents. One hundred call center agents of Metro Manila were interviewed on physical activity, smoking and consumption of alcoholic beverages and dietary pattern.  Majority were normal in nutritional status. Most were sedentary. Walking was the most usual physical activity. Half were smokers and more than two-thirds consumed alcoholic drinks. Half had 3 or more meals but most did not take their meals on time. Chi-square tests showed no associations between nutritional status and physical activity, smoking, alcohol consumption.
Background (max 200 words): The call center industry is tagged by our government as a “Sunshine Industry” because of its massive expansion thus generating thousands of employment. A call center is a central customer service operation where agents handle telephone calls on behalf of a client. Clients include mail-order catalog houses, telemarketing companies, computer help desks, banks, financial series and insurance group, transportation and computer handling firms, hotels and IT companies. The industry’s main target markets includes the United States, Australia and the United Kingdom.  Most of the work hours start long after rush hours in Metro Manila. On the other side of the world, the companies’ American clients are just beginning their day.  During break time, some even occupy the various dining areas in Manila. In Ortigas for instance, call center agents enjoy their 30-minute to one-hour break in food chains.  Because of their erratic work schedule that may affect the regularity of their meals and meeting the nutrient requirements for their age, there is a need to look into the nutrition-related lifestyle practices, dietary pattern, nutrient intake and most especially the nutritional status of call center agents.
Objectives (max 100 words): The main objective of the study was to determine the association of nutritional status with nutrition-related lifestyle practices, dietary pattern, and nutrient intake among selected call center agents. Specifically, the study aimed to: o Determine the nutritional status of call center agents covered in this study o Determine their nutrition-related lifestyle practices o Determine their daily intake for of energy, protein, carbohydrates, and fat o Determine/describe their daily eating pattern o Determine if there are association between their nutritional status with the variables nutrition-related lifestyle practices, dietary pattern and nutrient intake
Methodology (max 400 words): One hundred (100) call center agents from different companies in Metro Manila were taken by non-probability sampling. Those assigned in the night shift (between 9pm to 8am) were purposively selected as participants of this study. An interview schedule was pre-tested among call center agents of different companies who were not included in the study to determine its understandability and length of time of interview. The final interview schedule included name, age, sex, civil status, height, weight, BMI and contact number of the participants, nutrition-related lifestyle practices such as physical activity, smoking and alcoholic beverage drinking, and dietary data namely food frequency checklist and 24-hour food recall sheet. A calibrated bathroom scale and steel tape were used to collect anthropometric data. Data on time of meals were organized based on the following time slots per meal: 5-8:59 am (breakfast); 11 am – 1:59 pm (Lunch) and 6-8:59pm (Dinner). The mean intake of calories, carbohydrates, protein & fat were calculated using the DBASE software based on the Philippine Food Composition Table (FNRI, 1997). Nutrient adequacies for energy and protein were computed based on the RENI. Descriptive statistics such as means, frequencies and percentages were used to describe the association of the variables. Chi-square test was used to determine possible associations between nutritional status and the related variables: nutrition-related lifestyle practices, dietary pattern, and nutrient intake. Data were coded and analyzed mostly using the Statistical Package for Social Science (SPSS).
Results (max 400 words): The study showed that 24% of the call center agents studied were either overweight or obese. This lends support to the findings of Tunajeck (2007) that night shift work can lead to weight gain and obesity. Most of the call center agents said they engaged in physical activity but described their level of physical activity as sedentary and light active. Most of call center agents considered walking as their only daily physical activity everyday. According to the participants, they did not have time to engage in physical activity because of their busy schedule.  Results showed that more than half (53%) of the call center agents were smokers, consuming 7 or more sticks per day.  About two- thirds (68%) of the call center agents in this study admitted alcohol drinking. The study revealed that most (95-95%) of the call center agents did not have regular time in taking their meals. Majority of them did not take breakfast, lunch and dinner on time due to their erratic schedule, although half (51%) of them took 3 or more meals a day. This is another area of concern for this group of people since such dietary pattern if continued as a regular practice can put their health & nutritional status at high risk. Results showed that frequently consumed food by the call center agents were Meat/Poultry/ followed by Cereal/ Cereal Products then sweets/ dessert. The adequacy of intakes of energy, protein, carbohydrates & fats were generally poor except for the female group < 19 years old. This is quite expected because of this erratic schedule that affects their eating pattern especially the regularity of the time for eating meals. However, there is also possibility that the food recalls are not accurate due to limited time to interview the participant. They allowed only 10 minutes to be interviewed because are usually in a hurry to go back to their work, having 15 minutes cigarette break. Despite the poor nutrient intake of the call center agents, only eight (8%) were found underweight. This again could be related to the possibility of inaccuracy in their reports in the 24-hour food recalls due to the limited time for interview. Lastly, the study showed that there was no association among the variables using chi-square test probably because there were only 100 participants.
Conclusion (max 400 words): The following conclusions can be drawn based on the results of the study: o Most of the call center agents were normal in nutritional status with about one-fourth classified as obese or underweight.  o In terms of physical activity most of them were sedentary or light active. Walking was the most usual physical activity. About half of them were smokers and more than two-thirds consumed alcoholic drinks. o Half of the participants had 3 or more meals but most of them did not take their meals on time. The most frequently consumed foods were meat products, cereal/cereal products and sweets and desserts. o Intake of protein, carbohydrates and fat were generally poor, except for the females <19 years of age. o There were no association found between nutritional status and the following variables: nutrition-related lifestyle, dietary pattern and nutrient intake. Based on the results, the researcher recommends steps for the implementation of programs to improve the situation of call center agents, thereby lessening their exposure to health and nutrition risks. A nutrition education and information program should be initiated and maintained by the call center companies to enable the call center agents to minimize the negative impact of the lifestyle brought about by the nature of their job. This can be done through health & nutrition information materials & nutrition seminars on wellness where they will have access to information & counseling from health workers, nutritionists & doctors. Provision of facilities and resources for a wellness program in the workplace such as a gym, gym instructor & selected equipment. The wellness program may also include routine exercise for call center agents including those on night shift. Provision or access to healthy meals in the companies’ pantries or canteens as an alternative or substitute to meal allowance. These should exclude or have minimal offering of vendo machine for high calorie, high fat and high carbohydrate food. The study also recommends the conduct of a similar study with more participants using representative samples from call center companies of Metro Manila from different shifts to be able to determine possible associations among the variables studied

Non-Communicable Diseases and Emergencies: A Call for Renewed Action

 

Author(s): Alessandro Demaio1, Rebecca Horn2, Jennifer Jamieson3, Maximilian de Courten1, Ib C  Bygbjerg1, Siri Tellier1
Affiliation(s): Copenhagen School of Global Health, University of Copenhagen, Denmark1, ChronAid International, Washington DC, USA2, The Alfred Hospital, Melbourne, Australia3
Name your project or intiative: Non-Communicable Diseases and Emergencies: A Call for Renewed Action
1st country of focus: Denmark
Additional countries of focus: Global
Relevant to the conference theme: Non-communicable chronic diseases
Summary: In the aftermath of the 2011 United Nations High Level Meeting on Non-Communicable Diseases (NCDs), there is now an unprecedented opportunity for a renewed call to action on the management of NCDs during and following emergencies (including natural disasters, conflict and non-conflict related emergencies). Despite some good progress in recent years, there continues to be significant gaps in the scientific evidence and technical guidelines with regards to the health effects and mitigation strategies for NCDs and emergencies. This call offers a way to advance the prevention and management of Non-Communicable Diseases in emergencies. It emphasises that NCDs should not have a token inclusion in emergency preparation and management, but rather a meaningful and integrated one that addresses the existing care gap for this vulnerable population.
What challenges does your project address and why is it of importance?: Recent years have demonstrated the devastating health consequences of emergencies and highlighted the importance of a comprehensive and collaborative approach to humanitarian responses. Simultaneously, NCDs are now increasingly recognised as a real and growing threat to population health and development: a threat that is magnified during and following emergencies.  Avoiding excess morbidity and mortality is a primary goal for humanitarian responses both in the acute phase and post-disaster phase of an emergency. NCDs, however, continue to receive limited attention from humanitarian organisations in the preparation for, and management of emergencies. To ensure continuity of care for people with NCDs in emergencies it is necessary to have a health infrastructure with resilience to disasters. This however requires some background population knowledge about prevalence of and treatment modalities for NCDs to undertake preparedness planning. Such information may often be unavailable.
How have you addressed these challenges? Do you see a solution?: This abstract calls on all sectors to recognise and address the gaps in scientific evidence with regards to NCDs in emergencies and the serious challenges posed by these two concomitant threats to health and development. More specifically, it calls for:• Systematic reviews relating to the sources and magnitude of excess morbidity and mortality from NCDs linked to emergencies;• Increased monitoring and reporting of morbidity and mortality patterns from NCDs both in the acute and post emergency phases; • Incorporation of NCDs (prevention and management) into existing emergency-related policies, standards, and resources; • Greater integration and preparation for NCDs and in health service provision including the development of evidence-based global and national guidelines on the management of NCDs in the acute and post emergency phases; • Inclusion of NCDs into training of humanitarian and emergency-response workers and planners.
How do you know whether you have made a difference?: In order to address the problems of NCDs in emergencies and minimise excess morbidity and mortality, we encourage international research, humanitarian and governing sectors to recognise and address NCDs in emergency situations. We want to facilitate research to quantify the impact NCDs have and will have on the consequences of emergency in specific countries, populations and globally; and vice versa to quantify the impact of emergencies on NCD exacerbation and complications. We furthermore call for evidence-based, global technical guidelines for the management of NCDs during and following emergencies. We urge governing and advisory bodies to incorporate NCDs into global practice in emergencies and to allocate specific funding and resources for the prevention and management of NCDs during and following emergencies. As an outcome, following our presentation, we hope to promote and facilitate a network of likeminded researchers, planners and field workers to further the agenda and contribute to the above action points.
Have you or the project mobilized others and if so, who, why and how?: The compounding morbidity and mortality burden created by NCDs during and following emergencies continue to be under-recognised, under-researched and under-resourced. We call for all sectors, including health, government, non-government and community sectors, to further acknowledge, understand, study and address the structural determinants of NCDs within emergencies. We are currently publishing a specific call to action on the theme of NCDs and emergencies, which outlines key ways forward for achieving these. In addition, we already are engaged in discussions with colleagues at the WHO Chronic Diseases Prevention and Management (CPM), Geneva; the WHO Disaster Risk Management for Health Unit, Geneva; Copenhagen School of Global Health Masters of Disaster Management Programme; ChronAid, USA; and the International Federation of Red Cross and Red Crescent Societies, Community Based Health and First Aid Unit, Geneva in ways to collaborate on this topic.
When your donor funding runs out how will your idea continue to live?: As we are essentially aiming at improved planning, policies and guidelines for NCD prevention and management related to emergencies – such achievements will continue once agreed upon, adopted and implemented. The funding for research on the quantification of the compounding of NCDs and emergencies will depend on time limited research grants.

Basque Country: Reinventing Healthcare Delivery Model to Tackle Chronic Diseases

Author(s): Roberto Nuño-Solinís1
Affiliation(s): 1Basque Foundation for Health Innovation and Research, Sondika, Spain
1st country of focus: Spain
Additional countries of focus: Global
Relevant to the conference theme: Redesigning health services
Summary: In July 2010, the Department of Health and Consumer Affairs of the Autonomous Community of the Basque Country (2.2 million inhabitants in northern Spain) issued the "Estrategia para afrontar el reto de la cronicidad en Euskadi" (Strategy for tackling the challenge of chronicity in the Basque Country). This Strategy contains a series of specific policies and projects aimed at reinventing the health delivery model with the purpose of improving the quality of care for chronic patients, prevention of these pathologies, and advancing towards a more sustainable model.  The defined model is more proactive, integrated, preventive and focused on the needs of people. The expected transition is a complex cultural change for healthcare professionals and citizens. To facilitate this change, there is an explicit implementation strategy. On the one hand, launching top-down initiatives, some of them with a technological content (interoperable medical record, electronic prescription, ehealth development, etc.) and other of organizational nature (development of integrated care, innovative models for subacute hospitals, new nursing roles, etc), and on the other hand, supporting and facilitating innovation bottom-up projects led by frontline healthcare staff.  At present, 13 vertical projects and approximately 70 bottom-up projects are being implemented. This combination of initiatives seeks to achieve the critical mass for systemic change. Today, most projects are in development phase, although some of them have been successfully concluded, the challenge of full scale implementation remains. We will present the project of population stratification that can better target the interventions with a predictive approach, as well as examples of integrated care and of innovation from professionals with positive results.  The future prospects of the initiated change depends on exploiting all this innovative potential with a focus on social innovation, therefore transcending the mere medical scope.
What challenges does your project address and why is it of importance?: Chronicity from a systemic view. It represents the main burden of disease, mortality and economic cost compromizing the sustainability of heath systems worldwide.
How have you addressed these challenges? Do you see a solution?: In the Basque Country, this challenge has been addressed with strategic implementation projects aimed at reinventing health delivery with a primary care-based population focus. This is the first stage solution that must be followed by a social innovation approach in a further stage that encompasses broad social participation including patients, their representatives and community agents.
How do you know whether you have made a difference?: Several innovative projects have been succesful improving quality of life and satisfaction of chronic patients, as well as decreasing health services utilization and costs. The "global picture" of the transformation is still a work in progress.
Have you or the project mobilized others and if so, who, why and how?: The main agents of the Strategy are public providers, planners, managers and policy makers in the Basque Country.

Localization of Tobacco Regulations in 12 Selected Pilot Provinces: Philippines

Author(s): Maria Soledad Antonio1, Bill Bellew2
Affiliation(s): 1Department of Health, Philippines, 2International Union Against Tuberculosis and Lung Diseases
1st country of focus: Philippines
Relevant to the conference theme: Health governance
Summary: The project is designed to achieve implementation across the Philippines of the national legislation entitled “Tobacco Regulations Act of 2003” (Republic Act 9211). In our devolved setting, the local government units (LGUs which are the provinces down to the municipal level) have low compliance with respect to national mandates. The ultimate goal is to achieve an effective implementation of an LGU ordinance on RA 9211 in 12 selected provinces chosen because these sites have institutionalized health systems and planning processes from the municipal to the provincial level.
What challenges does your project address and why is it of importance?: 1. Variable levels of readiness among Local Chief Executives(LCEs). Even though the selected pilot provinces are the early adopters of the health reforms, we are still anticipating some “early adopters”, some “late majority” and some “laggards’.  Some LCEs are on board and will serve as champions.  Others will have to be convinced by experience of others before they embrace the innovation of a smoke free policy. 2. Pressure from business establishments and public utility vehicles for the local government not to implement smoke free ordinance. 3. Opposition from the Tobacco Industry
How have you addressed these challenges? Do you see a solution?: 1. To address the problem of the readiness of the local chief executives we have a strong advocacy policy by the civil societies and the health department. We also conduct organized visits of the local chief executives to the cities with comprehensive smoke free implementation. 2. The business establishments and public utility vehicles resistant to the implementation of smoke free environment were addressed by the passage of the smoke free ordinance in their local government unit. They are mandated by the law to follow its provisions or else they will be penalized. 3. The tobacco industry interference is being addressed by having strategic marketing, communication and public information on the deals of the tobacco industry and on how to resist their interference. The project also established a well trained advocacy network. This network anticipates industry tactics based on lessons from other countries and will aim to develop anticipatory positions / advocacy strategies.
How do you know whether you have made a difference?: We conducted a baseline cross sectional survey in the first pilot provinces who enacted a comprehensive tobacco control ordinance.  We assisted that pilot province and trained their enforcers on how to enforce the law.  We also did a multi level orientation on the ordinance and media campaign on the ordinance and the ill effects of tobacco use and second hand smoke exposure. After that intervention, we did another cross sectional study after one year of implementation and had a decrease in tobacco usage, strong support of smoke free ordinance in the province, decrease in second hand exposure, changes in knowledge, attitudes and behavior consistent with those revealed by studies conducted in high income studies
Have you or the project mobilized others and if so, who, why and how?: The project included participation of community players such as local government partners and enforcers, it intends to influence local development plans to increase priority in smoke free environment.  Participation of these stakeholders also enabled complementation of resources like human resources, money and time.
When your donor funding runs out how will your idea continue to live?: Since the 12 pilot provinces are the early adopters of the health reforms, they have functional local health boards with institutionalized planning and monitoring system on the activities of the health reforms from the municipality to the provinces. They also have an integrated health systems approach within the province called inter-local health zone. The project contributed to the identified local government unit sustainability strategy of making existing structures work and employing a multi-sectoral approach to health service delivery specifically on the hazards of tobacco use. The project had an intensive effort to enact a smoke free ordinance that includes access of funds for maintaining activities of local tobacco control (like performance incentives of the law enforcers, SMS reporting, etc).  With the intensive effort of the project – effective local legislation, massive public information, strategic partnership, monitoring system in place, compliance is expected.  After 2 years of intensive effort of the project we  anticipate the self-enforcement of the smoke free policy.  This would lead to the individual and the community’s change in behavior, lifestyle change leading to an increase in compliance, smoke free environment, reduced second hand smoke, decrease in the prevalence of tobacco use, increase in the smoking cessation rate and ultimately, in the long term, the reduction of non-communicable diseases brought about by tobacco use.