Health promotion and Disease Prevention in Denmark – from a National Perspective Barbara Hjalsted, M.D., MPH. The National Centre for Health Promotion and Disease Prevention, Denmark

Contents Visions, strategy and actors in prevention Riskfactors and their burden on the Danish population Social inequalities in health Challenges and opportunities

Visions for public health The population is provided with the necessary knowledge to make healthy choices in all phases of life, supported by health promoting environments Health promotion and prevention become an integrated part of the Danish health care system Health promotion and prevention are high on the public agenda and are embedded in other sectors, that have an effect on public health Health in all policies

Dimensions of our work Riskfactors (eg. alcohol, smoking, physical inactivity, stress, unhealthy diets) Diseases (eg chronic diseases (COPD, diabetes), infectious diseases) Target groups and settings (eg muni-cipalities, ethnic groups, children, health care system)

Prevention is cost effective! 20 30 40 50 60 70 80 90 Age difference in mortality maybe at work at work Expenses a life with prevention palliative care a life without prevention Early in this presentation the curves for survival, quality of life and the frequency of chronic conditions as they were established in the Danish study a few years ago were demonstrated.. Another way to express the goal for our efforts is this graph borrowed from Kaiser Permanente. If we take the curve for Usual care, where expenses are low in the long first period of life, we see that there is a long period of disease and incapacity to work. It could be the typical COPD patient . We want to reduce the total costs by the prevention of long lasting illness and improve as well quality as quantity of life. This can be achieved by better prevention and a better organisation of chronic disease management as demonstrated in the other and more attractive curve Source: Kaiser Permanente

The Government Health Program: Healthy throughout life Aim: Increase life expectancy free of disability or illness for everyone at all ages The mean life expectancy should be increased substantially The number of years with good life quality should be increased Social inequality in health should be reduced Udviklingen i middellevetiden i 70-erne og 80-erne betød ud over samlet fagområde, at der blev øget politisk fokus på sagen, herunder en række regeringsprogrammer. Her det nuværende. Den grundlæggende ramme for alt vores arbejde som statslig aktør på folkesundhedsområdet er Regeringens folkesundhedsprogram fra 2002, Sund hele Livet. Bemærk målene – det svarer til dem, vi lige har sluttet os til, at man rammer hvis man arbejder med risikofaktorerne.

National Health Package incl National Health Package incl. National Action Plan for Prevention October 2009 Aim: Increase life expectancy with 3 years within the coming 10 years Strategy: investment in treatment, economic incentives for the municipalities, strengthened prevention Action plan: 30 concrete prevention initiatives including risk factor interventions, focus on vulnerable groups, healthy work sites, monitoring, research Svær helt at få hold på: De 30 initiativer rummer ”alt godt fra havet”: Arenaer: kommuner, EU, globalt, arbejdspladser, detailhandel, forskningsmiljøer, uddannelse (ej regioner) Emner: livvstil, rygning, fødevarer, alkohol, smertestillende midler, fysisk aktivitet (cykling) Focusgrupper: ressourcesvage, børn-unge Metoder: Kampagner, økonomiske incitamenter, aktivebyrum, evidens samt monotorering

The Danish Health Act 2005 Section 119, subsection 1: The city council is responsible – when carrying out the responsibilities in relation to the citizens - for creating environments for healthy living Section 199, subsection 2: The city council offers health promotion and prevention services for all citizens 98 municipalities and 5 regions There are not exact demands on how the municiplities should carry out their new responsibility. There are a large degree of freedom to decide on which risc factors, target groups and settings the municipality would like to focus on.

The Danish Health Act 2005 Section 119, subsection 3: The Regional Councils offer patient oriented prevention in the hospital sector and in the private practice sector and supervision in relation to the activities of the municipalities

Health act: Two kinds of prevention Citizen oriented prevention To maintain healthy citizens, promote healthy environments, and prevent diseases in the population at large Patient oriented prevention To prevent sickness from developing further and to prevent complications and relapse Med folkesygdommene og Sund Hele Livet antydes to forskellige former for forebyggelse, den borgerrettede og den patientrettede forebyggelse. De to typer forebyggelse kan adskilles i visse dimensioner, men ikke i andre. Borgerrettet og patientrettet forebyggelse lapper helt over, når det handler om risikofaktorer – både i den borgerrettede og i den patientrettede forebyggelse arbejdes der med fysisk inaktivitet, alkohol, tobak, kost. Borgerrettet og patientrettet forebyggelse lapper delvist over, når det handler om metoder – der arbejdes med f.eks. motiverende samtaler, etablering om støttende netværk og træning. Men i den patientrettede forebyggelse arbejdes der desuden med mestring af egen sygdom, og der kan bruges patient- til –patient metoder. Der, hvor borgerrettet og patientrettet forebyggelse er adskilt er i deres formål og det er dem, jeg har skrevet op her. Tænkningen omkring borgerrettet og patientrettet forebyggelse er noget, der forfølges i den nye sundhedslov, både i lovtekst og i bemærkninger, og det er dermed en tænkning, som er en vigtig del af vores forståelse af forebyggelsesfeltet lige nu.

Partners in prevention National health and other sector authorities Other NGOs Local municipalities Citizen Patient Patientorganizations Hospitals Partners in prevention Private sector General practice Regional authorities Other practicing specialists

Risk factors and their burden

Life expectancy in 30 OECD countries Tilvækst i middellevetid over tid (1960-2007) i venstre graf Den samlede middellevetid og kønsforskellen opgjort i højre graf Konklusion: Middellevetiden stiger langsommere i DK end mange sammenlignelige lande. Det er især kvinderne der har haft en træg udvikling. Analyser viser at vi særligt halter bagefter pga. vores tobaks og alkoholforbrug.

Lifestyle: smokers, in percentage Males Females Source: National Institute of Public Health – The National health report 2007

Alcohol consumption per year Norway Sweden Poland Italy Finland Holland Greece Belgium Great Britain Portugal Denmark France Spain Austria Germany National Institute of Public Health – The National health report 2007 Liters of pure alkohol pr. capita

Riskfactors - physical inactivity 4,500 annual deaths are related to physical inactivity A physically inactive person dies on average 5-6 years earlier than the active 3,1 mio. sick-days among physical inactive Net cost in the health care system nearly 3 billion Danish kr. annually

Risk factors and death many are premature and can be prevented Source: Risik factors and public health in Denmark, National Institute of Public Health, 2006

Risk factors and contacts to the general practitioner Source: Risik factors and public health in Denmark, National Institute of Public Health, 2006

Risk factors and hospital admissions Source: Risik factors and public health in Denmark, National Institute of Public Health, 2006

Costs of the health care system Source: Risik factors and public health in Denmark, National Institute of Public Health, 2006

DALY related to risk factors Source: Risik factors and public health in Denmark, National Institute of Public Health, 2006

Health is created and maintained outside the health sector! Health in all policies, hia

Risk-population in a typical municipality app. 50,000 inhabitants 10,500 smokers 17,000 citizens not adequately physically active 20,000 overweight citizens (BMI > 25) 4,700 citizens drinking more alcohol than 14/21 units per week National recommendations

1.5 mio. Danes have a chronic disease In a typical municipality with 50,000 inhab.: 2-3,000 citizens with type 2 diabetes 2,000 citizens with heart disease 2,000 with COPD (Chron. Obstr. Pulm. Disease) 2,300 with cancer 8,000 citizens with muscular- skeletal disease 2,000 citizens with depression De 8 folkesygdomme tegner sig for cirka 70% af de tabte gode leveår på grund af sygdom, nedsat funktionsevne og tidlig død Ca. 1/3 af befolkningen lider af en af de såkaldte folkesygdomme. Det koster både den enkelte i livskvalitet og samfundsøkonomisk dyrt. Selvom man har en sygdom er det langt fra for sent at forebygge. Men forebyggelsen vil så handle om at standse sygdomsudviklingen og forbedre livskvaliteten for de der har en kronisk sygdom.

Gennemsnit for perioden 1998-2007 Social inequality KØN: Kvinder lever gennemsnitligt længere end mænd i alle landets kommuner, men forskellen mellem de to køns middellevetid er ikke lige stor alle steder. Forskellen varierer fra knap tre (Hørsholm) til lidt over otte år (Samsø). For 85 af de 98 kommuner er forskellen mellem mænds og kvinders middellevetid fra 3½ til 5½ år.   På figurerne nederst er kommunerne inddelt i fire grupper efter middellevetidens længde, de 15 kommuner med de korteste middellevetider, de 15 kommuner med de længste og de øvrige fordelt ligeligt i to grupper. Der er en figur for mænd og en figur for kvinder. Kommunerne med de korteste middellevetider er koncentreret på Lolland-Falster, i det sydvestlige Sjælland samt vest for København.  Både mænd og kvinder har relativt korte middellevetider i de tre kommuner København, Lolland og Ishøj. Mange kommuner med lange middellevetider findes nord for København. Blandt mændene lever de længst i Allerød og Hørsholm. Blandt kvinderne lever de længst i Dragør og Hørsholm. I Glostrup, Vallensbæk, Greve, Ringsted og Brønderslev er mændenes placering i forhold til mænd i andre kommuner betydelig bedre end kvindernes placering. Omvendt er kvindernes placering betydelig bedre end mændenes i de fire ø-kommuner Langeland, Ærø, Fanø og Samsø.   Mange forhold påvirker dødeligheden i en kommune. En sund befolkning med gode levevilkår, gode sundhedsvaner og et godt sundhedsvæsen vil andet lige have en lang middellevetid. Boligforholdene, som kan påvirke flytningsmønsteret mellem kommunerne, kan også have indflydelse på middellevetiden. Personer med lav indkomst og dårligt helbred vil sjældent bosætte sig i kommuner med dyre boliger, som Rudersdal, Hørsholm eller Gentofte, men vil have bedre muligheder for at bosætte sig i kommuner, hvor huslejen er lavere. En middellevetid eller en forventet levetid på f.eks. 78 år skal tolkes således at en nyfødt kan forvente at blive 78 år. Beregningerne bygger et gennemsnit for perioden 1998-2007 og er foretaget ved at gruppere de gamle kommuner, så de passer bedst muligt til de nuværende kommuner. Der er tale om gennemsnitsbetragtninger i forhold til middellevetid, da nogle dør i en ung alder og nogle bliver meget gamle. For at kunne beregne middellevetiden kræves der oplysninger om dødsfald i forskellige aldersgrupper, både blandt børn, unge, voksne og ældre. De beregnede middellevetider er ikke påvirket af aldersstrukturen i kommunen.  Gennemsnit for perioden 1998-2007

Short education – a risk factor 7.000-8.000 deaths annually related to short education Short educated die around 3 years earlier than those with long education Short educated lose 7-8 disease free years of life compared to those with long education 3.7 mio. contacts to general practitioners per year Net health system cost a little over 3 billion Dkr. annually NCD leading tp poverty Assessment, review of social inequality in health

Social inequality in health – lifestyle Smoking, men: Long educated: 1987 42%, 2005 27%. Short educated: 1987 57%, 2005 45% Physical inactivity: 35% among employed and highly educated. 22% among the unemployed. Alcohol: Proportion having drunk one or more units the last workday is highest among the highest educated Unemployment: Unemployed are more ill and have higher mortality than persons at work

Challenges for health promotion and disease prevention Slow increase in life expectancy Increasing chronic disease burden Inequalities in health – widening of the gap Healthy choices: individual versus structural perspective Accumulation and dissemination of evidence Collaboration between sectors Prevention has no constituency

Opportunities Political commitment Partnerships, health impact assessment Capacity building Quality assurance Patient education Working with norms Vulnerable groups Supportive environments Expanding the evidence base Making the healthy choice the easy choice!

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