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T.M.Maximova, V.A.Alabjeva

N.A.Semashko Institute for Research on Social Hygiene, Public Health, Economics and Management of the Russian Academy of Medical Sciences

Social-hygienic evaluation of present trends of basic features in Russia’s population health

The target to protect health population under present complex conditions of social and economic reforms in the country needs for all-round information on regularities of health population forming and for evaluation of present problems and possible ways of further dynamics.

The population health status reflects trends of economic development and prosperity of the country accurately enough. Many population health problems have deep socio-economic roots and subsequently one or another way of social development affecting interests of great mass of population predetermines health trends. At the same time many processes of health forming in our country reflects world trend and stable socio-biological regularities.

In connection with this the information for insuring of solution of management targets must be goal-oriented, it must reflect real steps of society for solution these targets and evaluation of reaction health population characteristics to these actions.

In the country negative trends of general characteristics of health population continue to have place, negative increase of population becomes larger. Study of these characteristics forming regularities reveals that trends of birth-rate, that is one of components of the process of the natural reproduction of population not only reflect crisis phenomena in the country, but they are typical for others countries with sustainable development, i.e. family planning became the practice for millions of people.

The trend to reduction of rates of population increase is noted in the world as a whole. This rate fell from 1,73% a year in the second half of 1980s to 1,57% a year in the beginning of 1990s.

According to present forecasts of the United Nations it is expected that rate of population increase will fall up to 0,5% in 2050 and already in 2000s-2020s it will be negative (-4-5% and over) in such country as Germany, Switzerland, Denmark and others. Some authors consider decrease of birth-rate as a manifestation of general (biosocial) law of behavior of living beings in the interests of population (P.P.Moiceev, 1995).

Measures of fertility regulation under our conditions include abortions for the greater part and the other actions (use of contraceptives and others) for the smaller part.

National statistic registered high rates of abortions during tens of years, but really no steps was taken for decreasing this rate all over the country. The experience of some territories (Altai Territory) shows that goal-oriented activity in this direction gives a real effect, that is reflected in statistical rates of abortions.

Mortality is the most important component of process of depopulation that troubles all of us.

What information is necessary for real actions decreasing mortality? The ONU conducts questionings of governments on evaluation of mortality rates in their countries. In 1993 31% of all governments of the world answered that mortality rates in their countries are acceptable. It must be known whether the government of our country is included in these 31% and is ready to take real measures.

It is necessary to have a full knowledge about the fact that the intensity of the mortality increase does not correspond to changes of prevalence of the conditions that are the main causes of death (according to the data of official statistics). This give to rise to the question about effectiveness of present health system that must ensure an opportune diagnostic and adequate correction of arising pathology.

For development of an appropriate social policy it is necessary to have a rather full notion about population morbidity in its different aspects as an objective mass phenomenon of beginning, development and completion of pathologic processes of different nature. It is necessary also to know that this phenomenon is really dissimilar on a social plane, to reveal its peculiarities in different groups of population, to evaluate a perception of pathology by people themselves, to know its influence on quality of life and its role in the forming and correction of different factors including the activity of health system.

Quantitative evaluation of population morbidity is not only object for theoretical researches but it have a practical value for taking appropriate decisions on health protection, including those at the level of an region or concrete territories and for definition of real contributions of society to the system of life ensuring and social protection. This information are needed also for evaluation of effectiveness of one or an other action affecting vital interest of great mass of population.

Epidemiological problems, knowledge of population characteristics and regularities of forming of morbidity seem to be simple against the considerable progress in the field of modern researches on molecular and immune mechanisms of diseases development and elaboration of new methods of ingenious diagnostic and therapy of diseases at this level (Veltischev Ju.E., 1995).

Probably it is time admit that to study regularities of population health and morbidity characteristics is not a narrowly statistical target but an fundamental scientific direction in medicine and the work in that direction requires high professional qualification.

Comparative evaluation of morbidity rates in their dynamics is a complex statistical problem. During the time there is place for changes not only of real characteristics of morbidity but also other parameters. These are changes of diagnostic capacity of medicine and theoretical and clinical knowledges, separation of new physician specialties and organizational forms and appropriate changes of statistics reflecting them (changes of approaches to a cipher work, grouping of diagnoses particularly in connection with revision of classification of diseases).

At the same time the accumulated statistical data make it possible to do some comparisons and to judge of morbidity trends.

The data on children morbidity are most available now for comparison mainly with the data in the year 1970, but for some diseases also with the data of more early published works on general morbidity of this contingent. The main changes of children morbidity are shown in the table 1.

Table 1

Dynamic changes in the frequency of some groups of diseases in children from 1970 to 1988-1989 (%) (applications for medical care)

Groups of diseases Highest levels (1970) Average levels (1970) Diapasons of average levels (1988-1989)
Infectious and parasitic diseases including 198 141 100-135
intestinal infections ...*) 20,9 15-30
Mental disorders including 36,0 18,3 20-37
neuroses, vegetovascular dystonia ...*) 4,8 10-18
Diseases of eye 59,5 43,9 40-70
Diseases of ear and mastoid process including 109,0 50,1 30-50
purulent otitis ...*) 43,5 10-22
Diseases of blood circulation system 17,2 8,5 3,0-7,0
Diseases of respiratory organs including 1362,0 902,9 1400-1600
pneumonia ...*) 35,5 8-13
chronic bronchitis 4,8 1,1 4-6
bronchial asthma 3,5 1,2 3-6
Diseases of digestive organs including      
gastritis, duodenitis 11,7 5,6 10-20
cholecystitis 17,2 4,7 9,8-13,0
Diseases of urinogenital system including      
acute cystitis ...*) 1,2 1,3-1,5
acute and chronic pyelonephritis ...*) 3,0 5-12
Diseases of skin and hypodermic cellulose including 96,9 63,4 45-95
purulent diseases of skin 42,3 36,7 20-30
Dermatitis ...*) 13,5 28-39
Congenital anomalies 24,6 7,9 11-21

*) There is no data

It is necessary to note that in comparison with the data of population health study (1988-1989) mental disorders, chronic bronchitis and bronchial asthma, diseases of digestive organs, acute and chronic pyelonephritis were registered more frequently in 1970. At the same time decrease of rates of purulent otitis, purulent diseases of skin and pneumonia are noted in 1988-1989. The dynamics of frequency of pneumonia can be traced from 1955, when level of this pathology in different time was 72-144‰, in 1970 this level was 35,5‰ and in 1988 8-13‰.

It is necessary to take into account a change of forms of this pathology, spectrum of agents of diseases and kinds of treatment of accompanying diseases.

Together with decrease of rate of purulent diseases of skin (in 1955 the frequency of pyodermia was 60-70‰, in 1970 - 36,7‰, in 1988 -20-33‰) the more high frequency of dermatitis is noted (in 1970 - 13,5 ‰ and in 1988 - 28-39‰).

According to the data of medical examinations the trend to the more frequency of mental disorders, bronchial asthma, diseases of digestive organs, particularly chronic gastritis, diseases of urinogenital system are noted. At the same time the rates of diseases of ear and mastoid process, diseases of blood circulation in children (at the expense of rheumatism) decrease. So trends noted by medical examinations are really the same that is revealed according to the data on application to medical services.

The available materials permit to judge of changes of structure correlations of pathologic conditions in adult population in comparison with 1970.

Increase of shares of blood circulation system diseases, diseases of osteomuscular system and connective tissues, digestive system diseases in the presence of decreasing shares of infectious and parasitic diseases, respiratory organs diseases, diseases of skin and hypodermic cellulose with practically the same shares of injuries and intoxications (not over 10%) are the main features of change of pathology structure (Table 2).

Table 2

Peculiarities of structure of adult population morbidity according to the data on applications for medical care (%)

Classes of diseases

Portion of morbidity structure (%)

 

1970

1988

Infectious and parasitic diseases

4,4

2,5-3

Neoplasms

1,8

1,5-2

Diseases of endocrine system

1,6

1,5-2

Mental disorders

4,2

5-6

Diseases of nervous system and organs of senses

8,5

5-9

Diseases of blood circulation system

10,4

13-15

Diseases of respiratory organs

32,9

23-27

Diseases of digestive organs

7,3

8-10

Diseases of urinogenital system

5,3

5-8

Diseases of skin and hypodermic cellulose

5,2

3,0-3,5

Diseases of osteomuscular system

7,3

10-12

Injuries and poisonings

9,0

8-10

The portion of injuries in morbidity structure did not change practically over a long period of time. It was 7% in 1912 (Ovcharov V.K., 1970), about 10% - in 1940 (Koslov S.P., 1955), 9,6% - in 1955-60 (Ovcharov V.K., 1970), 9,0% -in 1970 (Romensky A.A., 1978), 8-10% - in 1988 according to our data.

Available materials permit to compare a limited number of concrete diseases in some age groups, which are characterized by forming chronic pathology dependent on age (Table 3).

Table 3

Dynamics of registered frequency of some diseases in adult population from 1970 to 1988 (%)

Diseases and groups of diseases

Age groups (years)

40-49

50-59

60 and more

1970

1988

1970

1988

1970

1988

Hypertensive disease and ischemic heart disease

64,3

88-95

139,0

190-210

180-220

432-433

Bronchial asthma

2,7

1-3

3,7

2-4

3-4

7-12

Chronic bronchitis

11,7

16-32

17,7

47-48

24-27

60-68

Glaucoma

1,1

1,2

3,9

4-6

19,9

7-21

Diabetes mellitus

3,4

7,7

10,8

18-25

18,5

35-60

Evident trend to more frequency of the main kinds of blood circulation system pathology (hypertension, ischemic disease of heart), bronchial asthma and particularly chronic bronchitis is noted.

According to the data of Oganov R.G. and Gundarov I.A. (1989) the share of hypertensive conditions frequency did not change from 1960 to 1980 (the share of persons with high arterial pressure was 20,7 - 22,0%% correspondingly.

Ovcharov V.K. (1970) noted increase of the ulcerous disease rate from 5,2% in 1955 to 9,6% in 1962-1964. The frequency of this pathology in 1970 was 15,1 in men and 4,5 in women. According to the data of 1988, in a number of territories the frequency of the ulcerous disease was 19‰ among men and 7-9‰ among women.

So the comparison of data permits to judge of some population morbidity trends and the received data on present levels of morbidity can be used for subsequent comparisons.

Health directing bodies must to know what kinds of pathology does the net of health services not reveal. All spectrum of pathology excluding diseases that are not characteristic for our region must be in the structure of our population pathology.

In process of morbidity studying a lot of pathology are reveal whose forms were not make more exact, it was noted the absence of diseases whose agents was make more exact (it reflects the quality of the treatment). In mass practice immunological deviations, ferment insufficiency, multiple pathology having place in ICD-9 are not revealed because their diagnostics need for appropriate technical equipment of medical facilities and that influences the quality of treatment.

This information can be used for making decisions on equipment for our health facilities.

Comparing the data on population morbidity received on the basis of comparative methods in 1988 and 1993 one can evaluate changes of similar characters having place in spectrum of registered pathology during 5 years (the city of Moscow).

In 1993 the trend to more high frequency of endocrine disturbances in adults and in children, diseases of blood circulation system, diseases of osteomuscular system and connective tissues was noted with decrease of registration of mass diseases of respiratory organs. In addition the rise of frequency of mental disorders in children (at the expense of neuroses and vegetative dystonia, enuresis and others) and the rise of digestive organs diseases in adult and some trend to increase of injuries and intoxication’s.

Some authors speak about pathomorphism of different kinds of pathology. It is adopted to define term "pathomorphism" as stable important changes of clinicomorphologic symptoms of separate diseases (particular pathomorphism) and also changes of structure of morbidity and mortality (general pathomorphism) (Potapova I.I., 1984).

The data about changes of clinical symptoms of different diseases shows up. For example seasonal prevalence of acute conditions of gastroduodenal zone diseases including ulcerous disease is less seen, their clinical symptoms smooth. Owing to perfection of diagnostic methods rare and hard diagnosed diseases as vascular ectasis (diseases of Rendu-Osler, Krone etc.) are registered more frequently. A lot of rare diseases are not already considered as casuistry, for example symptomatic (acute) gastroduodenal hemorrhage (Zaprudnov A.M., 1991; Zerbino D.D., 1992). Medicament lesions of intestine and Kidneys, commissures, diseases of operated organs, hospital infections and diseases practically eradicated in the past (scabies, pediculosis) became more frequent during the last years.

Physicians who have possibility to compare first of all note that such diseases as bronchitis, pneumonia, ulcerous disease, atrophic processes on mucous membranes and others take an effaced course without of evident symptoms. This is one of particularities of diseases course in the population under conditions of ecological tension that may be general trends. This may be also one of causes of low rate of application for medical care.

Gastritis frequently is accompanied by gastromenia. Physicians, obstetricians and gynecologists note anemia which resist to treatment (65,1% of interrogated persons note more long course of diseases). 20,8% of physicians of different specialties note that pathology is formed if there are manifestations of allergy and astheno-neurotic syndromes or they accompany pathology. Evident weakness, fatigability, decrease of capacity for work are the main symptoms.

In physician's opinion longer course of diseases, even such as acute respiratory infections is the second particularity. Surgeons-traumatologists consider that slowed-up consolidation of fructures have place even if the fragments of bones have the right positions, more slow cicatrization of ulcers is noted (Maximova T.M. and others, 1991).

According to our data (selective observation, data on applications for medical care), duration of one case of disease is 8-9,5 days in children and 9-11 days in adults if there are evident particularities connected with the character of pathology.

The conditions connected with diseases of the osteomuscular system and connective tissues (10-14 days), infectious diseases and diseases of the urinogenital system (8-10 days), diseases of the skin and injuries (7-8 days) in children are the longest. In adults the longest diseases are those of blood circulation system (13-15 days under polyclinic conditions and 20-23 days in the hospitals), diseases of digestive organs, urinogenital system, injuries and intoxications (in the limit of 10-13 days, in hospital - 15-16 days), diseases of osteomuscular system and connective tissues (20-23 days).

The duration of treatment of mental disorders in children is 5-7 days, in adults - 8-9 days, in hospital - 40-60 days.

In this case the duration of physician's observation on the patient under real conditions is evaluated, but it is necessary to consider also subjective deviations of health, that may have place before the application for physician's help and after ending of contacts with physician.

Health system works today under not only new economic conditions connected with difficulties of assignment of necessary sums for medical provision, but under the conditions of new interaction doctor - patient and also new factors of health forming and behavior of population in respect of its health.

According to the data of questioning of physicians in city of Moscow and region of Moscow (May 1994), 37,5% of physicians note a decrease of number of patients visited them, more a half of physicians (53,1%) note a decrease of cases of giving out of sick-leave certificates (among physicians with stage of work over 5 years 61% note it).

75% of pediatricians (the largest share among all physicians) note a decrease of cases of giving out of sick-leave certificate for care of an ill child. According to our data temporary discharge of mothers of work connected with care of an ill child have place only in a half of ill-cases in children and at the same time the share of this cases connected with chronic pathology is infinitesimal. So even if there is extreme necessity maternal care is not provided to child completely and that can lead to forming of chronic pathology.

80,4% of physicians note that course of diseases become harder. 91,7% of physicians, particularly surgeons, note that the patients applicate for a medical care in more hard cases with neglected stages of illnesses, i.e. the contingent which come into contact with health system are changed and need for new methods and conditions of work.

According to the data of questioning only each fifth people applicates for medical care with appearance of first symptoms of illness and 50% of people make it only with appearance of serious troubling changes of their health status.

In the structure of late applications for medical care of population at the able-bodied age the impossibility to miss working time, including the fear to lose subsidies (that subsidies are not included in the average earnings at some enterprises, but are given for a coming to working place and are not given to ill persons) is in the first place in men and in women.

The role of medicine in health providing to contingent of ill persons is essentially more high than the role that is given to it in general theoretical works as a factor of health forming.

The volume of preventive work decreases in the last time, in opinion of physicians. Only about 7-10% of physicians-therapists note that a number of preventive examinations and preventive visits to medical services increase. The treatment of patients with chronic diseases for preventing recurrence of illness was one of forms of active work for prevention more hard course of illnesses. Under present conditions the most part of the enterprises that provided payment for such preventive treatment of the sick persons with such chronic diseases as hypertension and ulcerous disease essentially decrease their payments and in each fifth case liquidated them. It is recommended to the patients to buy drugs for preventive treatment at their-self expense.

Less than 10% of the therapists note that they direct patients to sanatorium and spa treatment as well as before, more than 80% therapists make it more seldom or don't make it at all, among 15% of physicians note that patients refuse a sanatorium and spa treatment for lack of money.

The questions about dietetics are practically taken away (64% of physicians note that they have not the possibility to direct patients, including those with hypertension, to receive dietary cookeries because dietetic canteens are liquidated, 15,4% make it more seldom than before).

The curative work with harder contingent of ill persons is complicated by the fact that doctor and patient enter in new relations to whom they are not sufficiently ready. First at all the necessity to discuss cost of drugs with patients is a new feature of this relation that is noted by 90% of physicians. Physicians know that necessary drugs are beyond the means of considerable contingents of ill persons (according to opinion of 37,8% of physicians drugs are beyond the means of separate patients, but a half of physicians (50%) consider that this concern the main mass of patients).

At the same time the majority of practitioners (82,4%) note that they have full knowledge about mechanism of action of only part of present imported drugs that filled the drug-stores, 10 % of physicians practically have not such information and only 7,6% know mechanism of imported drug action sufficiently. More than a half of physicians considers under this complicated conditions that they direct patients to hospital for treatment as well as before. But almost every fifth physician tries to give out-patient treatment to more quantity of ill persons, in several cases this process is regulated by administration of polyclinics and 12,5% of physicians note that patients refuse hospital treatment more frequently than before.

A half of physicians only notes they are not limited by some formal regalement and can treat a patient during the time that is necessary according to their professional notions. At the same time 37,7% of physicians in respect of some diseases tries keep to recommended tentative time limits. Every tenth physician orientates on control index of diseases’ duration because it is checked by administration (Methodic instructions from 25 May 1984, N 10-11/67), patients also insist on rapid discharge now.

As to in-patient treatment 65% of physicians note that hospitals permanently are provided not completely by necessary drugs. One per cent of physicians only (zero among surgeons) consider that in case of need they are provided by blood preparations and blood substitutes, protein preparations, preparations for parenteral nutrition and others that is vital necessary for equivalent treatment and for saving life of ill-persons. According to opinion of interrogated experts that leads to delay of planned operations in a number of cases with worsening pathology (in oncology for example). When a disease can turn into more hard and incurable study, in the case of urgent operation the absence of these preparations can be a decisive factor for saving life or death of patient (hard injuries, perforating ulcers and others). Decrease of volume of activity of specialized cardiology teams of emergency medical care and of medical aviation that are important for remote regions.

Under the conditions of insufficient medical provision considerable part of physicians (about 70% of physicians with stage of work under 20 years) are forced to recommend to patients these or others kinds of paid examinations and treatments (14,5% of physicians recommend paid examinations, 8,4% - paid operations, 2,4% - paid donors). Every third surgeon recommends paid operations. In spite of administrative prohibition 50% of therapists proposed to patients to buy necessary drugs for in-patient treatment.

The young specialists with the stage under 5 years are the most active in this plan, about 80% of them recommend paid kinds of examinations and treatments more frequently than their older colleagues.

Practically the same data on frequency of propositions of paid medical services are received by questioning of population.

Of course the data on morbidity accumulated by special studies and official statistic reveal certain trends but they can't be a signal to action.

The spectrum of pathology of Russia population is typical and for other countries (data on general morbidity in the cities of Russia and Australia, acute pathology in children of Russia and USA, stability of frequency of congenital anomalies (Population of RF, 1991).

Under present conditions it is necessary to have a new vision of theoretical works of national authors about statistics of morbidity per person that more completely characterizes contingent of ill persons than average data on morbidity.

The similarity of distribution of persons with different conditions among men and women visited medical facilities in large capital city (Moscow) and in city of region subordination (Kineshma) shows sufficient stability of population characteristics. It can be based for definition of volume of work with one or another contingent of population (Table 4).

Table 4

Composition of persons applicated for medical care to health facilities (%).

Character of pathology

City of Moscow

City of Kineshma

 

men

women

men

women

1. Acute diseases and injuries including

25.7

19.2

22.8

15.9

acute diseases

17.7

14.5

14.2

11.5

injuries

6.4

3.9

6.7

3.4

2. Chronic diseases

45.7

51.5

52.9

54.9

3. Chronic diseases

28.6

29.3

24.3

29.2

coupled with

       

acute diseases

22.7

23.5

17.1

22.4

injuries

2.9

3.0

4.3

4.3

acute diseases and Injuries

3.0

2.8

2.9

2.5

The main share of population was applicating for a medical care by cause of a chronic pathology. 60% from them – of an earlier detected chronic disease (about 40% of these patients have chronic disease during more than 7 years), in 6-10% of cases these are acute attacks of diseases, i.e. physicians work with enough good known contingent of population.

On the base of knowledge about composition of pathology and present notions on correction of its different forms full orientation must be done not only in the frequency of contacts with medical personnel but also in drug provision.

It is not enough to tell the mortality from cardiovascular diseases was increasing. It is necessary to have right means to observe the course of medical correction of this category of patients and to evaluate which share of patients did not receive an accurate treatment and for what reasons (low qualification of physicians, absence of drugs, initialization of modern methods of treatment and so on).

In the whole the composition of results of diseases in persons that are under medical observation during a year are pessimistic enough: about a half of ill-persons have no change in their conditions, 10% of them have a change for a worse including disability and death.

Any pathology concerns all organs and systems and is a factor of an integrated system importance.

At the same time there is not any undifferentiated pathology of the whole that don't contain in itself a main link more or less marked but defining quality specific of given pathology. In connection with it studies on diseases combinations and revealing of main complexes of chronic pathology must be the most important directions of present per person elaboration. These studies will promote to find right measures for correction of chronic pathology. The studying of the morbidity data by the use of per person analysis shows that according to the data on application for medical care modern combinative pathology is formed involving 2 and 3 systems of organism. This is shown on the materials of two different cities (Table 5).

Table 5

Shares of persons with combinative pathology involving different quantity of organism systems in patients with chronic diseases at the age of 30 years and over according to the data on applications for help to health facilities (%).

Quantity of system involved

City of Moscow

City of Kineshma

in combinative pathology

men

women

men

women

2 systems of organism

24.7

26.9

26.6

30.2

3 systems of organism

12.7

13.0

10.1

12.2

4 systems of organism

5.4

6.4

3.5

2.6

5 systems of organism

2.6

3.1

0.8

0.7

6 systems and over

0.8

0.6

0.1

0.1

Subjective health evaluations can be considered as one of indices of population health status. On the one hand they reflect objective somatic status of individuals including their perceptions of one or another pathologic deviation and level of adaptation to it or its consequences (different limits of life activity), on the other hand they reflect a compound complex of factors and conditions and particularities of situation in time of interview-survey. It looks as if difficulty of interpretation of subjective evaluations orientates to obligatory objectivation of results for receiving sure conclusions. At the same time with rise of education and culture level and increase of knowledge of the population about the behavior conducive to health the reliability of the population knowledge about his health status considerably rises. And so to take into account subjective perception of health status becomes important in both cases when it coincides with objective data and when it differs from them.

Generalized data on subjective perception of health reveal typical features of different groups of the population, the comparison of these features make it possible to note health problems of different nature.

The dynamics of subjective evaluations of health with age reflects decrease of vital energy in the population, which really coincides with statistical data on changes of general morbidity and increase of chronic pathology and mortality with age. Decrease of share of persons with high subjective evaluation of health and increase of persons with low evaluation of it are the main feature of aging process. It is general process, the age changes are stable according to the results of our studies and to the data of the other researchers.

A comparison of subjective health evaluations with the data of morbidity according to applications for health services reveal the connection of these characteristics with the level of both acute and chronic pathology.

During questioning of the population the option of the answer is determined by complex of factors of material and socio-psychological environment. The same environmental factors in different levels (family relations, problems of work, including character of labor and interrelations of members of labor collective, education level, social position and others) determine a lifestyle and a behavior of a person to a considerable extent and together with concrete material factors (income, living conditions, quality and regularity of nutrition) are the environment where the person’s health has been formed.

The comparison of the data on subjective evaluations of health by the population of our country and foreign countries shows that our population is less optimistic and more seldom give a high evaluation to health. In foreign countries 90% and over of young people give high evaluation to their health (Komarov Ju.M., 1993). In Russia this index is 50% or a little higher. At the same time the shares of persons with low evaluations of health (normally these are persons with serious deviations in health) are sufficiently similar in Russia and foreign countries according to the results of our studies. At the age groups from 25 to 64 this share make 10,0% in the USA, 14,0% - in West Germany and 13,8% - in the USSR.

The results of interview-survey of the population health in the city of Moscow in 1988 and in 1994 don't reveal lowering of subjective health evaluations in the last years. On the contrary practically in all age groups of men and women the share of persons with high subjective evaluation of health have risen by 1994 and the share of persons that evaluate their health as bad or very bad have decreased (Table 6).

Table 6

Shares of persons with low evaluation of health by them-self in selected contingent of population of city of Moscow (%)

  Men Women
Age groups 1988 1994 1988 1994
20 - 39 years 12,1 7,0 12,9 17,5
40 - 59 years 21,1 10,2 23,0 17,6
60 years and over 40,8 29,4 57,8 52,3

At the same time other evaluations of these data are possible. So in the opinion of Zaharova O.D., 1994, the excess of mortality in the last years "have made a natural selection and liquidated the weakest persons and those who could not adaptate him-self to sudden changes of life orientations and stereotypes".

It is necessary to note that according to the data of last interview-survey (1994) a considerable part of the population began to take care of his health more actively under the new conditions. 20,1% of men began to take up physical training, 13,4% of them made an endeavor to give up smoking and 11% - to give up alcohol; women was more conservative as regards changing of their lifestyles. As a whole this is the considerable part of the population and all the possibility must be used to support this activity and to make conditions for its realization.

Goal-directed actions for positive influence on the population health must take into account world experience of implementation of Global strategy for health for all by the year 2000 adopted by World Health Organization and Targets for health for all adopted by Regional Organization of the WHO for Europe. This experience are reflected in particular in third report on monitoring of progress in implementation of strategies for health for all by the year 2000 presented to 95 session of the Executive Board of the WHO in 1995.

According to Targets for health for all "by the year 2000, there should be structures and processes in all Member States to ensure continuous improvement in the quality of health care and appropriate development and use of health technologies"(Target 31).

The analysis of the present world health situation shows that if efforts of international collaboration, including cooperation between international organizations, donors, foundations, research and educational institutions are considerably activated (as this had place during implementation of smallpox eradication program) successfully accomplished by 1980) it will be possible to eradicate poliomyelitis, leprosy and measles in the global scale and also eliminate diphtheria and hereditary syphilis by the year 2001.

In 1993 141 countries informed already about zero poliomyelitis morbidity, but at the same time great epidemics were registered in Azerbaijan and Uzbekistan. According to the data of WHO 95% and the measles incidence rate under 5 years will reduce the rate of mortality from measles in children by 90%. In our country cases of poliomyelitis are noted seldom but measles and diphtheria morbidity continues to rise. But the rising of this morbidity is noted not only in our country.

Under this conditions it is necessary to newly evaluate the directions of efforts of the general net of medical services and organs of state sanitary inspection. Not only morbidity rates but also production and purchasing of vaccines and the coverage of population by immunization must be under surveillance.

The second of the main directions of global strategy of health for all expects to reduce morbidity of cardiovascular and other chronic diseases whose risk factors are known and also to reduce death and disability due to them. It is supposed that the frequency of mental disorders will continue to increase in connection with stresses, destruction of former lifestyle and other factors. In many developed countries the rate of morbidity and mortality from diseases of blood circulation system decreased and will continue to decrease as the lifestyle of the population will improved. In several countries this decrease will be over 40% (Osmond S., 1991), it will be 18-20% even in persons at the age of 65 and over. At the same time the rate of morbidity of diabetes mellitus is high (2-5% in adult population of Europe) and it continue to rise. For real decrease of mortality it is necessary fundamental knowledge about regularities of distribution of pathologic conditions (La Porte P.E. et all., 1992).

As regards decrease of mortality from cardiovascular diseases in our country it is necessary first at all to have full notion about the fact that having more high level of mortality from blood circulation system diseases we register also more low level of mortality from a number of diseases (diseases of the endocrine system, infectious and parasitic diseases in the population at the older ages, diseases of the urinogenital system). That shows not only the large prevalence of blood circulation system diseases but also accuracy of diagnostics of pathologic conditions in our country. It is necessary to revalue mass methods of correction of these forms of pathology and to make life conditions of the large population conducive to health, as even in a society with considerable material well-being health promotion depends on the level of vital standards (Morrison J., 1994), that is particularly important for forming health quality of the future generations (McKee M., 1993). The knowledge of regularities of health population forming, social trends and achievements will take it possible to convert epidemiological information into plans of actions and politics on local, regional and federal levels.

It can be done within the framework of social and hygienic monitoring of health. The activity of this monitoring can be a link connecting research works with goal-orientated actions of the society in the field of protection of the population health.

Literature

1. La Porte H.E. et all. Conting birds, bees and NCD. Lancet, 1992, v.339, Feb. 22, pp.494-495.

2. McKee M. Poor children in rich countries. British medical journal, 1993, Dec., pp.1575-1576.

3. Morrison J. Future of Medicine. British medical journal, 1994, Oct., p. 1088.

4. Osmond S. Targets for health for all. The health policy for Europe. WHO, Copenhagen, 1992.- 58 p.

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