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To achieve comparable information from different countries, standards are needed for data collection procedures, quality requirements, definitions of the indicators and reporting. Creating such standards is the objective for the EHRM Project. To facilitate the assessment of trends in the indicators, it is desirable that the standards are kept unchanged. Nevertheless, it is evident that the standards will need further development in the future, because of improvement in the data collection methodology and new experiences from the monitoring. The developing of the standards can not be done in the national level, but will require international collaboration.
The EHRM recommendation defines a core set of measurements for a national survey. However, the proposed risk factor data will only represent a subset of the data collected in most health surveys. When planning any extensions to the surveys, the countries will benefit from the existence of networks which facilitate the exchange of experiences between the countries.
The data collection and processing should be organized locally by each country. They have the necessary knowledge for adapting the general principles to the national circumstances, and they have the necessary skills for communicating with the subjects of the survey. Furthermore, their expertise will be essential in interpreting the results of the survey. Nevertheless, the countries will benefit from the existence of networks which facilitate the sharing of experience and exchange of expertise between the countries.
Training and quality control should be an integral part of the local operations of the national surveys. To facilitate the standardization between the countries, international collaboration in training and quality control will be necessary, and development of common training material, such as audiovisual tapes for training of blood pressure measurers.
A specific area where an international facility is needed is laboratory standardization and quality control. From the 1970s to 1990s, lipid standardization in Europe was carried out by WHO Regional Lipid Reference Centre (RLRC) in Prague, Czech Republic. Now, as WHO RLRC is no longer operating, it is important to establish a replacement to serve European surveys. Such a reference laboratory is needed for providing secondary calibrators for the survey laboratories as well as providing external quality control. For American surveys, the standardization has been in the hands of the Centers for Disease Control (CDC) Atlanta for several decades using methods which guarantee stability of the reference values over the years. Without a laboratory reference centre with sufficient expertise and established reference methods, there is no way to guarantee the validity of time trends within countries or the comparability of results between countries.
After the surveys, the only way to assess the quality and comparability of the data for the indicators from the different countries is through a centre, which is independent of the national surveys.
According to the experience from the WHO MONICA Project, rapid external quality assessment not only helps in assessing the quality for reporting, but also facilitated to remedy many of the shortcomings which were revealed.
The analysis of survey data for the national purposes should primarily be done locally in each country. The countries should be encouraged to utilize the data as extensively as possible, not only for policy making and public health purposes, but also for research. Although public health would be the main motivation for the monitoring, its use for research helps in creating national expertise in interpreting the data and in improving the quality of the data.
The countries will benefit from the existence of networks which facilitate the sharing of experience in analyzing and reporting the data.
This report was made within EU's Health Monitoring Programme, with its aim "to contribute to the establishment of a Community health monitoring system", in order to:
These aims imply the need for international collaboration in reporting key indicators for each country and making them available to the member states. One anticipated mechanism for reporting the data is the "Health Indicators Exchange and Monitoring System" (HIEMS), which the European Commission is preparing.
For the time being it seems that HIEMS will include summary data for the key indicators, which can be viewed graphically through the world wide web. The data can be presented for each country separately, but comparisons can also be made between countries. For the usefulness of the HIEMS data, it will be important that it also includes information about the quality of the data, as well as summary statements of the risk factor status in each country.
It will be important that the information on the quality of the data comes from the centre which makes the data assessment. The summary statements for each country must come through collaboration between the country and an international "editor". The former is needed for relating the data to the national situation, and the latter for standardizing the statements so that they are comparable between the countries. In principle, each country can compute the indicators locally and feed them directly to the HIEMS system. However, calculation of indicators is facilitated if it can occur in connection with quality assessment. This would of course require close collaboration between the individual countries and the quality assessment centre.
Also other international collaboration in analyzing and reporting the data should be highly encouraged.
To assure comparability of the indicators, it is necessary to have international collaboration for:
To improve quality, to increase motivation for monitoring and to share expenditures and reduce duplication, the countries would benefit:
A centre with sufficient expertise should be established with the responsibility to facilitate the national surveys to follow the agreed standards of data collection. This would be done through:
The chronic disease risk factors considered in the EHRM Project define a sensible area of responsibility for such a centre, but also the inclusion of a wider set of indicators collected through population surveys, such as those on nutrition, physical activity and health should be considered.
The centre should operate in collaboration with EU, WHO and other agencies.
A European Laboratory Reference Centre should be established to provide secondary calibrators for the survey laboratories and external quality control. The Centre should collaborate with CDC.
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