Quality Coordinators' Perspectives on Quality Improvement in Primary Healthcare in Kosovo: A Qualitative Study.

AIMS: This qualitative descriptive study provides insights into the experiences of quality coordinators (QCs) in primary healthcare to inform policy and practice actions and empower QCs to enhance healthcare quality. METHODS: We conducted focus group discussions with purposefully selected QCs to understand their motivations, job experiences, factors influencing healthcare quality, and suggestions for quality improvement. Content analysis and deductive coding were used to scrutinize the responses and answer the research questions. RESULTS: The QCs thought highly about their job performance and were motivated by both extrinsic and intrinsic factors. Clinical audits, collegial reviews, and managerial support positively affected QCs' performance. In contrast, a lack of managerial support, limited working hours, and changes in organizing work caused the opposite. Empowerment and external support positively influenced healthcare quality, whereas lack of resources, managerial support, or training had a negative influence. Suggestions to improve quality include the role of QCs, external supervision, and centralization of the QCs' network. CONCLUSION: Appointing QCs alone does not guarantee quality improvement. It is essential to ensure that QCs have the appropriate skills, tools, management support, and open communication channels. Further research is required to evaluate the effects of sex and age on QCs' performance.

Tumour Size Distribution of Invasive Breast Cancer in a One-Year Period: Case Study Herzegovina.

BACKGROUND: To analyse the early stage breast cancer tumour size distribution as an important prognostic factor among the female patients within our local geographic region of Herzegovina. SUBJECTS AND METHODS: This cross-sectional retrospective study included 379 patients who were treated in 2017 at the Oncology Clinic, University Clinical Hospital Mostar. The patients were divided into two groups based on their primary tumour size: early (≤2 cm) and late (>2 cm) stage groups. RESULTS: The number of patients tested for advanced stage tumours surpassing 2 cm was statistically higher (χ2=106,325; p<0.001). 39.32% (N=149) of the patients presented with tumours ≤2 cm (T1) and 52.24% (N=198) of the total number of the patients presented with tumours >2 cm but ≤5 cm in greatest dimension (T2). The patients' knowledge about breast cancer, availability and adherence of mammography did not show any statistically significant difference with regard to tumour size, while the number of patients with smaller tumours who indicated that they underwent regular mammography was statistically significantly higher (χ2=13,629; p<0.003). CONCLUSIONS: Our data shows that in our region, more women with a diagnosis of breast cancer presented with a larger tumor size. Although there was no statistically significant difference with regard to prior knowledge about breast cancer and availability to mammography, this may be due to a small sample size. Our region does not have a screening mammogram program and this data suggests that the implementation of such a program may improve adherence to existing mammography guidelines which might capture tumors at a smaller size and hence an earlier stage.

The relationship between health locus of control, depression, and sociodemographic factors and amount of time breast cancer patients wait before seeking diagnosis and treatment.

BACKGROUND: In the Federation of Bosnia and Herzegovina, the prevalence and incidence of breast cancer has been increasing, and the national programme of early prevention, administered locally, is sporadic and without quality assurance. While many factors may influence women's decision to adopt prevention-oriented behaviours regarding breast cancer, this study has emphasised the importance of sociodemographic factors, psychological factors and mental wellbeing. SUBJECTS AND METHODS: Participants in the study were all patients who, during one year, were admitted for the first time for diagnosis and treatment in the biggest Clinical hospitals of the Herzegovina-Neretva region Patients were divided into two groups based on their TNM classification: "early stage" and "late stage". Three instruments were used in this study: an individual questionnaire about demographic and socioeconomic characteristics of the woman, the Multidimensional Health Locus of Control scales, and the Hamilton Depression Rating Scale. RESULTS: The majority of patients diagnosed with advanced disease were admitted to hospital in the late/advanced stages of the disease. Multi-variant analysis showed that the most statistically significant positive predictor for early admittance in hospital is living with family and marital status while religiosity has a negative predictive value. The results indicate that 59.7% of respondents do not have depression, while the remainder do have some degree of depression. There was no statistically significant difference in the degree of depression between women who were diagnosed and treated early and those who were not. The employment status of the respondents was the only significant factor related to degree of depression. CONCLUSION: Although health locus of control and depression are not statistically significant predictors of early hospital treatment, the recommendation is that further studies focus on the implementation of MHLC and HDRS scales within the community. This could be useful in planning appropriate and specific interventions, not only because of early diagnosis, but also to ensure good mental health and resilient behaviour.

Paternalism and autonomy: views of patients and providers in a transitional (post-communist) country.

BACKGROUND: Patient autonomy is a fundamental, yet challenging, principle of professional medical ethics. The idea that individual patients should have the freedom to make choices about their lives, including medical matters, has become increasingly prominent in current literature. However, this has not always been the case, especially in communist countries where paternalistic attitudes have been interwoven into all relationships including medical ones. Patients' expectations and the role of the doctor in the patient-physician relationship are changing. Croatia, as a transitional country, is currently undergoing this particular process. METHODS: Qualitative research was conducted by means of six focus group discussions held in the years 2012 and 2013 in Croatia. Focus groups were held separately with each of the following: first year and final (6(th)) year medical students, physicians engaged in medical ethics education, physicians practicing in a clinical hospital, family medicine residents and individuals representing patients with chronic disease. This research specifically addresses issues related to patient autonomy, in particular, the principles of truth telling, confidentiality, and informed consent. All focus group discussions were audio taped and then transcribed verbatim and systematized according to acknowledged qualitative analysis methods. RESULTS AND DISCUSSION: Patient autonomy is much more than a simple notion defined as the patient's right to make treatment decisions independently. It has to be understood in context of the broader socio-cultural setting. At present, both patients and medical doctors in Croatia are increasingly appreciating the importance of promoting the principle of autonomy in medical decision-making. However, the current views of medical students, physicians and patients reveal inconsistencies. CONCLUSIONS: Knowing how to respect the various facets of patients' autonomy should be part of physician's professional duties, and also be reflected in his or her core clinical competencies. For this reason greater importance should be dedicated to patient autonomy issues in medical education in Croatia.

Are nurse presenteeism and patient safety culture associated: a cross-sectional study.

Working as a nurse involves great dedication and sacrifice: working night shifts, working overtime, and coming to work sick. The last is also known as presenteeism. Research has shown that poor nurse performance can affect both caregiver's and patient's safety. The aim of this cross-sectional study was to investigate whether nurse presenteeism affected patient safety culture and to look deeper into the characteristics of nurse presenteeism and patient safety culture in Croatia. The study was conducted in one general hospital in Croatia over April and May 2012 and specifically targeted medical nurses as one of the largest groups of healthcare professionals. They were asked to fill two questionnaires: the six-item Stanford Presenteeism Scale (SPS-6) and the Hospital Survey on Patient Safety Culture (HSOPSC). We found no association between presenteeism and patient safety culture. Overall positive perception of safety was our sample's strength, but other dimensions were positively rated by less than 65 % of participants. The lowest positive response concerned "nonpunitive response to error", which is consistent with previous studies. Presenteeist nurses did not differ in their characteristics from nurses without presenteeism (gender, age, years of experience, working hours, contact with patients and patient safety grades). Our future research will have to include a broader healthcare population for us to be able to identify weak spots and suggest improvements toward high-quality and cost-effective health care.

Assessing primary care in Croatia: could it be moved forward?

It is well known that countries with strong primary care achieve better health outcomes at lower costs. Therefore, the effort of World Health Organization in promoting primary care as a basic principal of successful health care system is an ongoing process. Although Croatia was recognized as a country with primary care orientation due to the development of health centers and introduction of specialist training of general practitioners, it seems that many health care reforms aimed at better organization of health institutions and decreasing of health care costs did not result with higher primary care orientation. By application of the Primary Care Score instrument in 2014 (Croatia received 11.2 out of 20 possible points), and international comparison performed in 2002, it was concluded that among the eighteen OECD countries Croatia could be categorized as an "intermediate primary care country", obtaining the scores just a bit above the average.

Home visits in Croatian family practice: a longitudinal study: 1995-2012.

Similar to other countries, home visits in Croatia are within the scope of family medicine (FM). The significant changes have been implemented within the FM with almost no scientific evaluation. The study was undertaken with the main aim to determine the overall trends in home visiting in Croatian FM between 1995 and 2012. A data sources were Croatian Health Service Yearbooks, 1995-2012. The numbers of family doctors, practice visits and home visits were collected. Results indicate that the annual number of home visits is relatively small, whether it is viewed per patient (0.1) or per doctor (160) with a decreased trend. The geographical variations are observed too. It seems that HC reforms did not have any influence on the observed trends. This should seriously be taken into the consideration in the future planning on the ways to keep growing hospital expenses under control.

Trends in preventive activities for the adult population in family medicine in Croatia: 1995-2012.

A few preventive activities were recorded in Croatian family medicine (FM) from 1995 until 2003, and then in 2004, additional fee-for-service reimbursement for general check-ups for people aged 45 to 65 years was introduced. The aim of this study was to investigate the trends in preventive activities before and after the introduction of those measures by using the Croatian Health Service Yearbooks for 1995-2012 as the main database. Data on the number of preventive, general, and total number of check-ups were collected. The results showed that the total number of check-ups registered in FM was low, suggesting that the additional reimbursement did not bring any improvements. In fact, the trend in the number decreased after 2004. These results are not unexpected because of the ineffectiveness of general check-ups as indicated in the literature. General check-ups should be replaced by targeted preventive interventions with evidence-based effectiveness.

Case oriented approach to co-occurrence of risk lifestyle behavior with overweight, excess abdominal fat and high blood pressure: the CroHort study.

Objective of this paper is to estimate interim risk factors (INTF) proportions and changes within 5-years of groups with at least one risk health behavior (BEHF) in CroHort population. Results show that CroHort 2008 group has higher proportions of excess abdominal fat and overweight. Men older than 65 without any BEHF have smaller proportions of INTF in 2008 than in 2003. Proportion of people with high blood pressure is smaller in 2008 for all groups except for young women who show increase. Analysis of middle age group shows significant increase in all INTF in women smokers while men smokers have the highest increase in abdominal fat. Physical inactivity in women is associated with increase of all INTF, while men have decrease in overweight INTF. Alcohol intake has protective effect on middle aged men, except for increase in waist circumference. Women show constant increase in all INTF with heavy alcohol intake.

Prevalence and five-year cumulative incidence of abdominal obesity in Croatian women of childbearing age: the CroHort study.

Generalised obesity is increasing in prevalence globally, however trends in abdominal obesity are less well known. In 2003, 1,999 women of childbearing age participated in the Croatian Adult Health Survey, of whom 598 (29.9%) participated in the second cycle in 2008. For 2008, the prevalence of abdominal obesity using the International Diabetes Federation (IDF) criterion (waist circumference > or = 80 cm) was estimated at 70.3% (95% CI 61.8% to 75.7%), whereas the prevalence of abdominal obesity using the National Cholesterol Education Program, Adult Treatment Panel III (NCEP ATP III) criterion (waist circumference > or = 88 cm) was estimated at 48.6% (42.6% to 54.7%). The preceding five-year cumulative incidence was 54.3% (44.5% to 64.2%) and 35.2% (28.0% to 42.4%) using the IDF and NCEP ATP III criteria, respectively. The burden of abdominal obesity is high and rapidly increasing in Croatian women of childbearing age, the key population subgroup for obesity control.

Health status of population in Federation of Bosnia and Herzegovina in 15 years of transitional period.

War in Bosnia and Herzegovina lasted from 1991 to 1995 and resulted in profound consequences marked by the large number of victims, increase in the diseases and disorders prevalence, that were not common before it occurred. The effects it had on health status of the entire population was reflected through many negative demographic trends, increasing prevalence of chronic diseases and the spread of a number of unhealthy behavioral patterns and a lot of migrations. All this presents a problem for institutions of health system which are attempting to control these negative influences especially during the transition period, marked by the direct adverse consequences of the 1991-1995 war. The present paper presents a summation of various sources which are attempting to provide a synthetic overview and provide basic information in relation to the health status of the population, and also to provide a baseline evaluation for deployment of public health interventions.

[Community health course--student's evaluation]. / Evaluacija predmeta "zdravlje u zajednici" studenata medicine.

INTRODUCTION: Since 1952, Andrija Stampar School of Public Health, School of Medicine, University of Zagreb, has provided a community health course, based on the medical education approach that the main fields of physicians' action are human settlements and not only consulting rooms and clinics. AIM: The aim of the study was to compare community health course students' evaluations immediately after attending the course at the 4th and 6th study years. SUBJECTS AND METHODS: The survey included 224 4th year medical students attending the community course during the academic year 2007-2008 and 192 same-generation 6th year students (85.7%) during the academic year 2009-2010. Students were required to fill out an evaluation questionnaire about the activities during the community health course using grades from 1-poor to 5-excellent, and to write personal remarks and essay. RESULTS: The academic year 2007-2008 students (n=224) were very satisfied (grades 5 and 4) with preparatory seminar (98% of students), final seminar (97%), course organization (90%) and course contents (89%). The same grades were allocated by 98% of students to public health field research, 94% to work in community nurse service, 93% to work in family practice and health promotion in school and kindergarten, and 87% to water sampling. Satisfaction with the community health course was very emotionally described in final essays: "... work with community nurse service in the poorest part of Croatia has changed my life. I have learned in only few hours to wish less and to give more. Every physician should experience it, because that is real life". Results of the same-generation students (n=192) in the academic year 2009-2010, now at 6th study year, showed them to be still very satisfied (grades 5 and 4) with the activities in the community health course: 94% with health promotion, 92% with work in the community nurse service and family medicine, 86% with course contents, 82% with course organization, 78% with final seminar, 64% with preparatory seminar, 63% with field research, and 49% with water sampling. DISCUSSION: At some medical schools, there are similar attempts to bring students more closely to life conditions, especially to rural communities. Different schools of medicine in the world have attempted to improve and adapt current curricula towards community-oriented education of medical students during undergraduate study and residency. In some countries, there is also the need of improvement of health care in rural areas. CONCLUSION: Results of the course evaluation showed that students had recognized the exceptional value of community health course as a whole. They perceived it as the most valuable and most useful experience in their medical study. By participating in local health care and social care activities in rural area, they got an insight into both the health care system and socio-medical determinants of health.

Psychological distress within cardiovascular risks behaviors, conditions and diseases conceptual framework.

Psychological distress (PD) is being increasingly recognized as a risk factor for cardiovascular diseases (CVD). Our aim was to recognize an association of PD and CVD in the Croatian adult population. We also explored association's strength obtainable as relative risk of PD on three levels; cardiovascular risk behaviors, conditions and diseases. This study used Croatian Adult Health Survey 2003 (CAHS 2003) data (N = 9,070). PD status was measured by the five-item Mental Health Scale of the Short Form questionnaire (SF-36) hence one distinguished subgroup consisted of population with PD and other without PD. Prevalence of cardiovascular risk behaviors, cardiovascular risk conditions and self-reported cardiovascular diseases within each subgroup were calculated using bootstrap method. Women had higher prevalence of PD in general population. Among distressed population women had higher prevalence of body mass index over 30, metabolic syndrome and angina pectoris. Men with PD had higher prevalence of high blood pressure and myocardial infarction with contradictory lower prevalence of angina pectoris then myocardial infarction. Physical inactivity was proven to be a risk behavior determinant with most impact on mental health. All CVD are consistently associated with higher prevalence and relative risks for PD both in men and women.

Importance of health care issues in 2005 presidential elections in Croatia.

Health and health care provision are among the most important and politically sensitive public service areas. Politicians carefully incorporate health care program changes in their political agendas to gain votes. However, knowing health care priorities of the electoral body is not useful only to politicians, but also to health policy makers, as it enables them to target the most problematic areas in health care. We conducted a telephone survey of representative sample of voters (n=643) immediately before the presidential elections in Croatia in 2005, to determine the possible differences in health care priorities between left-wing and right-wing voters, and found a high level of homogeneity in their opinions. Health care organization, corruption, and financing issues were identified as the top priorities by both left- and right-wing voters. This agreement in voters' expectations, probably caused by a similar frame of mind of Croatian citizens inherited from pre-democratic times of self-government, could be used by health policy makers to rationally invest the means and efforts in dealing with the most problematic health care issues.

The role of school medicine doctors in health education in Croatia--past, present and future.

Croatia never had a separate vocation (occupation) of a health educator. Health education is one of the main tasks in the long tradition of preventive work of doctors-school medicine specialists. Additionally, in the school curriculum in the Republic of Croatia the health-educational contents are integrated into various subjects, and are conducted by teachers. However, there are requests to introduce a new subject into schools called Health Education. We asked physicians of school medicine their opinion on the introduction of this new subject. 30% of the physicians were dissatisfied with the current condition, 10% were satisfied, while there were no very satisfied school medicine doctors. They believe that health education goals are oriented solely to passing on knowledge (facts), while efforts are not done to change habits and attitudes of young people. They recognize themselves as persons mostly involved in health education in schools. Half of the school medicine doctors believe that the school curriculum should contain both a separate subject as well as integration of health education into other subjects. Before introducing any changes into healthcare or education system, it is necessary to examine the attitudes of students and parents, to direct the changes towards the promotion of the cooperation between the healthcare system, education, civil society, school and community where investing into the health of young people is done through comprehensive and holistic programmes.

Readability of patient information on diabetes on the Croatian Web sites.

Many studies on readability, have shown that patient information is frequently written at the reading level too high for the average population to understand. The aim of this study was to determine the reading level of patient information on diabetes found on the Croatian Web sites and written in Croatian language. Patient information on diabetes from 10 Croatian Web sites was tested for readability using the SMOG formula. The reading levels of the tested materials ranged from 11 to 15, which showed that these materials would not be understood by at least 80% of the Croatian adult population.

[Hypermedia in medical education: quality of health care]. / Hipermedija u medicinskoj edukaciji: kvaliteta zdravstvene zastite.

The recent technological developments have found its place in medical education as well. Hypermedia has become very popular through the widespread use of the Internet. In its research project, the Department of Educational Technology of the Andrija Stampar School of Public Health studied and applied the educational methods in continuing training of health professionals using hypermedia and taking into account the specificities of medical and health practices. Potentials of hypermedia in medical education are presented within the topic on quality of health care. The result of this project is an interactive educational disk designed for physicians and other health professionals in primary health care faced with the issue of quality. This paper gives an overview of the experience gained during the work on the project and describes the created educational disk with all its specificities observed in the development of the educational hypermedia materials.