Geographic variation of mutagenic exposures in kidney cancer genomes.

International differences in the incidence of many cancer types indicate the existence of carcinogen exposures that have not yet been identified by conventional epidemiology make a substantial contribution to cancer burden1. In clear cell renal cell carcinoma, obesity, hypertension and tobacco smoking are risk factors, but they do not explain the geographical variation in its incidence2. Underlying causes can be inferred by sequencing the genomes of cancers from populations with different incidence rates and detecting differences in patterns of somatic mutations. Here we sequenced 962 clear cell renal cell carcinomas from 11 countries with varying incidence. The somatic mutation profiles differed between countries. In Romania, Serbia and Thailand, mutational signatures characteristic of aristolochic acid compounds were present in most cases, but these were rare elsewhere. In Japan, a mutational signature of unknown cause was found in more than 70% of cases but in less than 2% elsewhere. A further mutational signature of unknown cause was ubiquitous but exhibited higher mutation loads in countries with higher incidence rates of kidney cancer. Known signatures of tobacco smoking correlated with tobacco consumption, but no signature was associated with obesity or hypertension, suggesting that non-mutagenic mechanisms of action underlie these risk factors. The results of this study indicate the existence of multiple, geographically variable, mutagenic exposures that potentially affect tens of millions of people and illustrate the opportunities for new insights into cancer causation through large-scale global cancer genomics.

Whole exome sequencing in Serbian patients with hereditary spastic paraplegia.

Hereditary spastic paraplegia (HSP) is a group of neurodegenerative diseases with a high genetic and clinical heterogeneity. Numerous HSP patients remain genetically undiagnosed despite screening for known genetic causes of HSP. Therefore, identification of novel variants and genes is needed. Our previous study analyzed 74 adult Serbian HSP patients from 65 families using panel of the 13 most common HSP genes in combination with a copy number variation analysis. Conclusive genetic findings were established in 23 patients from 19 families (29%). In the present study, nine patients from nine families previously negative on the HSP gene panel were selected for the whole exome sequencing (WES). Further, 44 newly diagnosed adult HSP patients from 44 families were sent to WES directly, since many studies showed WES may be used as the first step in HSP diagnosis. WES analysis of cohort 1 revealed a likely genetic cause in five (56%) of nine HSP families, including variants in the ETHE1, ZFYVE26, RNF170, CAPN1, and WASHC5 genes. In cohort 2, possible causative variants were found in seven (16%) of 44 patients (later updated to 27% when other diagnosis were excluded), comprising six different genes: SPAST, SPG11, WASCH5, KIF1A, KIF5A, and ABCD1. These results expand the genetic spectrum of HSP patients in Serbia and the region with implications for molecular genetic diagnosis and future causative therapies. Wide HSP panel can be the first step in diagnosis, alongside with the copy number variation (CNV) analysis, while WES should be performed after.

Frequency of C9orf72, GRN, and MAPT pathogenic variants in patients recruited at the Belgrade Memory Center.

Most of the heritability in frontotemporal dementia (FTD) is accounted for by autosomal dominant hexanucleotide expansion in the chromosome 9 open reading frame 72 (C9orf72), pathogenic/likely pathogenic variants in progranulin (GRN), and microtubule-associated protein tau (MAPT) genes. Until now, there has been no systematic analysis of these genes in the Serbian population. Herein, we assessed the frequency of the C9orf72 expansion, pathogenic/likely pathogenic variants in GRN and MAPT in a well-characterized group of 472 subjects (FTD, Alzheimer's disease - AD, mild cognitive impairment - MCI, and unspecified dementia - UnD), recruited in the Memory Center, Neurology Clinic, University Clinical Center of Serbia. The C9orf72 repeat expansion was detected in 6.98% of FTD cases (13.46% familial; 2.6% sporadic). In the UnD subgroup, C9orf72 repeat expansions were detected in 4.08% (8% familial) individuals. Pathogenic variants in the GRN were found in 2.85% of familial FTD cases. Interestingly, no MAPT pathogenic/likely pathogenic variants were detected, suggesting possible geographical specificity. Our findings highlight the importance of wider implementation of genetic testing in neurological and psychiatric practice managing patients with cognitive-behavioral and motor symptoms.

Screening Men and Women above the Age of 50 Years for Abdominal Aortic Aneurysm: A Pilot Study in an Upper Middle Income Country.

OBJECTIVE: Screening for abdominal aortic aneurysm (AAA) is recommended in high risk populations based on local conditions. Differences in lifestyle and risk factors between countries with different income status make risk stratification based on geographic location necessary. The majority of epidemiological studies on AAA have reported data from high income countries. The aim of this study was to explore the prevalence and risk factors for AAA in an upper middle income country in Eastern Europe. METHODS: A pilot screening project for AAA, supported by a mass media campaign, was conducted in 2023 in seven cities in Serbia. Ultrasound evaluation of the abdominal aorta was performed by a registered vascular surgeon on individuals who agreed to participate. Participants who attended screening completed a questionnaire on demographic and clinical information. To assess risk factors for AAA, univariable logistic regression analysis was performed to compute the odds ratio (OR) with 95% confidence interval (CI). Multivariable logistic regression was subsequently performed with adjustments for sex, age, family history of AAA, and other relevant factors. RESULTS: A total of 4 046 participants (51.2% male and 48.8% female; mean age 68.8 ± 7.6 years) responded to the campaign. An aneurysm was found in 195 (4.8%) screened individuals (8.2% of men and 1.3% of women). In males aged 50 - 64 years, the prevalence of AAA was 5.4%. Male sex, older age, family history of AAA, being a smoker or ex-smoker, being overweight, and alcohol consumption were predictors of AAA in the univariable analysis. After adjustments in the multivariable analysis, male sex (OR 8.04, 95% CI 4.87 - 13.28), older age (OR 1.04, 95% CI 1.02 - 1.07), positive family history (OR 2.47, 95% CI 1.61 - 3.78), smoker status (OR 3.10, 95% CI 2.10 - 4.59), ex-smoker status (OR 2.13, 95% CI 1.39 - 3.27), and being overweight (OR 1.85, 95% CI 1.25 - 2.74) were independent risk factors for AAA. CONCLUSION: The prevalence of AAA has not been reduced in all countries, and screening strategies might be changed based on local epidemiological data. The results of this pilot study underline the importance of exploring the prevalence of AAA in populations with a high prevalence of smoking.

Combustion-Derived Pollutants Linked with Kidney Disease in Low-Lying Flood-Affected Areas in the Balkans.

Tens of thousands of people in southern Europe suffer from Balkan endemic nephropathy (BEN), and four times as many are at risk. Incidental ingestion of aristolochic acids (AAs), stemming from the ubiquitousAristolochia clematitis(birthwort) weed in the region, leads to DNA adduct-induced toxicity in kidney cells, the primary cause of BEN. Numerous cofactors, including toxic organics and metals, have been investigated, but all have shown small contributions to the overall BEN relative to non-BEN village distribution gradients. Here, we reveal that combustion-derived pollutants from wood and coal burning in Serbia also contaminate arable soil and test as plausible causative factors of BEN. Using a GC-MS screening method, biomass-burning-derived furfural and coal-burning-derived medium-chain alkanes were detected in soil samples from BEN endemic areas levels at up to 63-times and 14-times higher, respectively, than in nonendemic areas. Significantly higher amounts were also detected in colocated wheat grains. Coexposure studies with cultured kidney cells showed that these pollutants enhance DNA adduct formation by AA, - the cause of AA nephrotoxicity and carcinogenicity. With the coincidence of birthwort-derived AAs and the widespread practice of biomass and coal burning for household cooking and heating purposes and agricultural burning in rural low-lying flood-affected areas in the Balkans, these results implicate combustion-derived pollutants in promoting the development of BEN.

Molecular analysis of canine distemper virus H gene in the golden jackal (Canis aureus) population from Serbia.

Canine distemper virus (CDV) is a highly contagious and often fatal disease affecting wild and domesticated carnivores. The virus is a single-stranded RNA virus from the genus Morbillivirus and the family Paramyxoviridae. While domestic dogs are the most common hosts, the virus poses a significant threat to endangered wildlife due to its broad host range. This study aimed to characterize the CDV Haemagglutinin (H) gene in golden jackals and explore the molecular evolution of the virus in an underrepresented host. A total of 88 brain samples from hunted golden jackals were tested for the presence of CDV viral nucleic acid, and the H gene of positive samples was amplified and sequenced using the Sanger method. Phylogenetic analysis, conducted using maximum likelihood methods, revealed that all Serbian sequences clustered within the Arctic lineage. Notably, the analysis identified a tyrosine (Y) at position 549 of the H protein, a mutation commonly associated with wildlife hosts, instead of the histidine (H) typically found in domestic strains. Additionally, a mutation at position 310 was observed, which could potentially affect the protein's function and virus-host interactions. These findings provide valuable insights into the genetic diversity and evolutionary dynamics of CDV in golden jackals, with broader implications for understanding the virus's adaptability to different hosts. Further research is needed to investigate the functional impact of these mutations, particularly their role in vaccine efficacy and disease transmission across wildlife and domestic species.

Earlier age of symptom onset in younger generation of familial cases of multiple sclerosis.

AIM: The aim of this study was to assess the prevalence of familial MS (fMS) in Belgrade MS population, discern the differences between the persons with fMS and sporadic MS, and to detect the presence of anticipation phenomenon in fMS patients. METHODS: The data on the demographic and clinical characteristics of MS patients was obtained from the Belgrade MS population Registry. In cases of vertical transmission of MS, the family members were divided into the younger and older generation, in order to assess the potential presence of anticipation phenomenon. To adjust for follow-up time bias, a secondary analysis including only patients who had the onset of symptoms before 39 years (75.percentile), and those who were 39 + years, was performed. RESULTS: The prevalence of fMS in Belgrade MS population is 6.4%. FMS cases had earlier age at MS symptom onset (30.4 vs. 32.3 years) compared to sporadic MS cohort. When comparing fMS cases across generations, the younger generation had significantly lower age at onset compared with the older one (25.8 vs. 35.7 years, p < 0.001). After adjustment for the different length of the follow-up, the difference in age at symptom onset between the groups was reduced, but it still existed and was statistically significant (30.0 years in younger vs. 36.4 years in older generation, p = 0.040). CONCLUSION: In our study, the analysis of fMS cases across generations, showed an earlier age of symptom onset in the younger generation, even after adjustment. These results indicate the possibility of existence of anticipation phenomenon.

Neurological and neuromuscular manifestations in patients with West Nile neuroinvasive disease, Belgrade area, Serbia, season 2022.

INTRODUCTION: We aimed to describe neurological manifestations and functional outcome at discharge in patients with West Nile neuroinvasive disease. METHODS: This retrospective study enrolled inpatients treated in the University Clinic for Infectious and Tropical Diseases in Belgrade, Serbia, from 1 June until 31 October 2022. Functional outcome at discharge was assessed using modified Rankin scale. RESULTS: Among the 135 analyzed patients, encephalitis, meningitis and acute flaccid paralysis (AFP) were present in 114 (84.6%), 20 (14.8%), and 21 (15.6%), respectively. Quadriparesis/quadriplegia and monoparesis were the most frequent forms of AFP, present in 9 (6.7%) and 6 (4.4%) patients, respectively. Fourty-five (33.3%) patients had cerebellitis, 80 (59.3%) had rhombencephalitis, and 5 (3.7%) exhibited Parkinsonism. Ataxia and wide-based gait were present in 79 (58.5%) patients each. Fifty-one (37.8%) patients had tremor (41 (30.3%) had postural and/or kinetic tremor, 10 (7.4%) had resting tremor). Glasgow coma score (GCS) ≤ 8 and respiratory failure requiring mechanical ventilation developed in 39 (28.9%), and 33 (24.4%) patients, respectively. Quadriparesis was a risk factor for prolonged ventilator support (29.5 ± 16.8 vs. 12.4 ± 8.7 days, p = 0.001). At discharge, one patient with monoparesis recovered full muscle strength, whereas 8 patients with AFP were functionally dependent. Twenty-nine (21.5%) patients died. All of the succumbed had encephalitis, and 7 had quadriparesis. Ataxia, tremor and cognitive deficit persisted in 18 (16.9%), 15 (14.2%), and 22 (16.3%) patients at discharge, respectively. Age, malignancy, coronary disease, quadriparesis, mechanical ventilation, GCS ≤ 8 and healthcare-associated infections were risk factors for death (p = 0.001; p = 0.019; p = 0.004; p = 0.001; p < 0.001; p < 0.001, and p < 0.001, respectively).

Reactivity of anti-SARS-CoV-2 antibodies in Serbian voluntary blood donors.

BACKGROUND: The COVID-19 pandemic has major implications on the entire blood supply system worldwide. Seroepidemiological studies are certainly necessary for better understanding the global burden that the COVID-19 pandemic represents. OBJECTIVES: In this study, we analysed the association between demographic factors, COVID-19 severity, vaccination status and the reactivity of anti-SARS-CoV-2 IgG antibodies in Serbian blood donors. MATERIALS AND METHODS: In a prospective study, demographic data and data related to previous SARS-CoV-2 infection, COVID-19 severity and vaccination status among whole blood donors were analysed, from February 10 to August 10, 2022, at the Blood Transfusion Institute of Vojvodina, Serbia. The detection and determination of the level of anti-SARS-CoV-2 IgG antibodies were performed using LIAISON® SARS-CoV-2 TrimericS IgG immunoassay. RESULTS: A total of 1190 blood donors were included, 24.5% were female and 75.5% were male while their average age was 41 years. Anti-SARS-CoV-2 antibody values ranged from 2.40 to 3120 BAU/ml with a mean value of 1354.56 BAU/ml. Statistical analysis showed that COVID-19 severity and vaccination status are linked with reactivity of anti-SARS-CoV-2 antibodies, while gender and age of voluntary blood donors are not related to the values of anti-SARS-CoV-2 antibodies. CONCLUSION: The values of anti-SARS-CoV-2 antibodies in voluntary blood donors in Serbia are kept relatively high, especially in blood donors who have overcome the severe COVID-19, as well as in donors who have been vaccinated against COVID-19. Further SARS-CoV-2 seroprevalence studies in our country are certainly still necessary so global strategies to fight against COVID-19 would be adequately evaluated.

Screening for depression in the Serbian general population sample: an alternative to the traditional patient health questionnaire-9 cut-off score.

BACKGROUND: The Patient Health Questionnaire (PHQ-9) score ≥ 10 balances best sensitivity and specificity when detecting probable depression in patients. In the general population, different cut-offs are suggested. European studies on general populations validating the PHQ-9 against a diagnostic interview to detect depression are rare. METHODS: This was a cross-sectional observational epidemiological survey using multistage household probabilistic sampling to recruit a representative adult sample (N = 1203; age = 43.7 ± 13.6; 48.7% male). Mental disorders including current major depressive episode (MDE) were observer-rated (Mini International Neuropsychiatric Interview). The PHQ-9, quality of life (QoL), and loneliness were self-assessed. We performed validity and reliability tests of the PHQ-9 and receiver operating curve (ROC) analysis. RESULTS: The Serbian PHQ-9 was internally consistent and correlated in the expected directions with QoL and loneliness. At the cut-off score ≥ 8, sensitivity was .85 and specificity was .91. ROC analysis showed that the area under the curve was .95, indicating that the Serbian PHQ-9 can discriminate very well between persons with/without MDE. CONCLUSIONS: When the PHQ-9 is assessed against the structured diagnostic interview in the general population to detect depression, the cut-off of ≥8 balances best sensitivity and specificity.

Prevalence of metabolic syndrome and its association with rapid weight loss among former elite combat sports athletes in Serbia.

BACKGROUND: In terms of the potential influence of rapid weight loss (RWL) on the metabolic health of former combat sports athletes (CSA), the scientific literature is quite scarce. Therefore, the objective of the presented research was to determine the differences in metabolic syndrome (MetS) parameters and the prevalence of MetS between former athletes who performed RWL and athletes who did not. METHODS: The sample of the presented study comprised 150 participants from Serbia, equally divided into two groups: 75 former athletes who had practiced combat sports and 75 ex-athletes of various other sports who did not practice RWL during their careers. The following parameters related to the MetS were evaluated: waist circumference, high-density lipoprotein cholesterol, systolic blood pressure, diastolic blood pressure, fasting glucose, and triglycerides. The oral glucose tolerance test (OGTT) was used to assess the participant's body response to sugar. RESULTS: The RWL group had significantly higher both systolic (p < 0.001) and diastolic blood pressure (p < 0.001) compared to the group of athletes who did not practice weight reduction during their careers. Additionally, a tendency toward statistically significant differences between groups was recorded in the variable triglycerides (p = 0.069). Regarding OGTT, increased values of fasting blood glucose at the final measurement were revealed only in the RWL group (p = 0.003). The prevalence of MetS was substantially higher in CSA than in the control group (39.5% vs. 16.2%, respectively p = 0.002). CONCLUSIONS: This study suggests that former elite CSA who used RWL during their sports career are susceptible to negative metabolic alterations at the end of their competitive period.

Impact of serum chitotriosidase activity on tuberculosis treatment response: single center study from Serbia.

BACKGROUND: The aim of our study was to investigate serum chitotriosidase level in tuberculosis patients, its relationship with microbiological and clinical parameters, and response to treatment. MATERIALS AND METHODS: This longitudinal panel study included 149 patients with confirmed TB disease. Serum chitotriosidase activity was measured at the beginning and the end of treatment. Factors associated with chitotriosidase activity were explored using univariate and multivariable logistic regression analysis. RESULTS: Out of 149 study participants, 71(47.7%) were female. The mean age was 53.0 (SD = 18.2). Majority of cases were new 118(79.2), predominantly 145 (97.3%) having pulmonary tuberculosis. More than half of the patients were sputum smear positive 91 (61.1%) while culture positive in 146 (98%) of them. According to radiological findings, cavitary lesions were found in 92 (63.4%) patients. Anti TB treatment was associated with significant decrease in serum chitotriosidase level (< 0.001). New TB treatment (OR = 4.41%;95% CI = 1.20-9.89), and cavitary lesions (OR = 3.86;95%CI = 0,59-26.57) were found to be significantly associated with decrease of chitotriosidase activity. CONCLUSIONS: The results of our study showed that serum chitotriosidase values are strong biomarkers for starting anti TB treatment and for treatment monitoring, since decrease in serum chitotriosidase level can predict favorable treatment response in patients with tuberculosis. Further studies are needed to explore these, and other factors associated with chitotriosidase activity among tuberculosis patients.

Health policy developments in the Western Balkan Countries 2000-19: towards European Health and Health Care Policies.

BACKGROUND: Albania, Bosnia and Herzegovina, Kosovo, Montenegro, North Macedonia and Serbia have committed to becoming European Union (EU) member states. This, among others, implies that candidate/potential candidate states adopt legally authorized EU policies, including health. The study aims to identify the main country-specific health policy areas critical to the EU accession health policy dimension and present the change in associated selected health indicators from 2000 to 2019. METHODS: The study draws on published reports and analyses of official statistics over time and cross-country. Health care policy adherence to the European Commission's recommended country-specific health actions was classified into five health policy areas: financing, payment, organization, regulation and persuasion. Key health policy areas for Western Balkan countries (WBCs) were identified. Health progress or lack thereof in catching up to the EU15 population health, health expenditure and the number of health professionals are measured. RESULTS: The European Commission prioritized financing and regulation for all WBCs in the five policy areas. Nine of the 18 analyzed selected health indicators showed divergence, and the other nine converged towards the EU15 averages. WBCs continue to face diverse public health challenges in improving life expectancy at birth, death rates caused by circulatory system diseases, malignant neoplasms, traffic accidents, psychoactive substance use, tuberculosis incidence, tobacco smoking prevalence and public-sector health expenditure. CONCLUSIONS: By 2019, there is limited evidence of WBCs catching up to the average EU15 health levels and health care policies. Closer attention towards EU health and health care policies would be favourable.

Perceptions on support, challenges and needs among parents and caregivers of children with developmental disabilities in Croatia, North Macedonia and Serbia: a cross-sectional study.

BACKGROUND: Parents/caregivers of children with developmental disabilities (CDD) have a wide range of support needs and there are various interventions available. Support, challenges, and needs among parents/caregivers of CDD likely vary in different geographical settings. This study aimed to analyze the perceptions of support, challenges, and needs among parents/caregivers of CDD in Croatia, North Macedonia, and Serbia. METHODS: We conducted a cross-sectional study in March-April 2023 within the Erasmus + SynergyEd project. The eligible participants were parents and caregivers of CDD in Croatia, North Macedonia, and Serbia, who filled out a modified Caregiver Needs Survey online. RESULTS: Among 953 participants, 542 (57%) were from Croatia, 205 (21%) were from North Macedonia and 206 (22%) were from Serbia. The most common diagnosis of participants' children was autism spectrum disorder (26%). The child most often received the first diagnosis at the median of 2 years, diagnosed by a team of professionals. More than half (58%) of children attended preschool and public school, while 22% did not attend any schooling. Additional support from the state/city/county was received by 66% of CDD. Most participants declared not participating in association/organization for family support. Participants mostly (68%) used experts who work with the child as a source of information about their child's condition, followed by the Internet (53%). In the last 12 months, 60% of participants had difficulties with the availability of services in their area or problems getting appointments. The biggest problem in getting support was ensuring the child's basic rights were protected. Participants stated that ensuring greater rights for CDD was the greatest need for their families. CONCLUSION: Parents/caregivers of CDD in Croatia, North Macedonia, and Serbia faced multiple challenges, but most of them were satisfied with the services provided to their children. Future efforts to develop policies and services related to CDD should consider the opinions of their parents/caregivers and disparities in access to services.

The Views of the Citizens Regarding COVID-19 Vaccination.

The pandemic caused by the SARS-CoV-2 virus has been ongoing for over three years. After the initial months of confusion and searching for different solutions in the fight against this disease, several different vaccines were developed. Although they were eagerly awaited, social networks were flooded with negative and discouraging comments about vaccines. Citizens' views on this issue varied not only from country to country but also within the same country. At the same time, a certain number of officials in some countries contributed to a negative view of vaccines. Therefore, the first goal of this paper is to review the results of research conducted in different countries and then analyze the results of research conducted in Serbia. The sample consisted of 301 respondents. The results of the research show that the majority of respondents refused to be vaccinated, as they do not believe in the effectiveness or safety of the vaccine against COVID-19, nor do they trust the state authorities in their fight against the pandemic.

First case of ichthyophonosis in farmed rainbow trout Oncorhynchus mykiss in Serbia.

Ichthyophonosis is a disease caused by the mesomycetozoean parasite Ichthyophonus hoferi that affects a variety of fish species, including rainbow trout Oncorhynchus mykiss Walbaum. This disease is characterized by granulomatous lesions and necrosis in various organs, which can have severe impacts on the health and welfare of the fish. Ichthyophonosis has been found in several parts of the world, including Europe, and is a significant concern in the aquaculture industry and for populations of wild marine fishes. The rainbow trout is a widely cultured salmonid species in many countries, including Serbia. Although the presence of I. hoferi in rainbow trout has been reported in several countries, it has never been documented in Serbia. In this article, we report the first case of ichthyophonosis in rainbow trout in Serbia.

First molecular confirmation of cyprinid herpesvirus 1 (CyHV1) in diseased carp in Serbia.

Mass mortality of farmed 1 yr old common carp Cyprinus carpio occurred at a carp farm in April 2022. In addition to high mortality, diseased fish exhibited papillomatous growths on the skin and fins, characteristic of carp pox. To investigate a possible viral cause, tissue samples were collected and nucleic acid was extracted using standard procedures. In a pooled sample from the gills and kidneys, carp edema virus (CEV) was detected by real-time PCR. In a skin tissue sample with papillomatous growths, cyprinid herpesvirus 1 (CyHV1) was detected by a conventional PCR targeting a conserved region of the DNA polymerase of cyprinid herpesviruses. PCR products were visualized through agarose gel electrophoresis, and the presence of CyHV1 DNA was confirmed by Sanger sequencing. This represents the first molecular confirmation of CyHV1 in common carp in Serbia.

Serbian Version of the eHealth Literacy Questionnaire (eHLQ): Translation, Cultural Adaptation, and Validation Study Among Primary Health Care Users.

BACKGROUND: As digital health services are increasingly developing and becoming more interactive in Serbia, a comprehensive instrument for measuring eHealth literacy (EHL) is needed. OBJECTIVE: This study aimed to translate, culturally adapt, and investigate the psychometric properties of the Serbian version of the eHealth Literacy Questionnaire (eHLQ); to evaluate EHL in the population of primary health care (PHC) users in Serbia; and to explore factors associated with their EHL. METHODS: The validation study was conducted in 8 PHC centers in the territory of the Macva district in Western Serbia. A stratified sampling method was used to obtain a representative sample. The Translation Integrity Procedure was followed to adapt the questionnaire to the Serbian language. The psychometric properties of the Serbian version of the eHLQ were analyzed through the examination of factorial structure, internal consistency, and test-retest reliability. Descriptive statistics were calculated to determine participant characteristics. Differences between groups were tested by the 2-tailed Students t test and ANOVA. Univariable and multivariable linear regression analyses were used to determine factors related to EHL. RESULTS: A total of 475 PHC users were enrolled. The mean age was 51.0 (SD 17.3; range 19-94) years, and most participants were female (328/475, 69.1%). Confirmatory factor analysis validated the 7-factor structure of the questionnaire. Values for incremental fit index (0.96) and comparative fit index (0.95) were above the cutoff of ≥0.95. The root mean square error of approximation value of 0.05 was below the suggested value of ≤0.06. Cronbach α of the entire scale was 0.95, indicating excellent scale reliability, with Cronbach α ranging from 0.81 to 0.90 for domains. The intraclass correlation coefficient ranged from 0.63 to 0.82, indicating moderate to good test-retest reliability. The highest EHL mean scores were obtained for the understanding of health concepts and language (mean 2.86, SD 0.32) and feel safe and in control (mean 2.89, SD 0.33) domains. Statistically significant differences (all P<.05) for all 7 eHLQ scores were observed for age, education, perceived material status, perceived health status, searching for health information on the internet, and occupation (except domain 4). In multivariable regression models, searching for health information on the internet and being aged younger than 65 years were associated with higher values of all domain scores except the domain feel safe and in control for variable age. CONCLUSIONS: This study demonstrates that the Serbian version of the eHLQ can be a useful tool in the measurement of EHL and in the planning of digital health interventions at the population and individual level due to its strong psychometric properties in the Serbian context.

The impact of welfare on maternal investment and sibling competition: evidence from Serbian Roma communities.

Siblings compete for limited parental resources, which can result in a trade-off between family size and child growth outcomes. Welfare incentives may improve parental circumstances in large families by compensating for the additional costs of an extra child and increasing the resources available to a family. The improvements in conditions may influence parents to increase their investment, expecting greater returns from the investment in child survival and development, while in turn increase sibling competition for the investment. This study assessed whether welfare benefits have influenced parental investment trade-offs and competition between siblings among Serbian Roma, a population largely dependent on welfare. Using data from the UNICEF Multiple Indicator Cluster Survey 6, this study assessed the associations between maternal investment, child cash benefits, sibship size, and child anthropometry, as an indicator of health, among 1096 Serbian Roma children aged 0 to 59 months. Living in a small family benefited Roma children, while the incentives increased competition between siblings. Maternal investment was negatively associated with incentives, as the improvements brought about were insufficient to influence a change in maternal perceptions about the local setting uncertainty and thus promote an increase in investment.