Assessment of climate change impact on the malaria vector Anopheles hyrcanus, West Nile disease, and incidence of melanoma in the Vojvodina Province (Serbia) using data from a regional climate model.

Motivated by the One Health paradigm, we found the expected changes in temperature and UV radiation (UVR) to be a common trigger for enhancing the risk that viruses, vectors, and diseases pose to human and animal health. We compared data from the mosquito field collections and medical studies with regional climate model projections to examine the impact of climate change on the spreading of one malaria vector, the circulation of West Nile virus (WNV), and the incidence of melanoma. We analysed data obtained from ten selected years of standardised mosquito vector sampling with 219 unique location-year combinations, and 10 years of melanoma incidence. Trends in the observed data were compared to the climatic variables obtained by the coupled regional Eta Belgrade University and Princeton Ocean Model for the period 1961-2015 using the A1B scenario, and the expected changes up to 2030 were presented. Spreading and relative abundance of Anopheles hyrcanus was positively correlated with the trend of the mean annual temperature. We anticipated a nearly twofold increase in the number of invaded sites up to 2030. The frequency of WNV detections in Culex pipiens was significantly correlated to overwintering temperature averages and seasonal relative humidity at the sampling sites. Regression model projects a twofold increase in the incidence of WNV positive Cx. pipiens for a rise of 0.5°C in overwintering TOctober-April temperatures. The projected increase of 56% in the number of days with Tmax ≥ 30°C (Hot Days-HD) and UVR doses (up to 1.2%) corresponds to an increasing trend in melanoma incidence. Simulations of the Pannonian countries climate anticipate warmer and drier conditions with possible dominance of temperature and number of HD over other ecological factors. These signal the importance of monitoring the changes to the preparedness of mitigating the risk of vector-borne diseases and melanoma.

[Coming from Afar and Rediscovering Oneself: Group Intervention for Immigrant and Refugee Women Having Experienced Violence]. / Venir de loin et se retrouver : intervention de groupe pour femmes immigrantes et réfugiées ayant vécu la violence.

Objectives This paper has a clinical perspective and presents an innovative intervention that could be offered in different institutions and practice environments. The object here is a group intervention addressed specifically to immigrant and refugee women having experienced different forms of violence. The consequences of being exposed to intentional and dehumanizing violence, paired with the challenges associated with migration and forced exile, can fragilize the individuals and challenge their capacity to adapt. Even though psychological and psychosocial support in the years following their arrival could be beneficial, immigrants and refugees rarely use institutional services, and experts point out that the services are not tailored to them. In that respect stems the importance of promoting the development of more meaningful interventions for immigrants and refugees, in accordance with the principle of equity and equality of chances to have access to appropriate services, but also to better equip the specialists by giving them access to safe and culturally sensitive interventions. Following that perspective, a group intervention for immigrants and refugees having experienced violence was created in 2010 with the collaboration of researchers from l'IUPLSSS and social workers from CIUSSS de l'Estrie-Chus. Method Firstly, this article aims to present this group intervention. Innovative features of the proposed program will be highlighted, followed by an overview of the clinical and empirical supports that recommend the use of groups and art to intervene with immigrants and refugees. A more detailed description of the intervention will follow, describing the objectives of the intervention as well as the intervention framework, including some necessary components to assure the therapeutic reach of the groups and the establishment of a safe space. Secondly, the article presents a brief summary of the preliminary results of a current study aiming to evaluate the impacts of the intervention. During this study, qualitative and quantitative data was collected from 3 groups (n = 17) and analyzed with content analysis and non-parametric analyses to measure the changes between pre and post intervention. Results The results of the qualitative and quantitative analyses show that women report positive changes at the end of the group, namely in regard to post-traumatic stress symptoms and different dimensions of their well-being. Conclusion To conclude, the advantages and limits of this intervention will be discussed, but also its relevance for the practice environments. Even if it isn't the only answer for the intervention in a post-violence context, it consists of a good option for providing adapted services to the reality and needs of immigrants and refugees.

"Imagine All the People:" Andrija Stampar's Ideology in The Context of Contemporary Public Health Initiatives

Recently, the World Health Organization launched its Universal Health Coverage initiative with the aim to improve access to quality health care on a global level, without causing financial hardship to the patients. In this paper, we will identify and analyze the ideological similarities between this influential initiative and the work of one of the founders of the WHO-Andrija Stampar (1888-1958)-whose social medicine was built of various normative, sociological and philosophical elements. Our aim is to demonstrate the crucial role of carefully erected and thought-out ideology for the success of public health programs.

Public health experiences from interwar Croatia (Yugoslavia) and making western medicine in the 1930s China

To gain control and domination over a particular territory, medicine was often used as a tool for promoting different interests. Using the activities of the League of Nations Health Organization and the Rockefeller Foundation on the territory of China in 1930s, this paper analyses the interconnection of the international and local factors in the transformation of the traditional Chinese milieu to suit the new and trendy public health projects. These activities were conducted not only to improve the public health conditions in the country, but also to introduce the Chinese public health to the processes of internationalization and standardization to the west oriented type of medicine and medical education. Initiated processes necessarily interfered with the political influences, economical interests and cultural environment as well as with military actions in this very turbulent time of Chinese history. Public health activities were carried out by the group of international experts. Among them the main position took two Croatian physicians: Andrija Stampar (one of the founders of the World Health Organisation later) and Berislav Borcic (a director of the School of Public Health in Zagreb). On the basis of correspondence between these two physicians, as well as the travel diary of Andrija Stampar, this essay presents some less known details about the situation in China and the interlacing between politics and medicine.

The intersection of class origin and immigration background in structuring social capital: the role of transnational ties.

The study investigates inequalities in access to social capital based on social class origin and immigration background and examines the role of transnational ties in explaining these differences. Social capital is measured with a position generator methodology that separates between national and transnational contacts in a sample of young adults in Sweden with three parental backgrounds: at least one parent born in Iran or Yugoslavia, or two Sweden-born parents. The results show that having socioeconomically advantaged parents is associated with higher levels of social capital. Children of immigrants are found to have a greater access to social capital compared to individuals with native background, and the study shows that this is related to transnational contacts, parents' education and social class in their country of origin. Children of immigrants tend to have more contacts abroad, while there is little difference in the amount of contacts living in Sweden across the three groups. It is concluded that knowledge about immigration group resources help us predict its member's social capital, but that the analysis also needs to consider how social class trajectories and migration jointly structure national and transnational contacts.

Access to occupational networks and ethnic variation of depressive symptoms in young adults in Sweden.

Social capital research has recognized the relevance of occupational network contacts for individuals' life chances and status attainment, and found distinct associations dependent on ethnic background. A still fairly unexplored area is the health implications of occupational networks. The current approach thus seeks to study the relationship between access to occupational social capital and depressive symptoms in early adulthood, and to examine whether the associations differ between persons with native Swedish parents and those with parents born in Iran and the former Yugoslavia. The two-wave panel comprised 19- and 23-year-old Swedish citizens whose parents were born in either Sweden, Iran or the former Yugoslavia. The composition of respondents' occupational networks contacts was measured with a so-called position generator. Depressive symptoms were assessed with a two-item depression screener. A population-averaged model was used to estimate the associations between depressive symptoms and access to occupational contact networks. Similar levels of depressive symptoms in respondents with parents born in Sweden and Yugoslavia were contrasted by a notably higher prevalence of these conditions in those with an Iranian background. After socioeconomic conditions were adjusted for, regression analysis showed that the propensity for depressive symptoms in women with an Iranian background increased with a higher number of manual class contacts, and decreased for men and women with Iranian parents with a higher number of prestigious occupational connections. The respective associations in persons with native Swedish parents and parents from the former Yugoslavia are partly reversed. Access to occupational contact networks, but also perceived ethnic identity, explained a large portion of the ethnic variation in depression. Mainly the group with an Iranian background seems to benefit from prestigious occupational contacts. Among those with an Iranian background, social status concerns and expected marginalization in manual class occupations may have contributed to their propensity for depressive symptoms.

Social capital, friendship networks, and youth unemployment.

Youth unemployment is a contemporary social problem in many societies. Youths often have limited access to information about jobs and limited social influence, yet little is known about the relationship between social capital and unemployment risk among youth. We study the effect of social capital on unemployment risk in a sample of 19 year olds of Swedish, Iranian, and Yugoslavian origin living in Sweden (N = 1590). We distinguish between two dimensions of social capital: occupational contact networks and friendship networks. First, ego's unemployment is found to be strongly associated with friends' unemployment among individuals of Yugoslavian origins and individuals of Swedish origin, but not Iranian origin. Second, occupational contact networks reduce unemployment risks for all groups, but especially so for Iranians. The effect sizes of the two dimensions are similar and substantial: going from low to high values on these measures is associated with a difference of some 60-70 percent relative difference in unemployment risk. The findings are robust to a number of different model specifications, including a rich set of social origin controls, personality traits, educational performance, friends' characteristics, and friendship network characteristics, as well as controls for geographical employment patterns. A sensitivity simulation shows that homogeneity bias need to be very strong to explain away the effect.

Refugee children have fewer contacts to psychiatric healthcare services: an analysis of a subset of refugee children compared to Danish-born peers.

PURPOSE: Studies show a high level of mental health problems among refugee children. This study examined whether a subset of refugee children living in Denmark accessed psychiatric healthcare services more than those born in the country. METHODS: This study compared 24,427 refugee children from Asia, The Middle East, Sub-Saharan Africa and former Yugoslavia, who obtained residency in Denmark between 1 January 1993 and 31 December 2010 with 146,562 Danish-born children, matched 1:6 on age and sex. The study looked at contacts with psychiatric hospitals as well as psychologists and psychiatrists in private practice. RESULTS: Between 1 January 1996 and 30 June 2012, 3.5 % of the refugee children accessed psychiatric healthcare services compared to 7.7 % of the Danish-born children. The rate ratio of having any first-time psychiatric contact was 0.42 (95 % CI 0.40-0.45) among refugee boys and 0.35 (95 % CI 0.33-0.37) among refugee girls, compared to Danish-born children. Figures were similar for those accessing private psychologists or psychiatrists, emergency room, inpatient and outpatient services. CONCLUSIONS: Refugee children used fewer psychiatric healthcare services than Danish-born children. This may indicate that refugee children experience barriers in accessing psychiatric healthcare systems and do not receive adequate assessment of their mental health and subsequent referral to specialist services.

Ethnic inequalities in acute myocardial infarction and stroke rates in Norway 1994-2009: a nationwide cohort study (CVDNOR).

BACKGROUND: Immigrants to Norway from South Asia and Former Yugoslavia have high levels of cardiovascular disease (CVD) risk factors. Yet, the incidence of CVD among immigrants in Norway has never been studied. Our aim was to study the burden of acute myocardial infarction (AMI) and stroke among ethnic groups in Norway. METHODS: We studied the whole Norwegian population (n = 2,637,057) aged 35-64 years during 1994-2009. The Cardiovascular Disease in Norway (CVDNOR) project provided information about all AMI and stroke hospital stays for this period, as well as deaths outside hospital through linkage to the Cause of Death Registry. The direct standardization method was used to estimate age standardized AMI and stroke event rates for immigrants and ethnic Norwegians. Rate ratios (RR) with ethnic Norwegians as reference were calculated using Poisson regression. RESULTS: The highest risk of AMI was seen in South Asians (men RR = 2.27; 95 % CI 2.08-2.49; women RR = 2.10; 95 % CI 1.76-2.51) while the lowest was seen in East Asians (RR = 0.38 in both men (95 % CI 0.25-0.58) and women (95 % CI 0.18-0.79)). Immigrants from Former Yugoslavia and Central Asia also had increased risk of AMI compared to ethnic Norwegians. South Asians had increased risk of stroke (men RR = 1.26; 95 % CI 1.10-1.44; women RR = 1.58; 95 % CI 1.32-1.90), as did men from Former Yugoslavia, Sub-Saharan Africa and women from Southeast Asia. CONCLUSIONS: Preventive measures should be aimed at reducing the excess numbers of CVD among immigrants from South Asia and Former Yugoslavia.

Thirty years of the "Anica Bitenc Travelling Fellowship" - a tribute to Dr. Igor A.S. Bitenc.

Thirty years ago, in 1984, Dr. Igor A. S. Bitenc, M.D., F.R.C.S.(C), a retired orthopaedic surgeon from Canada, who was of Yugoslav descent, and who had always remained attached to his original homeland, founded a travelling fellowship for young orthopaedic surgeons from former Yugoslavia named the "Anica Bitenc Travelling Fellowship" after his late mother. The first Fellow visited Canada in 1985 and was followed by five Fellows from different areas of Yugoslavia in successive years. Due to the tragic war in Yugoslavia in the 90's, the Fellowship was postponed for several years. It was resumed in 1997, but only for three newly formed states of Croatia, Slovenia and Serbia. Funding of the Fellowship was provided by an endowment from Dr. Bitenc and managed by the Canadian Orthopaedic Association, which hosts one Fellow per year on the rotational basis from Slovenia, Croatia and Serbia. The Fellowship finally proved to be very successful and, owing to the benevolence of Dr. Bitenc, 24 young orthopaedic surgeons from various regions of former Yugoslavia have had the opportunity to visit the best orthopaedic centres in Canada so far. Dr. Bitenc has ensured the Fellowship will continue for many years to come by bequeathing an endowment of $ 300.000. This unforgettable act of human nobility and patriotic sensibility will be of enormous help in future to many orthopaedic surgeons and their numerous patients in the countries of South Slavs.

[Railway medical hygiene and health protection system in Croatia between 1945 and 1953]. / Sustav Sanitetsko-Higijensko Zdravstvene zastite na Zeljeznici U Hrvatskoj od 1945. do 1953.

This paper describes the system of medical hygiene and health care adopted by the Croatian section of Yugoslav Railways in the aftermath of World War Two until 1953, based on archival information. In 1945, the human resources section of the Railway Administration in Zagreb included the Department of Social Welfare with offices that managed health insurance in cases of illness and accidents, workers' pension fund, and sanitary care‥ On 19 June 1947, the regional railway executive board established a medical section within the so called Secretariat and appointed Dr Marijan Derkos as its head. On 3 July 1948, central and regional healthcare offices for traffic staff were established to manage and oversee the activities of health institutions providing services for railway workers. The seat of the regional office in Zagreb was in Grgurova street. After the dismantlement of the central healthcare office in charge of railway health institutions in 1953, regional boards established new institutions, that were now self-financed.

Good fences: the importance of setting boundaries for peaceful coexistence.

We consider the conditions of peace and violence among ethnic groups, testing a theory designed to predict the locations of violence and interventions that can promote peace. Characterizing the model's success in predicting peace requires examples where peace prevails despite diversity. Switzerland is recognized as a country of peace, stability and prosperity. This is surprising because of its linguistic and religious diversity that in other parts of the world lead to conflict and violence. Here we analyze how peaceful stability is maintained. Our analysis shows that peace does not depend on integrated coexistence, but rather on well defined topographical and political boundaries separating groups, allowing for partial autonomy within a single country. In Switzerland, mountains and lakes are an important part of the boundaries between sharply defined linguistic areas. Political canton and circle (sub-canton) boundaries often separate religious groups. Where such boundaries do not appear to be sufficient, we find that specific aspects of the population distribution guarantee either sufficient separation or sufficient mixing to inhibit intergroup violence according to the quantitative theory of conflict. In exactly one region, a porous mountain range does not adequately separate linguistic groups and that region has experienced significant violent conflict, leading to the recent creation of the canton of Jura. Our analysis supports the hypothesis that violence between groups can be inhibited by physical and political boundaries. A similar analysis of the area of the former Yugoslavia shows that during widespread ethnic violence existing political boundaries did not coincide with the boundaries of distinct groups, but peace prevailed in specific areas where they did coincide. The success of peace in Switzerland may serve as a model to resolve conflict in other ethnically diverse countries and regions of the world.

The use of the Karnofsky index in the assessment of clinical state in patients with chronic subdural hematoma: the first observation from Vojvodina.

AIM: To evaluate clinical status of patients with chronic subdural hematoma (CSDH) on hospital admission and to predict their outcome after the neurosurgery treatment using Karnofsky index scale (KI). METHODS: Clinical and surgery data of patients with CSDH were collected prospectively. Fifty 50 adults aged over 41 with CSDH diagnosed and hospitalized between November 2010 and April 2012 were investigated. In the analyzed sample there were more CSDHs in males than in females (1.5:1). The diagnosis of CSDH on hospital admission in patients was confirmed by non-contrast computed tomography (CT). Forty-three patients had undergone surgery with Burr-hole drainage and craniotomy, while seven patients were treated conservatively. The KI was used for evaluation of the patient's clinical state before neurosurgery treatment and the quality of survival in all patients, six months after hospital discharge. RESULTS: A statistically significant difference was found between the KI values in patients with CSDHs on hospital admission and KI after the surgical treatment. Six months after, out of 43 patients who underwent surgery in 24 (55.8%) patients KI was between 80-100%, in nine (20.9%) patients KI was between 50-70% and in 10 (23.2%) patients KI was 0-40%. CONCLUSION: Although the elderly with CSDHs are vulnerable because of their age, associated diseases and risk of recurrence of CSDH, their outcome assessed by KI after surgical treatment was good. The Glasgow Coma Scale (GCS) is used for rapid assessment of the state of consciousness in patients on admission and monitoring of the changes in their condition. KI scale could be used as a complementary assessment tool for the general condition of patients with chronic subdural hematoma. This study highlighted that the KI scale had a predictive value for patient's outcome with chronic subdural hematoma.

Prevalence and socioeconomic correlates of chronic morbidity among elderly people in Kosovo: a population-based survey.

BACKGROUND: Our aim was to assess the prevalence and demographic and socioeconomic correlates of chronic morbidity in the elderly population of transitional Kosovo. METHODS: A cross-sectional study was conducted in Kosovo in 2011 including a representative sample of 1890 individuals aged ≥ 65 years (949 men, mean age 73 ± 6 years; 941 women, mean age 74 ± 7 years; response rate: 83%). A structured questionnaire inquired about the presence and the number of self-reported chronic diseases among elderly people, and their access to medical care. Demographic and socioeconomic data were also collected. Binary logistic regression was used to assess the association of demographic and socioeconomic characteristics with chronic conditions. RESULTS: In this nationwide population-based sample in Kosovo, 42% of elderly people were unable to access medical care, of whom 88% due to unaffordable costs. About 83% of the elderly people reported at least one chronic condition (63% cardiovascular diseases), and 45% had at least two chronic diseases. In multivariable-adjusted models, factors associated with the presence of chronic conditions and/or multimorbidity were female sex, older age, self-perceived poverty and the inability to access medical care. CONCLUSION: This study provides important evidence on the magnitude and distribution of chronic conditions among the elderly population of Kosovo. Our findings suggest that, in this sample of elderly people from Kosovo, the oldest-old (especially women) and the poor endure the vast majority of chronic conditions. These findings point to the urgent need to establish a social health insurance scheme including the marginalized segments of elderly people in this transitional country.

Effects of treatment adherence on clinical and economic outcomes in patients with psoriasis.

AIM: To compare clinical and cost outcomes of psoriasis in non-biological treatment of adherent and non-adherent patients in a developing Balkans country going through socio-economic transition. METHODS: The study was designed as a retrospective cohort study involving patients with psoriasis adherent and non-adherent to the prescribed treatment regimen. The patients were followed for a period of one year, through four visits with intervals of three months. The adherence to the prescribed regimen was measured at the end of the follow-up period by the medication possession ratio. Clinical outcomes of the treatment were estimated by the Psoriasis Area Severity Index (PASI) at each visit and the treatment costs were collected from patients' files at each visit. RESULTS: The study enrolled 108 patients, 61 (56.5%) were adherent to the prescribed treatment, and 47 (43.5%) were non-adherent. A signiicant decrease of PASI score was noted in the patients adherent to prescribed therapy (p < 0.001). The costs also decreased significantly in the group of adherent patients (p=0.001), and the drop of costs was the highest from the visit 3. The decrease in PASI score and costs were less rapid in non-adherent patients. CONCLUSION: Better treatment adherence leads to faster clinical improvement and a more rapid decrease in costs of treatment, which diminish overall expenditure of the health system and society, leaving room for treatment of other diseases more efficiently. Therefore, health systems of developing countries should support additional research of causes of treatment non-adherence in patients with psoriasis, in order to minimize this fenomenon more efficiently, and make significant savings.

Socioeconomic conditions of elderly people in Kosovo: a cross-sectional study.

BACKGROUND: Kosovo is the newest state in Europe facing a particularly difficult socioeconomic and political transition. The available evidence on socioeconomic conditions and quality of life of elderly people in Kosovo is scarce notwithstanding the ageing trend due to lowering of fertility rates and a higher life-expectancy. In this context, the aim of our study was to assess the socioeconomic conditions of elderly people in post-war Kosovo. METHODS: A cross-sectional study was conducted in Kosovo in January-March 2011 including an age- sex-and residence (urban vs. rural)-stratified sample of 1,890 individuals (83.5% response) aged 65 years and over. A structured questionnaire included assessment of socio-demographic and socioeconomic characteristics including educational level and self-perceived poverty. Binary logistic regression was used to assess the association of self-perceived poverty with socio-demographic and socioeconomic factors. RESULTS: The educational level in this representative sample of elderly people in Kosovo was quite low, particularly among women. About 47% of respondents perceived themselves as poor, or extremely poor (41% of men and 52% of women). In multivariable-adjusted models, self-perceived poverty was higher among older women, low educated individuals, urban residents, and elderly individuals living alone. CONCLUSIONS: Findings from this study indicate that the socioeconomic situation of the elderly population in Kosovo is rather challenging. Demographic trends coupled with the economic and political transition raise serious concerns about increasing needs for socioeconomic support of elderly people in Kosovo. Specific policies and actions should be considered by a number of stakeholders, including government and civil society in transitional Kosovo.

Self-perceived need for interpreter among immigrants in Denmark.

AIM: Starting in June 2011, immigrants who have lived for more than 7 years in Denmark have to pay a user-fee for interpreters in GP consultations and when hospitalised. We do not know yet how many immigrants will be affected by this amendment to the Danish Health Act and which socioeconomic factors characterise the immigrants who might be affected. To shed light on this, we investigated self-perceived need for interpreter (SNI) in GP consultations among participants from the largest non-Western immigrant groups in Denmark, the association between socioeconomic factors and SNI, and the characteristics of the immigrants potentially affected by the act amendment. METHODS: Survey data on 2866 immigrants from former Yugoslavia, Iraq, Iran, Lebanon, Pakistan, Somalia, and Turkey, linked to registry information on socioeconomic factors were examined. We compared unadjusted proportions of SNI by country of birth. Logistic regression analyses were performed to investigate associations between SNI and socioeconomic factors. RESULTS: Overall, 20% of immigrants living longer than 3 years in Denmark and 15% after 7 years reported a need for interpretation in their encounters with GPs. Of the latter group, the majority were outside the labour force (72.3%) and reported poor health (56%). Sex, age, length of stay, education, employment and household income were important factors for SNI. CONCLUSIONS: The amendment to the Health Act will primarily affect immigrants with modest household income, poor health and who are outside the labour force, thereby contributing and creating ethnic and social inequalities in access to health care in Denmark.

Random sampling for a mental health survey in a deprived multi-ethnic area of Berlin.

The aim of the study was to assess the response to random sampling for a mental health survey in a deprived multi-ethnic area of Berlin, Germany, with a large Turkish-speaking population. A random list from the registration office with 1,000 persons stratified by age and gender was retrieved from the population registry and these persons were contacted using a three-stage design including written information, telephone calls and personal contact at home. A female bilingual interviewer contacted persons with Turkish names. Of the persons on the list, 202 were not living in the area, one was deceased, 502 did not respond. Of the 295 responders, 152 explicitly refused(51.5%) to participate. We retained a sample of 143 participants(48.5%) representing the rate of multi-ethnicity in the area (52.1% migrants in the sample vs. 53.5% in the population). Turkish migrants were over-represented(28.9% in the sample vs. 18.6% in the population). Polish migrants (2.1 vs. 5.3% in the population) and persons from the former Yugoslavia (1.4 vs. 4.8% in the population)were under-represented. Bilingual contact procedures can improve the response rates of the most common migrant populations to random sampling if migrants of the same origin gate the contact. High non-contact and non-response rates for migrant and non-migrant populations in deprived urban areas remain a challenge for obtaining representative random samples.

Long-term impact of war on healthcare costs: an eight-country study.

OBJECTIVE: Exposure to war can negatively affect health and may impact on healthcare costs. Estimating these costs and identifying their predictors is important for appropriate service planning. We aimed to measure use of health services in an adult population who had experienced war in the former-Yugoslavia on average 8 years previously, and to identify characteristics associated with the use and costs of healthcare. METHOD: War-affected community samples in Bosnia-Herzegovina, Croatia, Kosovo, FYR Macedonia, and Serbia were recruited through a random walk technique. Refugees in Germany, Italy and the UK were contacted through registers, organisations and networking. Current service use was measured for the previous three months and combined with unit costs for each country for the year 2006/7. A two-part approach was used, to identify predictors of service use with a multiple logistic regression model and predictors of cost with a generalised linear regression model. RESULTS: 3,313 participants were interviewed in Balkan countries and 854 refugees in Western European countries. In the Balkan countries, traumatic events and mental health status were related to greater service use while in Western countries these associations were not found. Participants in Balkan countries with post traumatic stress disorder (PTSD) had costs that were 63% higher (p = 0.005) than those without PTSD. Distress experienced during the most traumatic war event was associated with higher costs (p = 0.013). In Western European countries costs were 76% higher if non-PTSD anxiety disorders were present (0.027) and 63% higher for mood disorders (p = 0.006). CONCLUSIONS: War experiences and their effects on mental health are associated with increased health care costs even many years later, especially for those who stayed in the area of conflict. Focussing on the mental health impact of war is important for many reasons including those of an economic nature.