Key lessons learnt from COVID-19 intra-action reviews in the Republic of Moldova, Montenegro, Kosovo and North Macedonia 2020-2021: a qualitative study.

OBJECTIVES: Our study described how the WHO intra-action review (IAR) methodology was operationalised and customised in three Western Balkan countries and territories and the Republic of Moldova and analysed the common key findings to inform analyses of the lessons learnt from the pandemic response. DESIGN: We extracted data from the respective IAR reports and performed a qualitative thematic content analysis to identify common (between countries and territories) and cross-cutting (across the response pillars) themes on best practices, challenges and priority actions. The analysis involved three stages, namely: extraction of data, initial identification of emerging themes and review and definition of the themes. SETTING: IARs were conducted in the Republic of Moldova, Montenegro, Kosovo and the Republic of North Macedonia between December 2020 and November 2021. The IARs were conducted at different time points relative to the respective pandemic trajectories (14-day incidence rate ranging from 23 to 495 per 100 000). RESULTS: Case management was reviewed in all the IARs, while the infection prevention and control, surveillance and country-level coordination pillars were reviewed in three countries. The thematic content analysis identified four common and cross-cutting best practices, seven challenges and six priority recommendations. Recommendations included investing in sustainable human resources and technical capacities developed during the pandemic, providing continuous capacity-building and training (with regular simulation exercises), updating legislation, improving communication between healthcare providers at all levels of healthcare and enhancing digitalisation of health information systems. CONCLUSIONS: The IARs provided an opportunity for continuous collective reflection and learning with multisectoral engagement. They also offered an opportunity to review public health emergency preparedness and response functions in general, thereby contributing to generic health systems strengthening and resilience beyond COVID-19. However, success in strengthening the response and preparedness requires leadership and resource allocation, prioritisation and commitment by the countries and territories themselves.

Montenegro makes important strides towards achievement of the SDGs.

In 2018, Montenegro took an important step towards ratification of the Protocol on Water and Health to the 1992 Convention on the Protection and Use of Transboundary Watercourses and International Lakes. A multisectoral national consultation provided a forum where national stakeholders could assist in related decision-making. The Protocol is the first and only multilateral legal agreement linking sustainable water management and the prevention, control and reduction of water-related diseases in the pan-European region. It was adopted in 1999 at the Third Ministerial Conference on Environment and Health in London and entered into force in 2005 as legally binding for the ratifying countries. To date, 26 countries have ratified it, covering about 60% of the population of the pan-European region. Montenegro is on the way to becoming the next country to ratify it and has used it as an instrument to strengthen national action towards progressively reaching regional and global WASH-related commitments, specifically in relation to SDG 3 (good health and well-being), SDG 6 (clean water and sanitation) and the Ostrava Declaration on Environment and Health (2017).

Impact of Adverse Childhood Experiences on Alcohol Use in Emerging Adults in Montenegro and Romania.

BACKGROUND: Aiming at generating evidence for formulating targeted and cost-effective public health interventions for the effective control of alcohol use (AU) in emerging adults in South Eastern Europe. The study's objective was to assess if alcohol users experience adverse childhood experiences (ACE) more often than non-users, and to identify which ACE victims are the most vulnerable to AU. METHODS: The data was collected in 2010-2012 in two cross-sectional studies conducted in university settings in Montenegro and Romania (overall response rate 89.1%). In the present study, 3,283 students were included. The international ACE Study Questionnaires were used as a base for study instruments for collecting information on ACEs, health behaviours, and socio-economic factors. The association between AU and individual ACEs, adjusted to background factors, was assessed by using logistic regression. RESULTS: From the child maltreatment group, three ACEs were included in the final model as statistically significantly associated with AU, all of them from physical neglect/abuse types: frequently being hit so hard to have marks or being injured (OR=1.68; p=0.012), frequently being spanked (OR=1.38; p=0.012), and frequently having no person to take to the doctor if necessary (OR=0.58; p=0.031). From the household dysfunction group, two ACEs were included in the final model: exposure to mental health problems in the household (OR=2.85; p<0.001), and living with a problematic drinker/alcoholic (OR=1.51; p=0.019). CONCLUSIONS: The effect of exposure to ACEs on AU persists into emerging adulthood. This should be considered when developing cost-effective response to AU burden through targeted interventions, in particular in settings with scarce resources.

Sodium and Potassium Intake, Knowledge Attitudes and Behaviour Towards Salt Consumption Amongst Adults in Podgorica, Montenegro.

Excess salt and inadequate potassium intakes are associated with high cardiovascular disease (CVD). In Montenegro, CVD is the leading cause of death and disability. There is no survey that has directly measured salt and potassium consumption in Montenegro. The aim is to estimate population salt and potassium intakes and explore knowledge, attitudes and behaviour (KAB), amongst the adult population of Podgorica. Random samples of adults were obtained from primary care centres. Participants attended a screening including demographic, anthropometric and physical measurements. Dietary salt and potassium intakes were assessed by 24 h urinary sodium (UNa) and potassium (UK) excretions. Creatinine was measured. KAB was collected by questionnaire. Six hundred and thirty-nine (285 men, 25⁻65 years) were included in the analysis (response rate 63%). Mean UNa was 186.5 (SD 90.3) mmoL/day, equivalent to 11.6 g of salt/day and potassium excretion 62.5 (26.2) mmoL/day, equivalent to 3.2 g/day. Only 7% of them had a salt intake below the World Health Organization (WHO) recommended target of 5 g/day and 13% ate enough potassium (>90 mmoL/day). The majority (86%) knew that high salt causes ill-health. However, only 44% thought it would be useful to reduce consumption. Salt consumption is high and potassium consumption is low, in men and women living in Podgorica.

Participatory approaches to reaching the Sustainable Development Goals: Montenegro: working towards SDG 6 and ratification of the Protocol on Water and Health

In 2018, Montenegro took an important step towards ratification of the “Protocol on Water and Health to the 1992 Convention on the Protection and Use of Transboundary Watercourses and International Lakes” (hereafter, “the Protocol”). A multisectoral national consultation was held with the overall aim of facilitating the process towards Montenegro’s accession to the Protocol. This provided a forum where national stakeholders could assist in related decision-making. The consultation was triggered by the “Iceland Statement. Ensuring safe and climate-resilient water and sanitation” (2018), according to which the small countries committed to acceding to the Protocol by 2022. The Protocol is the first and only multilateral legal agreement linking sustainable water management and the prevention, control and reduction of water-related diseases in the pan-European region. It was adopted in 1999 at the Third Ministerial Conference on Environment and Health in London and entered into force in 2005, becoming legally binding for the ratifying countries. To date, 26 countries have ratified it, covering about 60% of the population of the pan-European region. The United Nations Economic Commission for Europe and the WHO Regional Office for Europe provide the joint secretariat of the Protocol. Montenegro is on the way to becoming the next country to ratify it. The Protocol is recognized as an instrument for use in strengthening national action towards progressively reaching regional and global WASH-related commitments, specifically in relation to SDG 3 (good health and well-being) and SDG 6 (clean water and sanitation) and the “Ostrava Declaration on Environment and Health” (2017). It stipulates the importance of formulating national priority targets and implementation plans, while promoting a whole-of-government approach to and coordinated intersectoral action in doing so.

Identification of adverse childhood experiences strongly predicting suicidal behaviour among emerging adults in Montenegro and Romania: a new way to targeted cost-effective prevention.

INTRODUCTION: Aiming at generating evidence for cost-effective public health (PH) interventions for suicidal behaviour (SB) prevention in South Eastern Europe, the objective was to identify adverse childhood experiences (ACEs) most strongly predicting SB in emerging adults. METHODS: Survey data of 3283 students aged 18-29 from Montenegro and Romania were analysed by logistic regression. Based on estimation of risk-for-SB, the profiles with the highest values were identified. RESULTS: The SB odds were the highest in respondents, experienced a suicide attempt in the household (OR: 13.81; p < 0.001), and whose primary family was not complete, in particular in those with the foster family background (OR: 18.30; p = 0.001). CONCLUSIONS: Magnitude of impact on emerging adults' mental health vulnerability tends to vary considerably with individual ACEs. This should be considered carefully when developing cost-effective response to SB burden through PH interventions in particular at the times of financial crises and in scarce resources settings.

Planning elderly and palliative care in Montenegro.

INTRODUCTION: Montenegro, a newly independent Balkan state with a population of 650,000, has a health care reform programme supported by the World Bank. This paper describes planning for integrated elderly and palliative care. DESCRIPTION: The current service is provided only through a single long-stay hospital, which has institutionalised patients and limited facilities. Broad estimates were made of current financial expenditures on elderly care. A consultation was undertaken with stakeholders to propose an integrated system linking primary and secondary health care with social care; supporting people to live, and die well, at home; developing local nursing homes for people with higher dependency; creating specialised elderly-care services within hospitals; and providing good end-of-life care for all who need it. Effectiveness may be measured by monitoring patient and carers' perceptions of the care experience. DISCUSSION: Changes in provision of elderly care may be achieved through redirection of existing resources, but the health and social care services also need to enhance elderly care budgets. The challenges for implementation include management skills, engaging professionals and political commitment. CONCLUSION: Middle-income countries such as Montenegro can develop elderly and palliative care services through redirection of existing finance if accompanied by new service objectives, staff skills and integrated management.