Effectiveness of behavioural change interventions on physical activity, diet and body mass index of public primary healthcare users in Kosovo: the KOSCO cohort.

BACKGROUND: Prevalent physical inactivity and poor nutrition contribute to high non-communicable disease (NCD) morbidity and mortality in Kosovo. To improve health services for patients with NCD the Accessible Quality Healthcare project developed behaviour change interventions following the principles of the WHO Package of Essential NCD (PEN) protocol. They were implemented into the public primary healthcare (PHC) system of five early-stage implementation municipalities (ESIM, 2018) and seven late-stage implementation municipalities (2020). OBJECTIVE: To assess the effect of the behaviour change interventions; motivational stages of behaviour change for physical activity and nutrition; and body mass index (BMI). DESIGN: Prospective cohort study. DATA COLLECTION AND ANALYSIS: We included 891 public PHC users aged 40 years and above, who were enrolled in the KOSCO (Kosovo Non-Communicable Disease Cohort) cohort in 2019 and followed-up biannually until February 2021. The PHC users who consulted for themselves any health service were approached and recruited for cohort participation. Each participant contributed up to four self-reports of nutrition and physical activity, and up to three reports of motivation to change for a better lifestyle. These outcomes were modelled prospectively with robust mixed-effects Poisson regressions. The association between behaviour change interventions and BMI was quantified using linear regression. RESULTS: There was a high rate of smokers 20.5% and obesity 53.1%, and high rates of self-reported diagnoses of diabetes: 57.1%; hypertension 62.6%. We found no effect of residing in an ESIM, but adherence to both guidelines was higher in ESIM at the latest follow-up time point. ESIM residence was also associated with a twofold increase in the probability of reporting a high motivation for a better lifestyle and with a statistically non-significant decrease in BMI of -0.14 kg/m2 (95% CI: -0.46 to 0.19) at the latest follow-up. CONCLUSION: The longitudinal results extend evidence on the effect of WHO PEN protocol in promoting physical activity and nutritional behaviour in the Kosovo context.

Prospective association between depressive symptoms and blood-pressure related outcomes in Kosovo.

Kosovo has the lowest life expectancy in the Western Balkans, where cardiovascular disease (CVD) accounts for over half of all deaths. Depression also contributes to disability in the country, with a prevalence of moderate to severe symptoms reported as high as 42% in the general population. Although the mechanisms are not yet well understood, evidence suggests that depression is an independent risk factor for CVD. Our study assessed the prospective association between depressive symptoms and blood pressure (BP)-related outcomes among primary healthcare users in Kosovo to understand the role of BP in the relationship between depression and CVD. We included 648 primary healthcare users from the KOSCO study. The presence of depressive symptoms was defined as moderate to very severe depressive symptoms (DASS-21 depressive symptoms score ≥14). Multivariable censored regression models assessed prospective associations between baseline depressive symptoms and changes in systolic and diastolic BP while taking hypertension treatment into consideration. Multivariable logistic regression models assessed prospective associations between baseline depressive symptoms and hypertension diagnosis among normotensive patients (n = 226) as well as uncontrolled hypertension in hypertensive patients (n = 422) at follow-up. Depressive symptoms were associated with attenuated diastolic BP (ß = -2.84, 95%-CI -4.64 to -1.05, p = 0.002) over a year of follow-up in our fully adjusted model, although the association with systolic BP (ß = -1.98, 95%-CI -5.48 to 1.28, p = 0.23) did not meet statistical significance. We found no statistically significant association of depressive symptoms with hypertension diagnosis among initially normotensive people (OR = 1.68, 95%-CI 0.41 to 6.98, p = 0.48), nor with hypertension control among initially hypertensive people (OR = 0.69, 95%-CI 0.34 to 1.41, p = 0.31). Our findings are not consistent with increased BP as an underlying mechanism between depression and elevated CVD risk and contribute valuable evidence to cardiovascular epidemiology, where the mechanisms between depression, hypertension and CVD are yet to be elucidated.

Perceived barriers to physical activity behaviour among patients with diabetes and hypertension in Kosovo: a qualitative study.

BACKGROUND: In a cohort of primary health care users across Kosovo (KOSCO cohort), high rates and poor control of diabetes and hypertension were observed. These conditions can be prevented and better controlled by adapting to a healthy lifestyle. Physical activity is an important target, as inactivity and related obesity were very prevalent in the KOSCO cohort. This qualitative study aims to identify individual and structural barriers to physical activity perceived by patients with diabetes and/or hypertension so as to inform health care providers and policy-makers in Kosovo on strategies for promoting physical activity. METHODS: Interviews were conducted from July to October 2020 with 26 public primary health care users from five municipalities of Kosovo (Mitrovica, Vushtrri, Fushe Kosova, Gjakova, and Malisheva). The qualitative study was nested into the KOSCO cohort. KOSCO was implemented in 2019 and recruited consecutive patients visiting the public primary health care centres in these municipalities. Participants of this qualitative sub-study were selected if they had a doctor's diagnosis of diabetes and/or hypertension. The interview guide consisted of questions related to physical activity barriers these patients are facing, despite having received motivational counselling sessions in primary healthcare centres. Data were analysed using a framework methodology. RESULTS: Three main themes moderating physical activity behaviour were identified: 1) neighbourhood built environment, 2) health-related problems, and 3) social support. The barriers to physical activity related to the first theme were structural features of the neighbourhoods such as: crowded sidewalks, lack of green spaces, lack of proper lighting in public spaces, as well as dense traffic. In regards to the second theme, the main health reasons for study participants to delay physical activity were related to: physical discomfort as well as stress, worry, and lack of energy. An additional barrier to exercise was lack of social support specifically from friends. CONCLUSION: The study identifies structural and individual targets for integrated and inter-sectoral physical activity promotion efforts.

Non-communicable disease prevention in Kosovo: quantitative and qualitative assessment of uptake and barriers of an intervention for healthier lifestyles in primary healthcare.

BACKGROUND: Smoking, physical inactivity, low fruit and vegetable consumption, and obesity are common in Kosovo. Their prevention is a priority to relieve the health system of from costly non-communicable disease treatments. The Accessible Quality Healthcare project is implementing a primary healthcare intervention that entails nurse-guided motivational counselling to facilitate change in the domains of smoking, diet, alcohol consumption and physical inactivity for at-risk patients. This study quantitatively assesses the uptake of motivational counselling and the distribution of health behaviours and stages of health behaviour change of the participants according to the intervention, as well as qualitatively describes experiences and perceived benefits of motivational counselling. METHODS: Study participants (n = 907) were recruited consecutively in 2019 from patients visiting the Main Family Medical Centres in 12 municipalities participating in the Kosovo Non-Communicable Disease Cohort study as part of the Accessible Quality Healthcare project. For the quantitative study, we used baseline and first follow-up data on smoking status, physical inactivity, obesity, fruit and vegetable as well as alcohol consumption, uptake of counselling, and stages for behavioural change. For the qualitative study, in-depth interviews were conducted with a subset of 26 cohort participants who had undergone motivational counselling. RESULTS: Motivational counselling was obtained by only 22% of the eligible participants in the intervention municipalities. Unhealthy behaviours are high even in persons who underwent counselling (of whom 13% are smokers; 86% physically inactive; 93% with inadequate fruit and vegetable consumption; and 61% are obese); only the rate of smoking was lower in those who obtained counselling. Among smokers, over 80% were still in the pre-contemplation phase of behaviour change. More advanced stages of behaviour change were observed among the highly prevalent group of inactive persons and participants with poor dietary habits, among the 5 intervention municipalities. According to the qualitative study results, the participants who obtained motivational counselling were very satisfied with the services but requested additional services such as group physical activity sessions and specialized services for smoking cessation. CONCLUSIONS: More tailored and additional primary health care approaches in accordance with patients' views need to be considered for the motivational counselling intervention to reach patients and efficiently facilitate lifestyle behaviour change.

Strengthening Primary Healthcare in Kosovo Requires Tailoring Primary, Secondary and Tertiary Prevention Interventions and Consideration of Mental Health.

Objectives: Kosovo has the lowest life expectancy in the Balkans. Primary healthcare (PHC) plays an essential role in non-communicable disease (NCD) prevention. We described primary, secondary and tertiary prevention indicators in Kosovo and assessed their association with depressive symptoms. Methods: PHC users (n = 977) from the Kosovo NCD cohort baseline study were included. Depressive symptoms were assessed using the Depressive Anxiety Stress Scale-21. Cross-sectional associations between depressive symptoms and prevention indicators were quantified with mixed logistic regression models. Results: Poor nutrition (85%), physical inactivity (70%), obesity (53%), and smoking (21%) were common NCD risk factors. Many cases of hypertension (19%), diabetes (16%) and Chronic Obstructive Pulmonary Disease (COPD) (45%) remained undetected by a PHC professional. Uncontrolled hypertension (28%), diabetes (79%), and COPD (76%) were also common. Depressive symptoms were positively associated with physical inactivity (OR 1.02; 95% CI 1.00-1.05 per 1-point increase in DASS-21) and undetected COPD (OR 1.07; 95% CI 1.00-1.15), but inversely with undetected diabetes (OR 0.95; 95% CI 0.91-1.00). Conclusions: Continued attention and tailored modifications to primary, secondary and tertiary prevention in Kosovo are needed to narrow the Balkan health gap.

Study protocol: a prospective cohort on non-communicable diseases among primary healthcare users living in Kosovo (KOSCO).

INTRODUCTION: With the lowest life expectancy in the Balkans, underlying causes of morbidity in Kosovo remain unclear due to limited epidemiological evidence. The goal of this cohort is to contribute epidemiological evidence for the prevention and control of non-communicable diseases such as depression, hypertension, diabetes and chronic respiratory disease in Kosovo as the basis for policy and decision-making, with a spotlight on the relationships between non-experimental primary healthcare (PHC) interventions and lifestyle changes as well as between depression and the course of blood pressure. METHODS AND ANALYSIS: PHC users aged 40 years and above were recruited consecutively between March and October 2019 from 12 main family medicine centres across Kosovo. The data collected through interviews and health examinations included: sociodemographic characteristics, social and environmental factors, comorbidities, health system, lifestyle, psychological factors and clinical attributes (blood pressure, height, weight, waist/hip/neck circumferences, peak expiratory flow and HbA1c measurements). Cohort data were collected annually in two phases, approximately 6 months apart, with an expected total follow-up time of 5 years. ETHICS AND DISSEMINATION: Ethical approvals were obtained from the Ethics Committee Northwest and Central Switzerland (Ref. 2018-00994) and the Kosovo Doctors Chamber (Ref. 11/2019). Cohort results will provide novel epidemiological evidence on non-communicable diseases in Kosovo, which will be published in scientific journals. The study will also examine the health needs of the people of Kosovo and provide evidence for health sector decision-makers to improve service responsiveness, which will be shared with stakeholders through reports and presentations.