Rights and responsibilities: Women leadership for health in Kyrgyzstan.

The World Health Organization (WHO) is committed to empowering countries by implementing a gender, equity, and human rights approach in the health sector. The objective of this gender and inclusion analysis is to assess potential gender disparities of health sector management in the Kyrgyz Republic. The employed mixed-method approach takes advantage of data triangulation. Besides information from the literature and policy documents available at the international and national levels, the analysis includes interviews and data from the self-assessment of health services managers in the Kyrgyz Republic. A convenience sample of 75 health managers was taken and after up to three reminders a commendable response rate of 80% was achieved which resulted the final sample size of N = 60. A factor analysis using quartimax orthogonal rotation was applied to investigate the correlation between Teaching Qualification, Digitalization, Training Usefulness, Computer Workplace, and Gender Equality. In 2021, the Kyrgyz Republic adopted a new Constitution, which provides a sound legal framework to support gender equality and promote women's empowerment. However, according to a survey, only 42.9% of the respondents felt that equal rights and opportunities were integrated into their job descriptions. Similarly, only 40.7% believed that their institutions' written documents reflected a commitment to equal rights and opportunities for both genders. Two factors were identified as influencing gender equality: (1) personal and (2) technical aspects. Regarding personal aspects, gender equality, teaching qualification, and training usefulness were found to be significant. Regarding technical aspects, the computer workplace was related. In recent years, the Kyrgyz Republic has been developing a culture of gender equality. Political will is essential to promote and make organizational change possible. It is important to create a written mid-term policy that affirms a commitment to gender equality in organizational behavior, structures, staff, and management board compositions. Healthcare institutions need to prepare strategic and operational plans that incorporate gender equality principles.

The burden of breast, cervical, and colon and rectum cancer in the Balkan countries, 1990-2019 and forecast to 2030.

BACKGROUND: Despite effective prevention and control strategies, in countries of the Balkan region, cancers are the second leading cause of mortality, closely following circulatory system diseases. OBJECTIVE: To describe trends in the burden of breast, cervical, and colon and rectum cancer in the Balkan region and per country between 1990 and 2019, including a forecast to 2030. METHODS: We described the 2019 Global Burden of Disease (GBD) estimates for breast, cervical, and colon and rectum cancers in eleven Balkan countries over the period 1990-2019, including incidence, years lived with disability (YLD), years of life lost (YLL), and disability-adjusted life years (DALYs) rates per 100,000 population and accompanied 95% uncertainty interval. With the Autoregressive Integrated Moving Average, we forecasted these rates per country up to 2030. RESULTS: In the Balkan region, the highest incidence and DALYs rates in the study period were for colon and rectum, and breast cancers. Over the study period, the DALYs rates for breast cancer per 100,000 population were the highest in Serbia (reaching 670.84 in 2019) but the lowest in Albania (reaching 271.24 in 2019). In 2019, the highest incidence of breast cancer (85 /100,000) and highest YLD rate (64 /100,000) were observed in Greece. Romania had the highest incidence rates, YLD rates, DALY rates, and YLL rates of cervical cancer, with respective 20.59%, 23.39% 4.00%, and 3.47% increases for the 1990/2019 period, and the highest forecasted burden for cervical cancer in 2030. The highest incidence rates, YLD rates and DALY rates of colon and rectum cancers were continuously recorded in Croatia (an increase of 130.75%, 48.23%, and 63.28%, respectively), while the highest YLL rates were in Bulgaria (an increase of 63.85%). The YLL rates due to colon and rectum cancers are forecasted to progress by 2030 in all Balkan countries. CONCLUSION: As most of the DALYs burden for breast, cervical, and colon and rectum cancer is due to premature mortality, the numerous country-specific barriers to cancer early detection and quality and care continuum should be a public priority of multi-stakeholder collaboration in the Balkan region.

Determinants of COVID-19 vaccine hesitancy: questionnaire development and validation.

OBJECTIVES: Vaccine hesitancy presents one of the critical constraints in combating COVID-19 pandemic. The aim of this study was to develop and validate an instrument for measuring factors that contribute to COVID-19 vaccine hesitancy. METHODS: The key constructs in the study instrument were factors that constitute the "3C" model of vaccine hesitancy: Confidence, Complacency and Convenience. Using a cross-sectional, online survey design, the 8-item COVID-19 Vaccine Hesitancy Questionnaire was administered to a sample of 667 adult citizens of Serbia in December 2020. We used confirmatory factor analysis to investigate the model that assumes three latent variables. To ensure that the instrument measures the same constructs in different groups, the measurement invariance examination was conducted. To examine criterion validity, Spearman's correlation was applied to determine the association between the instrument total score and the single-item measuring the likelihood of getting vaccinated against SARS-CoV-2. RESULTS: Confirmatory factor analysis established the three-factor structure, with subscales fitting within the "3C" model of vaccine hesitancy comprising confidence, convenience and complacency. The full scalar invariance was found across gender, and the partial scalar invariance was achieved for the age, region and education level. A higher level of the COVID-19 vaccine hesitancy was associated with the lower likelihood to get vaccinated against the SARS-CoV-2 virus. CONCLUSION: Our scale is brief and consistent, maintaining a good fit across key socio-demographic subgroups. This result implies that the scale could be useful for quick assessment of COVID-19 vaccine hesitancy in various target populations.

Data Mining Approach: What Determines the Wellbeing of Women in Montenegro, North Macedonia, and Serbia?

Background: Women's happiness and life satisfaction, often summarized as subjective wellbeing, are of great value for most individuals and are associated with various determinants. The countries of the Western Balkan are of particular interest after the political changes in the nineties. Are the women satisfied with their lives today? Methods: We use the most recent datasets of the Multiple Indicator Cluster Surveys (MICS) for women 15-49 years old and with comparable data coverage for three countries of the Western Balkan belonging to the former Yugoslavia, namely Montenegro, North Macedonia, and Serbia. After sorting out variables of limited relevance or quality (missing values >50%), the remaining 32 variables followed a descriptive analysis. Four potential determinants of subjective wellbeing (SWB), an integration of happiness and satisfaction with life, entered an interactive Classification and Regression Tree (iC&RT) to account for their mostly bivariate format: age, education, region, and wealth. Results: The iC&RT analysis determines the influence of 4 independent variables (age, education, region, and wealth) on overall happiness, satisfaction with life, and subjective wellbeing, resulting in a high overall SWB of 88.9% for Montenegro, 82.1% for North Macedonia, and 83% for Serbia. The high relevance of younger age, higher education, and wealth, as critical determinants of a high SWB, and the lesser role of regions except for Serbia is confirmed. The spread of SWB in defined population subgroups ranges from 80.5-92.6% for Montenegro, 64.2-86.8% for North Macedonia, and 75.8-87.4% for Serbia. Conclusions: The three selected South-Eastern European countries of the former Yugoslavia (Montenegro, North Macedonia, Serbia) represent high levels of subjective wellbeing of women and a narrow range between the lowest and highest population groups. Women in Montenegro take a top position regarding their subjective wellbeing.

Europeanization of health policy in post-communist European societies: Comparison of six Western Balkan countries.

Europeanization is assumed to influence health policy in the Western Balkans, but little is known about the actual impact of this process in these countries which constitute a complex geopolitical region of Europe. In this context, we used time trends to explore the Western Balkans health policies during the Europeanization through a cross-country comparative analysis of six countries. We conducted a health policy analysis by adapting the framework for globalization and population health coined by Huynen et al. in 2005. We analyzed 90 progress reports of Albania, Bosnia and Herzegovina, Croatia, Montenegro, North Macedonia and Serbia from 2005 to 2020. In particular, we considered chapter 28 on "Consumer and health protection" and other chapters that contained the words "health" or "population health". Evidence indicates that Europeanization influences Western Balkans' policies at different levels. Western Balkan countries revise national legislation in accordance with new European Union acquis as addressed in the progress reports and build cooperation with international institutions. They build national health reforms and reorganize relevant institutions to better address regulations in accordance to Europeanization. However, it is necessary to monitor law implementation so that the current legislation is enforced and further positive impact can be measured on population health.

Predictors of Clinical Inertia and Type 2 Diabetes: Assessment of Primary Care Physicians and Their Patients.

With the growing prevalence and complex pathophysiology of type 2 diabetes, many patients fail to achieve treatment goals despite guidelines and possibilities for treatment individualization. One of the identified root causes of this failure is clinical inertia. We explored this phenomenon, its possible predictors, and groups of patients affected the most, together with offering potential paths for intervention. Our research was a cross-sectional study conducted during 2021 involving 52 physicians and 543 patients of primary healthcare institutions in Belgrade, Serbia. The research instruments were questionnaires based on similar studies, used to collect information related to the factors that contribute to developing clinical inertia originating in both physicians and patients. In 224 patients (41.3%), clinical inertia was identified in patients with poor overall health condition, long diabetes duration, and comorbidities. Studying the changes made to the treatment, most patients (53%) had their treatment adjustment more than a year ago, with 19.3% of patients changing over the previous six months. Moreover, we found significant inertia in the treatment of patients using modern insulin analogues. Referral to secondary healthcare institutions reduced the emergence of inertia. This assessment of primary care physicians and their patients pointed to the high presence of clinical inertia, with an overall health condition, comorbidities, diabetes duration, current treatment, last treatment change, glycosylated hemoglobin and fasting glucose measuring frequency, BMI, patient referral, diet adjustment, and physician education being significant predictors.

Implementation of the Workload Indicators of Staffing Need (WISN) Method in Determining Staff Requirements in Public Health Laboratories in Serbia.

OBJECTIVES: This study aimed at identifying the needs for the health workforce in 16 public health laboratories in the Serbian capital by assessing the workforce stock, workload activities, activity standards, and workload pressure. METHODS: A review of laboratory records and regulations, interviews with key respondents, and observing work processes provided data for the World Health Organization method for determining staffing needs based on workload indicators (Workload Indicators of Staffing Need, WISN). RESULTS: A total of 99 laboratory workers spend almost 70% of their available working time in undertaking core activities. Core activities per sample can take from 0.25 to 180 min. Laboratory workers are under moderate or high workload pressure (the WISN ratio from 0.86 to 0.50). The WISN difference indicates a shortage of 22.22% of laboratory analysts and 20.63% of laboratory technicians. To balance the staffing to workload, these laboratories need an additional 8 FTE analysts and 13 FTE technicians. They could also consider selectively reducing workload pressure by automating some of the additional activities while maintaining the competence of laboratory workers and opportunities for professional development. CONCLUSIONS: Staffing policy should account for work processes, activity standards, and workload pressure to determine necessary staffing to meet the need for laboratory services in the local context.

Cross-cultural validation and psychometric testing of the counseling center assessment of psychological symptoms: experience of Serbia.

Psychological distress in university students represents a rising public health concern. The complexity of this phenomenon calls for a more in-depth scrutiny, in order to address the wide diversity of mental health issues that may arise in this population. The instrument designed for the purpose of measuring the student-specific distress is needed. An appropriate tool is the Counseling Center Assessment of Psychological Symptoms 62 (CCAPS-62), multidimensional scale widely used at many universities. The objective of the present study was to translate, culturally adapt and psychometrically validate CCAPS-62 in Serbian student population. A total of 1326 Belgrade University students were recruited from twelve different faculties. Considering the possible culturally conditioned differences in the quality of distress both exploratory and confirmatory factor analyses were performed. The results of the exploratory factor analysis supported the eight-factor model with the item composition of the factors different to a certain extent from the original version. This measurement model was verified by confirmatory factor analysis. Findings demonstrated good internal consistency for the total scale as well as for the eight subscales applied among Serbian students. Implications are discussed with respect to the cultural context of mental health concerns in student population.

Aligning Best Practices: A Guiding Framework as a Valuable Tool for Public Health Workforce Development with the Example of Ukraine.

Background: At present, in Ukraine, there is an insufficient capacity for up-to-date surveillance of the health status of the general population; public health (PH) promotion and disease prevention activities are scarce. Additionally, there is an urgent need to ensure, develop and support an efficient public health workforce (PHW) and appropriately address existing health issues. Ukraine currently introduces PH system reforms in line with its current burden of disease, the epidemiological profile and the Essential Public Health Services (EPHOs). This analysis aims to propose a pragmatic framework to provide guidance and recommendations related to the development, support and planning of the PHW in Ukraine. Methods: We constructed a framework based on a previously published scoping review and analyzed various policy analysis approaches. In line with the recommendations found in the literature and the best practices used elsewhere, this method enabled the construction of a framework for facilitating successful PHW development. In addition, an expert workshop was held, serving as a reality check for identifying crucial areas of the PH system in Ukraine. Results: The proposed framework includes a country's background, the evidence and available policy options, such as the health system (including core functions, organizational resources, regulations and norms), health system capacities (including human resources; PH capacity assessment; datasets and databases; forecasting strategies; licensing, accreditation and quality assurance) and capacity building (including PH education, training, core competencies and ethical and professional codes of conduct). To facilitate and support effective implementation of the framework, we propose (1) implementing strategies to facilitate changes in attitude, behavior and practices among the citizens; (2) implementing strategies to facilitate the necessary behavioral changes in the PHW; (3) implementing strategies to facilitate the necessary organizational and institutional changes; (4) implementing strategies to facilitate system changes and (5) identification of potential barriers and obstacles for the implementation of these strategies. Conclusion: The report highlights the practical tactics and best practices for providing suggestions for PHW support and planning. The employment of prominent analytical tools and procedures in policymaking processes suggests an effective strategy for PHW development in Ukraine.

Redesigning diabetes care delivery in Serbia, using JA CHRODIS Recommendations and criteria.

INTRODUCTION: Managing non-communicable diseases (NCDs) requires redesigning health care delivery to achieve better coordination of services at all levels of health care. The aim of this study was improving prevention and strengthening high quality of care for NCDs by using type 2 diabetes as a model disease. METHODS: The mix method approach served to analyse the impact of the intervention processes. Source of information were routine health statistics, interviews and observation. Key Performance Indicators in defined Improvement Areas assisted in the quality of diabetes care assessment. RESULTS AND DISCUSSION: During the study the National Diabetes Centre (NDC) was established. The NDC experts organized numerous educational events, 316 physicians and nurses have participated. New electronic data base was implemented in 20 pilot Primary Health Care Centres (PHCCs) with 38,833 electronic diabetes records. CONCLUSIONS: The intervention led to establishment of the NDC, strengthening competences of health care professionals and to the renewal of the Diabetes Care Units in PHCCs included in the study.

Factors Influencing Utilization of Preventive Health Services in Primary Health Care in the Republic of Serbia.

The use of preventive health services is a long-term health investment due to its potential to help individuals to take care of their health. This study aimed to explore the availability and performance of health services in primary health care (PHC) in the domain of general practice (GP), pediatrics, and gynecology, as well as to analyze the influence of sociodemographic and health determinants on the utilization of preventive health services. This descriptive study used data from the National Health Insurance Fund and the Statistical Office of the Republic of Serbia for 2015 and included 149 independent PHC units. The relationship between the utilization of preventive services and sociodemographic and health characteristics of the population was analyzed by bivariate and multivariate linear regression models. The higher health expenditure per capita and noncommunicable diseases mortality rate were, the more preventive health services were provided by a chosen GP. Children with a higher completion rate of primary school (p = 0.024), higher health expenditure (p = 0.017), and higher life expectancy at birth (p = 0.041) had more preventive health services. The fertility rate was positively associated with the number of preventive health services per 1000 women (p = 0.033). Our findings should serve as a starting point for where efforts should be made to achieve better health outcomes.

Corrigendum: Surprising Differences in the Practice of Exclusive Breastfeeding in Non-Roma and Roma Population in Serbia.

[This corrects the article DOI: 10.3389/fpubh.2020.00277.].

Surprising Differences in the Practice of Exclusive Breastfeeding in Non-Roma and Roma Population in Serbia.

Background: Exclusive breastfeeding is essential for early childhood development, although the use of adaptive milk formulas instead of breastfeeding is widespread nowadays. This study aimed to examine the prevalence of exclusively breastfed infants under the age of 6 months in non-Roma and Roma population and factors associated with this practice. Materials and Methods: This study is a secondary analysis of the Serbian Multiple Indicator Cluster Survey investigating non-Roma and Roma infants under the age of 6 months. The study included mothers of 321 non-Roma and 164 Roma infants younger than 6 months. Univariate and multivariate logistic regression served to analyze factors associated with the practice of exclusive breastfeeding in both populations. Results: The prevalence of exclusive breastfeeding was almost the same among mothers in both non-Roma and Roma population (13.3 vs. 13%, p = 0.910). Exclusive breastfeeding was significantly more often (p < 0.001) among wealthier women, women whose newborns were over 2,500 g on birth, multipara, and women who had not established menstrual cycle among both populations. Living outside the capital significantly diminishes the chance for exclusively breastfed infants in the non-Roma community (Vojvodina: OR 0.16, CI 95% 0.03-0.92; eastern Serbia: OR 0.02, CI 95% 0.01-0.35) as well as living in the rural area (urban: OR 10.35, CI 95% 1.94-55.28). Unexpectedly, in the non-Roma population, not staying in the same room with the newborn in the maternity ward increases the chance for the baby to be exclusively breastfed (OR 7.19, CI 95% 1.80-28.68). The same pattern has been observed in Roma population. Non-Roma mothers multipara are more likely to exclusively breastfeed their children than primipara (OR 7.78, CI 95% 1.09-20.93), while among Roma mothers, the inverse association has been found although not significant (OR 0.42, CI 95% 0.14-1.23). Attending a childbirth preparation program more than 18 times increases the chances of infants being exclusively breastfed (OR 18.65, CI 95% 1.34-53.67). In the Roma population, there was no single woman that attended a childbirth preparation program. Conclusion: The pattern of exclusive breastfeeding significantly differs between non-Roma and Roma populations. Preventive work should have focus on strengthening support to mothers and medical staff in maternity wards.

Successful promotion of physical activity among students of medicine through motivational interview and Web-based intervention.

BACKGROUND: Regular physical activity supports healthy behavior and contributes to the reduction of preventable diseases. Students in their social transition period are the ideal groups for interventions. The higher education period, associated with demanding changes and poor time management, results in a low level of physical activity. In this age, social media usually are a suitable channel of communication and multicomponent interventions are the most desirable. It has not been sufficiently investigated how effective a Web-based approach is among university students when it comes to physical activity in the long-term period. We combined a Web-based approach with motivational interviews and tested these two interventions together and separate to assess their impact on improving the physical activity of medical students 1 year after the intervention. METHODS: All 514 first-year students at the Faculty of Medicine in Belgrade were invited to fill in a baseline questionnaire. Also, they underwent measurement of weight, height and waist circumference. After that, students selected a 6 months intervention according to their preference: Intervention through social media (Facebook) (Group 1) or combined with a motivational interview (Group 2). Group 3 consisted of students without any intervention. One year after completion of the 6 months intervention period, all students were invited to a second comprehensive assessment. Analyses were performed employing a wide range of statistical testing, including direct logistic regression, to identify determinants of increased physical activity measured by an average change of Metabolic Equivalent of Task (MET). This outcome measure was defined as the difference between the values at baseline and one year after completion of the 6 months intervention period. RESULTS: Due to a large number of potential determinants of the change of MET, three logistic regression models considered three groups of independent variables: basic socio-demographic and anthropometric data, intervention and willingness for change, and health status with life choices. The only significant model comprised parameters related to the interventions (p < 0.001). It accurately classified 73.5% of cases. There is a highly significant overall effect for type of intervention (Wald = 19.5, df = 2, p < 0.001) with high odds for the increase of physical activity. Significant relationship between time and type of intervention also existed (F = 7.33, p < 0.001, partial η2 = 0.091). The influence of both factors (time and interventions) led to a change (increase) in the dependent variable MET. CONCLUSION: Our study confirmed the presence of low-level physical activity among students of medicine and showed that multicomponent interventions have significant potential for positive change. The desirable effects of the Web-based intervention are higher if an additional booster is involved, such as a motivational interview.

Factors Associated with the Leisure-Time Physical Activity (LTPA) during the First Trimester of the Pregnancy: The Cross-Sectional Study among Pregnant Women in Serbia.

Background: The benefits of physical activity during pregnancy include lower maternal weight gain, a lower likelihood of gestational diabetes, low back pain, preeclampsia, preterm delivery, caesarian delivery, and macrosomia. This study aimed to examine the factors associated with insufficient leisure-time physical activity (LTPA) during the first trimester. Methods: A cross-sectional study was conducted at the Clinic for Obstetrics and Gynecology of Clinical Center of Serbia, Belgrade, between January and June of 2018. The final analyses included 162/175 pregnant women. The questionnaire was used to obtain social characteristics, pregnancy, and lifestyle characteristics (Pregnancy Risk Assessment Monitoring System-PRAMS), pre-pregnancy LTPA (International Physical Activity Questionnaire-IPAQ), and LTPA during the first trimester (Pregnancy Physical Activity Questionnaire-PPAQ). Women were classified into two groups of sufficient and insufficient LTPA during the first trimester based on the recommendations of the World Health Organization. Multivariate logistic regression analysis was applied. Results: A total of 27.2% of the women had insufficient LTPA during pregnancy. Insufficient LTPA during pregnancy was associated with <12 years of education (OR: 2.3, 95% CI: 1.05-5.04), self-rated financial status as poor (OR: 0.34, 95% CI: 0.14-0.79), and hours spent walking before pregnancy (OR: 0.87, 95% CI: 0.77-0.99). Conclusions: Our results can help direct health care professionals advice for women who are planning pregnancy towards walking as it seems to be sustained during pregnancy.

Education and training in public health: is there progress in the European region?

BACKGROUND: The Association of Schools of Public Health in the European Region (ASPHER) is confronted with challenges to improve education for public health professionals. In this article, we attempt to answer the question: Did ASPHER members improve their organization and programmes to enable their graduates to acquire the competences to tackle the diverse areas of public health defined in the Ten Essential Public Health Operations (EPHOs)? METHODS: ASPHER run two surveys among its membership: In 2011, 66 Schools and Departments of Public Health (SDPHs) took part (82.5%), while in 2015-16, 78 SDPHs (81.3%). The performance of graduates was estimated using a Likert scale. RESULTS: In 2015-16, the SDPHs delivered 169 academic programmes (2.2 on average per SDPH). Among the SDPHs participating in both surveys, significant differences could not be determined, neither for the organization (except increasingly using social media) nor for teaching areas. The performance of graduates did not show significant differences except for the deterioration of EPHO-8 ('assuring sustainable organizational structures and financing'). However, the qualitative data revealed progressive dynamics regarding innovations in the organizational set-up, digitalization, teaching/training, introduction of new modules and research. CONCLUSIONS: The results generated do not allow us to state that the innovative elements introduced after the first survey in 2011 have had a clear impact reflected in the second survey carried out in 2015-16, but perhaps this is due to the need for a broader follow-up in order to objectify the potential consequences derived from the boost generated by the changes introduced.

Towards equal access to health services in Serbia

Serbia has a comprehensive universal health system withfree access to health care, but there are inequities in the utilisation of health services. Some vulnerable groups, such as those living in poverty or Roma people in settlements, have more barriers in accessing health care. Financial constraints are the main reason for unmet needs, in particular for the less educated and the poorest. Although citizens are generally satisfied with public and private health care services, a significant number of patients are on waiting lists. Therefore, reaching equal access to health services should be one of the leading health policy goals.

Prevalence and Predictors of Violence Victimization and Violent Behavior among Youths: A Population-Based Study in Serbia.

The study identifies the prevalence of violence victimization and the perpetration among youths, and explores the determinants and predictors using a socio-ecological model. The data of 36 variables from a representative sample of 1722 persons, ages 15-24 years, from the National Health Survey of Serbia in 2013, were analyzed by a multivariate logistic regression modeling. The study shows that 13.4% of youths experienced multi-victimization, while 10.4% were perpetrators of violence. Up to one-third of the victims were violence perpetrators. A small percentage of victims seek family and community support. Predictors of violence among youths were: male sex, households with fewer members, urban settlements, violence perpetration, self-assessed health as poor, lack of close friends and perception that it was difficult to obtain the assistance needed. Predictors of youth violence highlighted the need to improve health education, social support and community regulations, as well as strengthen the promotion of gender equality and a healthy environment.