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.

Women's Safety and Gender-Based Violence in the Republic of North Macedonia.

Violence against women in the Republic of North Macedonia is the most common form of human rights violation, and women's safety is thus a high-priority public health problem. There have been significant achievements in the area of policy development: legislation harmonization for human rights protection, prevention of violence against women, protocols for the treatment and support of female victims, especially those with disabilities, and further collaboration and coordination between different sectors. In practice, there is still a need to establish a system of institutions for effective prevention, protection, gathering of evidence, and support of women victims of gender-based violence in addition to the prosecution of perpetrators. Policies for the improvement of women's safety should be considered as a priority and undertaken at an individual, relationship, community, and society level.

Are Resilient Factors Increasing the Risk for Childhood Psychological Victimization?

BACKGROUND: Understanding the resilient factors and why some children do well despite early adverse experiences is crucial, because it can inform more effective policies and programs that help more children reach their full potential. AIM: The main objective of the study is to describe the associations between psychological abuse in childhood and resilient risk factors on individual, relational, contextual level among adolescents in the country and see the probability of resiliency to predict psychological victimisation. MATERIAL AND METHOD: Cross-sectional study on two-stage quota sample of 622 university students was applied in the study, including adolescents at first and second year at the main public Ss Cyril and Methodius University of Skopje, from the 12 faculties in the country. Adverse Childhood Experiences Study International Questionnaires was used for collecting information on psychological abuse, while the individual, relational and contextual resilient factors were measured using the Child and Youth Resilience Measure - Youth version. The study was conducted from March to September 2017. Statistical significance was set up at P < 0.05. RESULTS: The results from the study have shown statistically significant negative correlation between exposure to psychological abuse in childhood and individual (rpb = -0.159), relational (rpb = -0.263), contextual factors (rpb = -0.147), and resilience in total (rpb = -0.232). The regressive model presents that 5.2% of the variance of the variable experienced psychological abuse is explained with resilience (F(1, 527) = 28.909; P < 0.001), showing that resilience is negatively significant predictor for being psychologically abused in childhood (ß = -0.228; t = -5.377; P < 0.001). The regressive model explains the individual contribution of the predictor variables for the psychological abuse, presenting that only caregiver resiliency is a significant predictor for psychological abuse (ß = -0.282; t = -4.986; P < 0.001). CONCLUSION: Supporting children through prevention means foster competence and prevent problems. Preventive programmes represent developing protective factors in childhood, increasing competence and skills for the growth of resilience and decreasing the likelihood of developing psychopathology in adolescence and adulthood. It is of common interest of society for implementation of evidence-based interventions with fostering settings and in the long run enabling positive childhood basis for future generations.

The INHERIT Model: A Tool to Jointly Improve Health, Environmental Sustainability and Health Equity through Behavior and Lifestyle Change.

The need for analysis and action across the interrelated domains of human behaviors and lifestyles, environmental sustainability, health and inequality is increasingly apparent. Currently, these areas are often not considered in conjunction when developing policies or interventions, introducing the potential for suboptimal or conflicting outcomes. The INHERIT model has been developed within the EU-funded project INHERIT as a tool to guide thinking and intersectoral action towards changing the behaviors and lifestyles that play such an important role in today’s multidisciplinary challenges. The model integrates ecological public health and behavioral change models, emphasizing inequalities and those parts of the causal process that are influenced by human behaviors and lifestyles. The model was developed through web-based and live discussions with experts and policy stakeholders. To test the model’s usability, the model was applied to aspects of food consumption. This paper shows that the INHERIT model can serve as a tool to identify opportunities for change in important −food-related behaviors and lifestyles and to examine how they impact on health, health inequalities, and the environment in Europe and beyond. The INHERIT model helps clarify these interrelated domains, creating new opportunities to improve environmental health and health inequality, while taking our planetary boundaries into consideration.

Social Determinants of Self-reported Health Among Population in Republic of Macedonia - Results from a Case-control Study.

INTRODUCTION: Studying self-reported health is considered an indicator for morbidity and mortality that may be used in primary health care to detect poor health in certain population groups that predicts health care utilization. GOAL: The goal of the survey is to assess the socioeconomic self-rated health gradient and to describe contribution of behavioral risk factors to this gradient among population in Republic of Macedonia. MATERIAL AND METHODS: Data is collected through a "nested case-control study", conducted in the period March - December, 2013. "Cases" are households with TB patient(s) registered in the period July, 2012 - June, 2013 and "controls" are households randomly chosen in cases' immediate vicinity. RESULTS: The total study population is 562 households with total of 2720 respondents. Self-rated health was reported as excellent or good by only half of the respondents, with slightly less positive answers among cases compared to controls and evident differences in responses for poor or extreme difficulties in everyday life. Positive association was found between poor rated health and long-standing diseases and education was associated with poor self-rated health. Adding questions on mobility, self-care, pain, cognition, interpersonal activities and affect has only reaffirmed the findings, with statistically significant differences among study groups along all six dimensions. CONCLUSION: The ease of use of simple questions to ask for self-rated health makes it an extremely beneficial tool in health care planning.

Social determinants of equity in access to healthcare for tuberculosis patients in Republic of Macedonia - results from a case-control study.

BACKGROUND: Health is a complex phenomenon and equity as a basic human right an integral part of constitutions in almost all countries in the world. In Republic of Macedonia (RM), Tuberculosis (TB) is clustered regionally and in certain ethnic groups. The main objective of this study was to analyze Social Determinants of Health (SDH) and equity in access to healthcare services for TB patients in RM, aimed at complex analysis of factors that cause inequities. METHODS: Case-control study was conducted in the period March-December, 2013; "cases" are households of TB patients registered in the period July, 2012-June, 2013 and controls are households with no TB patients in their immediate vicinity. World Health Organization (WHO) World Health Survey questionnaire was used to collect data. RESULTS: Analysis of SDH of TB patients shows that patients are mostly males, of lower socio-economic status, are less educated, unemployed and TB is clustered in certain ethnic groups. Analysis of access has identified these determinants as important barriers in access to health services. CONCLUSION: The study has documented the basic SDH of TB patients in RM, as well as barriers in access to healthcare, providing useful baseline information to facilitate determination where to concentrate future efforts.

Strategy to improve quality in emergency medical services: from assessment to policy.

The aim of this paper was to present the strategic approach applied for improvement of quality in emergency medical services (EMS) in the Republic of Macedonia. This approach was accomplished through three stages: (I) assessment and recommendations for policies; (II) development of innovative evidence-based programmes; and (III) policy implementation. Strategic assessment of EMS was performed by applying WHO standard methodology. A survey was conducted in 2006/2007 on the national level in fifteen general hospitals, four university hospitals, and sixteen pre-hospital EMS. The overall evaluation was based on a hospital emergency department (ED) questionnaire, information on the general characteristics of the pre-hospital dispatch centre, review of ED medical records, and the patient questionnaire. The key findings of the assessment showed that EMS required extensive changes and improvements. Pre-hospital EMS was not well-developed and utilised. Hospital EDs were not organised as separate divisions ran by a head medical doctor. The diagnostic and treatment capacities were insufficient or outdated. Most of the surveyed hospitals were capable of providing essential diagnostic tests in 24 h or less. There was no follow-up of the EMS patients or an appropriate link between the hospital EDs and primary health care facilities. The main findings of the assessment, recommendations, and proposals for action served as the basis for new policies and integrated into Macedonia's official strategy for emergency medical services 2009-2017.

Attitude of the Macedonian intensivists regarding withdrawal of therapy in intensive care patients: curriculum for policy development.

UNLABELLED: Ethical confusion regarding withdraw of therapy led to the aim of the study in which the knowledge and attitude of the Macedonian Intensive Care Unit (ICU) doctors and their impact on decision making process were assessed. METHODS: Knowledge, Attitude and Practice (KAP) study has been conducted on a national sample of 217 ICU doctors (response rate 83.87%), applying restructured EURELD 2002 questionnaire as study instrument. CHI-square test was used for cross tabulations. RESULTS: 103 responders were females and 79 males with mean age 40, 2 years +/- 3 y. Significant percent of the doctors didn't know what is withdraw of therapy, chi-square 34.47 (p < 0.0001) and for most there was no difference between withdraw of therapy and euthanasia, chi-square 41.482 (p < 0.0001). Most of doctors didn't have any formal training (67%) and didn't know whether they had experience with withdraw or withhold. Similarly to other countries, for significantly higher percentage of the Macedonian intensivists patient's wishes and patient autonomy have to be main criteria for decision. Significantly higher group of doctors (p < 0.0001) would prefer to leave their own advanced directives. CONCLUSIONS: Legal principles in end of life care must be established in the country. Courts should have drawn a distinction between intentionally causing a patient's death (euthanasia) and allowing a patient to die as a result of the withdrawal of life support treatment. There is a need of additional improvement of postgraduate curriculum and continuous professional development of ICU doctors working with end-of-life patients.

Quality of care and its impact on population health: a cross-sectional study from Macedonia.

Research has revealed significant variation in both the quality of clinical care and the health status of populations. We conducted a study to determine if variations in the quality of clinical care can be quantitatively linked to variations in health status, at the patient and the population level. This study, conducted at health facilities in four municipalities in Macedonia, collected cross-sectional data on (1) structural measures (such as infrastructure, facilities, equipment and costs) and the quality of clinical care provided by physicians (as measured by clinical vignettes); (2) detailed health and socioeconomic status information on patients using the facilities; and (3) nearly the same information on a random sample of adults in each municipality. Data were collected from a total of 57 facilities, 273 physicians, 1451 patients, and 1627 adults from the general population. The main outcome measure was health status, based on self-reported health surveys. Objective health measures were obtained to control for preexisting conditions. The main explanatory variable was quality of clinical care, based on physicians' clinical vignette scores. Structural measures were included in our model but had a more distal relationship to health status. We found that quality of care strongly predicted self-reported health status of patients using the facilities even after controlling for other factors (p < .05). Quality of care was also associated with higher health status for the population living in the surrounding community, regardless of utilization (p < .05). This linkage between quality of clinical care and health suggests that policies that improve clinical practice have the potential to improve population health more rapidly than other interventions.

Using vignettes to compare the quality of clinical care variation in economically divergent countries.

OBJECTIVE: To determine whether clinical vignettes can measure variations in the quality of clinical care in two economically divergent countries. DATA SOURCE/STUDY SETTING: Primary data collected between February 1997 and February 1998 at two Veterans Affairs facilities in the United States and four government-run outpatient facilities in Macedonia. STUDY DESIGN: Randomly selected, eligible Macedonian and U.S. physicians (>97 percent participation rate) completed vignettes for four common outpatient conditions. Responses were judged against a master list of explicit quality criteria and scored as percent correct. DATA COLLECTION/ EXTRACTION: An ANOVA model and two-tailed t-tests were used to compare overall scores by case, study site, and country. Principal Findings. The mean score for U.S. physicians was 67 percent (+/-11 percent) compared to 48 percent (+/-11 percent) for Macedonian physicians. The quality of clinical practice, which emphasizes basic skills, varied greatly in both sites, but more so in Macedonia. However, the top Macedonian physicians in all sites approached or-in one case-exceeded the median score in the U.S. sites. CONCLUSIONS: Vignettes are a useful method for making cross-national comparisons of the quality of care provided in very different settings. The vignette measurements revealed that some physicians in Macedonia performed at a standard comparable to that of their counterparts in the United States, despite the disparity of the two health systems. We infer that in poorer countries, policy that promotes improvements in the quality of clinical practice-not just structural inputs-could lead to rapid improvements in health.

The impact of evidence-based education on a perinatal capacity-building initiative in Macedonia.

CONTEXT: The perinatal mortality rate (PMR) in Macedonia is among the highest in Europe. The World Bank supported a consultant (HEJ) to collaborate with a Macedonian team to develop a national perinatal strategy with the goal of reducing the PMR. Education was given priority in the form of a hospital-based initiative to develop the capacity of health professionals to introduce evidence-based perinatal practice into 16 participating hospitals. A "train the teachers" approach was used, with trainees introduced to modern education and clinical practice in Sydney and subsequently supported to train their colleagues in Skopje. OBJECTIVES: To describe the development, implementation and evaluation of the educational intervention. METHODS: A curriculum, based on specific Macedonian needs, was developed in order to integrate teaching in the knowledge, skills and attitudinal domains of learning, using small group, interactive techniques. Twenty-five Macedonian doctors and nurses participated in 4-month (phase 1a) and 6-month (phase 1b) teaching programmes at a tertiary perinatal unit in Sydney. Australian staff conducted 4 2-week modules for 36 trainees in Macedonia (phase 2). The phase 1 trainees conducted 8 modules for 57 colleagues in Skopje (phase 3). The intervention was evaluated by trainee questionnaires, assessments of competence, changes in hospital practice and pre- (1997-99) and post-intervention (2000-01) comparisons of PMR. RESULTS: A total of 115 doctors and nurses graduated from the programme. Positive responses to the education programme exceeded 80%. Evidence-based practice in 16 participating hospitals (covering 91% of all Macedonian births) was verified in 6 key areas of neonatology. The PMR fell significantly from 27.4 to 21.5 per 1000 births (RR 0.79, 95% CI 0.73, 0.85). The early neonatal death rate in babies weighing over 1000 g fell by 36%. CONCLUSIONS: The intervention has increased the capacity of Macedonians to practise best-evidence perinatal medicine and improve outcomes. Sustainability is predicted by the "train the teachers" approach, with concurrent strengthening of the infrastructure and organisational framework.