BBIBP-CorV vaccine effectiveness against COVID-19 in patients aged 60 years and older during the Delta-dominant period in the Federation of Bosnia and Herzegovina, a test-negative case-control study.

COVID-19 vaccine uptake in the Federation of Bosnia and Herzegovina (FBiH) accelerated in the second half of 2021, with greater vaccine availability. In this study, we estimated the vaccine effectiveness (VE) of complete primary series BBIBP-CorV vaccine against COVID-19 in patients aged 60 years and older, during the Delta-dominant period, using a test-negative case-control design. Surveillance sites were 11 primary health care centers (PHC) collecting patient data from October 1, 2021, to January 4, 2022, retrospectively according to a common protocol. In total, we included 1711 participants in the analysis: 933 cases and 778 controls. Of the 933 cases, 508 (54.4 %) had mild and 425 (45.6 %) had moderate to severe disease presentation. We observed no effectiveness against mild COVID-19. Overall vaccine effectiveness was 65.0 % (95 %CI: 40.1-79.5) against moderate to severe COVID-19. In time since vaccination analysis, VE was 78.7 % (95 % CI: 54.8-89.9) in patients who received their last dose < 90 days before onset; 66.0 % (95 % CI: -0.5-88.5) in those 90-119 days before onset; 42.1 % (95 % CI: -88.6-82.3) in those 120-149 days before onset and 45.0 % (95 % CI: -94.0-84.4) in those ≥ 150 days before onset. In our study, two doses of BBIBP-CorV provided considerable protection against moderate to severe COVID-19 in older adults, highest within 3 months after second dose, during the Delta-dominant period. Point estimates declined thereafter, suggesting a need for additional doses.

Ongoing measles outbreak, the Federation of Bosnia and Herzegovina, December 2023 to February 2024.

We report on an ongoing measles outbreak in the Federation of Bosnia and Herzegovina with 141 cases notified between week 52 2023 and week 6 2024. Among those with known vaccination status, 97% were unvaccinated and the most affected group is children under the age of 5 years (n = 87) who were not vaccinated during the pandemic years. Sixty-eight cases were hospitalised, the most common complications were measles-related pneumonia and diarrhoea. The sequenced measles viruses from four cases belonged to genotype D8.

In the Face of a Pandemic: "I Felt the Same as When the War Started"-A Qualitative Study on COVID-19 Vaccine Acceptance in Bosnia and Herzegovina.

Objectives: To conduct qualitative study with different target groups in Bosnia and Herzegovina in order to explore their views on barriers and drivers for COVID-19 vaccination, and to see if and how barriers and drivers vary between urban and rural locations, and different professional roles. Methods: The theoretical framework underpinning the study is the capability-opportunity-motivation (COM-B) behavior change framework, which has been adapted to monitor vaccine related behavior and attitudes. Data was collected from June to September 2022 through moderated discussions in focus groups. The total of 162 participants participated in 16 focus groups. Results: Among the key barriers to successful immunization identified across target groups were insufficient knowledge about vaccines, pandemic fatigue, concerns about the rapid development of the vaccine and its effectiveness, lack of confidence in the healthcare system. Some of the main drivers of vaccination against COVID-19 were confidence in science and expert recommendations. Conclusion: The COVID-19 immunization policy undergoes continuous changes, as do the pandemic prospects; we encourage further research to track the evolution of vaccine related attitudes, inform immunization policy, and create evidence-based interventions.

Evolution of seroprevalence to SARS-CoV-2 in blood donors in Sarajevo Canton, Federation of Bosnia and Herzegovina: Cross-sectional and longitudinal studies.

Background: Sarajevo Canton in the Federation of Bosnia and Herzegovina has recorded several waves of high SARS-CoV-2 transmission and has struggled to reach adequate vaccination coverage. We describe the evolution of infection- and vaccine-induced SARS-CoV-2 antibody response and persistence. Methods: We conducted repeated cross-sectional analyses of blood donors aged 18-65 years in Sarajevo Canton in November-December 2020 and 2021. We analyzed serum samples for anti-nucleocapsid (anti-N) and anti-spike (anti-S) antibodies. To assess immune durability, we conducted longitudinal analyses of seropositive participants at 6 and 12 months. Results: One thousand fifteen participants were included in Phase 1 (November-December 2020) and 1152 in Phase 2 (November-December 2021). Seroprevalence increased significantly from 19.2% (95% CI: 17.2%-21.4%) in Phase 1 to 91.6% (95% CI: 89.8%-93.1%) in Phase 2. Anti-S IgG titers were significantly higher among vaccinated (58.5%) than unvaccinated infected participants across vaccine products (p < 0.001), though highest among those who received an mRNA vaccine. At 6 months, 78/82 (95.1%) participants maintained anti-spike seropositivity; at 12 months, 58/58 (100.0%) participants were seropositive, and 33 (56.9%) had completed the primary vaccine series within 6 months. Among 11 unvaccinated participants who were not re-infected at 12 months, anti-S IgG declined from median 770.1 (IQR 615.0-1321.7) to 290.8 (IQR 175.7-400.3). Anti-N IgG antibodies waned earlier, from 35.4% seropositive at 6 months to 24.1% at 12 months. Conclusions: SARS-CoV-2 seroprevalence increased significantly over 12 months from end of 2020 to end of 2021. Although individuals with previous infection may have residual protection, COVID-19 vaccination is vital to strengthening population immunity.

The role of National Immunization Technical Advisory Groups in advising COVID-19 immunization policy during the pandemic: lessons from the Federation of Bosnia and Herzegovina.

A National Immunization Technical Advisory Group (NITAG) is a multi-disciplinary body of experts that provides evidence-based recommendations on immunizations to policy-makers to assist them in making immunization policy and program decisions. NITAGs faced challenges in making evidence-based recommendations for COVID-19 vaccines during the COVID-19 pandemic due to the new vaccine products available in a short time period and limited available data on vaccine effectiveness and vaccine safety. The authors reviewed the process used by the NITAG in the Federation of Bosnia and Herzegovina, called the expert body, to develop COVID-19 vaccine recommendations. The article reviews the evidence that was considered by the expert body when developing 23 recommendations on COVID-19 vaccination and describes the challenges and successes faced by the body. The expert body recommendations led to the successful roll-out of COVID-19 vaccines and provided guidance for COVID-19 vaccination during the pandemic. The expert body plans to improve its work and procedures for developing routine immunization recommendations with the support of the WHO Regional Office for Europe.

COVID-19 in the Federation of Bosnia and Herzegovina: Strengthening the public health surveillance using a web-based system to inform public health response, March 2020 - March 2022.

In response to the significant public health threat caused by coronavirus disease (COVID-19), real-time surveillance, containment, and mitigation measures were implemented in the Federation of Bosnia and Herzegovina (FBiH). Our objective was to describe the surveillance methodology, response measures, and epidemiology of COVID-19 cases in FBiH from March 2020 to March 2022. The surveillance system implemented across FBiH enabled health authorities and the population to monitor the development of the epidemiological situation, the daily number of reported cases, as well as basic epidemiological characteristics and geographic distribution of cases. As of 31 March 2022, 249,495 cases of COVID-19, and a total of 8,845 deaths were recorded in FBiH. Upkeeping of real-time surveillance, maintaining non-pharmaceutical interventions, and speeding up the vaccination roll-out were paramount for controlling COVID-19 in FBiH.

Population Perspectives on Impact of the COVID-19 Pandemic on Essential Health Services-Behavioral Insights from the Federation of Bosnia and Herzegovina.

The aim of this study was to analyze the impact of the COVID-19 pandemic on patterns of use of essential health services (EHS), health-seeking behaviors, and population health and wellbeing in the Federation of Bosnia and Herzegovina (FBiH) from the perspective of its adult population. A population-based survey was implemented in the FBiH in December 2020 on a sample of 1068 adults. Overall, 64% of respondents received care, significantly more being women (67% vs. 61%, p = 0.046), those with a chronic disease (CD) (75% vs. 65%, p < 0.001), and of an older age (58% in 18−34 vs. 67% in older, p = 0.031). These groups also postponed care more often (39% in 55+ vs. 31% in 18−34 years old, p = 0.01; 55% with CD vs. 31% without, p < 0.001; and 43% in females vs. 32% males, p < 0.001). Main reasons for postponing care were lack of available appointments and fear of infection. The presence of a CD was the strongest predictor of need, access, and disruptions of health care. Respondents reported increased expenses for medicines (40%) and health services (30%). The findings of the survey add user insights into EHS disruptions to existing health statistics and other data and may be used to inform strategies for mitigating the impact of COVID-19 on the disruption of health care services, strengthening health system preparedness and building resilience for future emergencies.

COVID-19 Risk Perception, Trust in Institutions and Negative Affect Drive Positive COVID-19 Vaccine Intentions.

Objectives: To investigate country-specific drivers and barriers of positive COVID-19 vaccine intentions in the Federation of Bosnia and Herzegovina (FBiH), one of the two entities comprising Bosnia and Herzegovina. Methods: A cross-sectional study design was used, using an online behavioural insights survey tool adapted to the context of FBiH. Three survey waves, each including approximately 1,000 adults, were conducted in July, September and December 2020. Fixed-effects regression analysis was used to explore the drivers, barriers and attitudes towards accepting a future COVID-19 vaccine. Results: COVID-19 risk perception, trust in health institutions and negative affect were positive predictors of positive COVID-19 vaccine intentions, as were living in urban areas and having a college education (versus having primary or secondary education). Conversely, being female, feeling that the pandemic was overhyped by the media and the country of vaccine production were negative predictors. Conclusion: This study provided snapshots on the state of attitudes regarding a future COVID-19 vaccine acceptance and hesitancy in 2020. These findings provided useful insights into the efforts to introduce and roll out the COVID-19 vaccines in FBiH. Further efforts should focus on better understanding the demographic, cultural and behavioural contexts of COVID-related vaccination perceptions in FBiH.

Satisfaction with Health Care Services in the Adult Population of the Federation of Bosnia and Herzegovina during the COVID-19 Pandemic.

Background and Objectives: Patient satisfaction with health care can influence health care-seeking behavior in relation to both minor or major health problems or influence communication and compliance with medical advice, which is especially important in emergencies such as the COVID-19 pandemic. Thus, it is important to continually monitor patient satisfaction with provided care and their dynamics. The aim of this study was to assess patient satisfaction with health care during the COVID-19 pandemic in the adult population of the Federation of Bosnia and Herzegovina (FB&H) and compare it with levels of satisfaction in the same population before the COVID-19 pandemic. Materials and Methods: A representative, population-based survey was implemented in the adult population of the FB&H using the EUROPEP instrument, which measures satisfaction with health care using 23 items. The sample included 740 respondents who were 18 years or older residing in the FB&H and was implemented in December 2020. All data were collected using a system of online panels. The survey questions targeted the nine months from the beginning of the pandemic to the time of data collection, i.e., the period of March to December 2020. Results: The mean composite satisfaction score across all 23 items of the EUROPEP tool was 3.2 points in all age groups; the ceiling effect was 22% for the youngest respondents (18-34 years old), 23% for 35-54 years old, and 26% for the oldest group (55+), showing increasing satisfaction by age. The overall composite score for both females and males was 3.2. The ceiling effect was higher in those with chronic disease (29% vs. 23% in those without chronic disease). The composite mean score for respondents residing in rural vs. urban areas was 3.2 with a ceiling effect of 22% in rural and 24% in urban residents. When comparing mean composite scores surveyed at various points in time in the FB&H, it was found that the score increased from 3.3 to 3.5 between 2011 and 2017 and dropped again to 3.3 in this study. Despite these observations in the overall trends of satisfaction scores, we note that no statistically significant differences were observed between most of the single-item scores in the stratified analysis, pointing to the relative uniformity of satisfaction among the analyzed population subgroups. Conclusions: The rate of satisfaction with health care services in the FB&H was lower during the COVID-19 pandemic compared to 2011 and 2017. Furthermore, while an increasing trend in satisfaction with health care was observed in the FB&H during the years prior to 2020, the COVID-19 pandemic may have contributed to the reversal of this trend. It is important to further monitor the dynamics of patient satisfaction with health care, which could serve as a basis for planning, delivering, and maintaining quality services during the COVID-19 pandemic and other emergencies.

Trends in Suicide Mortality in the Federation of Bosnia and Herzegovina - 2010-2020.

BACKGROUND: Suicide is a major public health problem, with far-reaching social, emotional and economic consequences. Suicide rates are high in all age groups are particularly high in all age groups but are one of the major causes of death among younger age groups, yeilding substantial years of premature life lost. Preventing suicide is one of the major mental health challenges in the world. OBJECTIVE: The aim of this study was to estimate the number and rates of suicide deaths in the Federation of Bosnia and Herzegovina (FB&H), and describe suicide characteristics by sex, age, method of suicide over the period of 2010 to 2020. METHODS: This is a retrospective population-based study from the period 2010 - 2020. Data were from the FB&H mortality register, Institute for Statistics FB&H. Data on deaths by cause of death are given according to the 10th edition of the International Statistical Classification of Diseases, Injuries and Causes of Death. Suicide data were presented rates by three age group, total number, male and female, crude rates, age-specific death rates and suicide mechanism by age and gender. RESULTS: The total number of suicides increased until 2017 to a peak of 201, then decreased to 157 for 2020. Males comprised over 70% of the suicide deaths. Over half of suicides were among those aged 30 - 64 and nearly one third among those 65 and above. However, the greatest increases were among youth aged 15 to 29, which grew from 2% to 9% of suicides over teh study period. The most common mechanisms for suicide were for hanging and firearms, both most common amond males. Poisoning was the most common mechanism among females. CONCLUSION: Understanding age and mechanism trends over time will help prioritize prevention strategies. Focus on mental health systems needs to ensure equal access to high-quality services in community based settings. For responses to this challenge to be effective, a comprehensive multisectoral suicide prevention strategy is needed.

Household transmission of SARS-CoV-2: a prospective observational study in Bosnia and Herzegovina, August-December 2020.

BACKGROUND: The secondary attack rate (SAR) of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) was estimated, and the risk factors for infection among members of households with a coronavirus disease 2019 (COVID-19) index case were identified to inform preventive measures. METHODS: Between 3 August and 19 December 2020, a household transmission study was implemented based on a standardized World Health Organization protocol. Laboratory-confirmed cases of SARS-CoV-2 infection were recruited through the federal COVID-19 database. Trained contact tracers interviewed index cases and household members to collect information on demographic, clinical and behavioural factors. Contacts were followed up for 28 days to identify secondary infections. SAR was estimated and odds ratios (OR) were calculated for risk factors for transmission. RESULTS: In total, 383 households and 793 contacts were included in this study. The overall SAR was 17% [95% confidence interval (CI) 14-21]. Contacts had higher risk for infection if the primary case had both cough and runny nose (OR 4.31, 95% CI 1.60-11.63), if the contact was aged 18-49 years (OR 4.67, 95% CI 1.83-11.93), if the contact kissed the primary case (OR 3.16, 95% CI 1.19-8.43), or if the contact shared a meal with the primary case (OR 3.10, 95% CI 1.17-8.27). CONCLUSIONS: These results add to the global literature by providing evidence from a middle-income setting. Standard preventive measures in households with positive cases remain critical to reduce transmission.

A qualitative interview study with parents to identify barriers and drivers to childhood vaccination and inform public health interventions.

Vaccination coverage in the Federation of Bosnia and Herzegovina, in Bosnia and Herzegovina, has been declining since 2014. This qualitative study aimed to identify barriers and drivers to childhood vaccination for parents. The COM-B (capability-opportunity-motivation-behavior) model was the underpinning theoretical framework. Face-to-face interviews with 22 parents of fully (n = 6), delayed/partially vaccinated (n = 9) and unvaccinated (n = 7) children were conducted. Interviews explored individual factors (capability-knowledge and skills; motivation-attitudes, confidence and trust) and context factors (physical opportunity-information, access, health systems; and social opportunity - social support, norms). Data were analyzed in NVivo using content analysis exploring differences in COM factors by vaccination status and location. Parents of fully vaccinated children typically reported individual and context drivers to vaccination. They accepted vaccination, trusted health workers, and were content with services. Parents of delayed/partially vaccinated children fell into two subgroups: (1) Those who accepted vaccination and attributed delays to their organizational skills or frustration with appointment times. (2) Those fitting the profile of "vaccine hesitant" - generally valuing vaccination and health worker advice, yet with concerns often triggered by media/social media. Parents of unvaccinated children mentioned individual and context barriers to vaccination, notably significant concerns about safety, some distrust of health workers and resentment of mandatory vaccination. Urban/rural differences included urban parents being more likely to report experiences with vaccine shortages and very few had received information leaflets. The study identified complex and inter-related barriers and drivers to parents' childhood vaccination behaviors. These insights have informed the development of tailored interventions to improve coverage.

An Overview of Human Resources and Capacity in Health Care Institutions in the Federation of Bosnia and Herzegovina in the Context of Responding to the COVID 19 Pandemic.

BACKGROUND: The organization of health care system on Cantonal level with the coordination from Federal level represents a real situation with the possibility of decentralization of health care system according to the experiences of developed countries. OBJECTIVE: To make an overview of the situation at the primary and hospital health care level with the aim of assessing the existing human resources and capacity of health care institutions in FB&H, with which we entered in COVID-19 pandemic. METHODS: This retrospective study presents the efficiency of health care in FB&H measured by number of medical doctors, and other medical staff during the time period of five years. Data of the Institute for Public Health FB&H were used. The Institute for Public Health FB&H is authorised by the law to conduct and implement statistical research in the field of health care in line with relevant laws and by-laws. The Institute is obliged to report on organisational structure, human resources and medical equipment. RESULTS: Presented data include the number of health care employees in medical institutions in FB&H in the period 2015-2019 per 100,000 inhabitants and their numbers in primary health care, family medicine, secondary and tertiary level of health care in 2019. The study also presents the number of doctors of medicine, specialists and medical residents in FB&H, the number of nurses of all profiles and levels of education as well as medical staff and other employees in the public health care system in FB&H in 2019. CONCLUSIONS: The COVID-19 pandemic in FB&H has confirmed the fact that human resources in health care are insufficient, especially in the field of public health and epidemiology. The availability of these health facilities and human resource is not uniform throughout the FB&H, which may affect the capacity of the health system in some parts of the FB&H to meet the needs of providing services during COVID-19 pandemic.

Phylogenetic pattern of SARS-CoV-2 from COVID-19 patients from Bosnia and Herzegovina: lessons learned to optimize future molecular and epidemiological approaches.

This is the first report of molecular and epidemiology findings from Bosnia and Herzegovina related to ongoing severe acute respiratory syndrome coronavirus 2 epidemic. Whole genome sequence of four samples from coronavirus disease 2019 (COVID-19) outbreaks was done in two laboratories in Bosnia and Herzegovina (Veterinary Faculty Sarajevo and Alea Genetic Center). All four BiH sequences cluster mainly with European ones (Italy, Austria, France, Sweden, Cyprus, and England). The constructed phylogenetic tree indicates possible multiple independent introduction events. The data presented contribute to a better understanding of COVID-19 in the current reemergence of the disease.

Tailoring Immunization Programmes: using patient file data to explore vaccination uptake and associated factors.

Vaccination uptake in the Federation of Bosnia and Herzegovina (FBiH), in Bosnia and Herzegovina, is suboptimal. This study aimed to (1) assess vaccination coverage, timeliness and drop-out for children born in 2015 and 2016 and compare these with official administrative coverage estimates, (2) identify associations between characteristics of children/caregivers and vaccination uptake. This was a cross-sectional study based on patient files for children 12-23 months (n = 1800) and 24-35 months (n = 1800). Methods were adapted from the World Health Organization cluster survey methodology. A two-stage stratified sampling procedure was conducted in urban and rural strata. A structured paper-based form was completed by a pediatrician/nurse from randomly selected primary care centers and patient files. Estimates were based on weighted analysis with a 95% confidence interval to account for the survey sampling design. Vaccination coverage was consistent with administrative coverage levels for BCG, DTP and MMR, and lower for HepB; all considerably lower than regional targets. Children in urban areas had lower vaccination uptake. An assumption that anti-vaccination sentiment prevails among caregivers was not confirmed; only 2% of children were not vaccinated at all, instead challenges related to delays and drop-out. An assumption of caregiver concerns for the MMR vaccine was confirmed with low uptake and delays. The FBiH has experienced vaccination schedule changes due to supply issues; findings confirmed that sustainability in supply and schedule is high priority. These data are new and provide important information for developing strategies to increase uptake.

Identifying barriers and drivers to vaccination: A qualitative interview study with health workers in the Federation of Bosnia and Herzegovina.

BACKGROUND: Vaccination coverage in Bosnia and Herzegovina has been declining over recent years. A World Health Organization Tailoring Immunization Programmes (TIP) project is underway to gain insights into the underlying reasons for this, to develop tailored interventions. As part of TIP, this study aimed to investigate the views of health workers on their barriers and drivers to positive childhood vaccination practices. METHODS: Face-to-face qualitative interviews explored 38 health workers' views on vaccination coverage, their vaccination attitudes, and system, programme and institutional influences on their vaccination practices. The data were analysed using content analysis and organised by the COM (Capability, Opportunity and Motivation) factors. FINDINGS: Very few differences in barriers and drivers were evident between high and low coverage primary care centres or across different professional roles. Capability: Drivers included awareness of the risks of low vaccination coverage, regular use of the Rulebook and Order, knowledge of how to advise parents on mild side effects and recognition of the importance of good communication with parents. Key barriers were the use of false contraindications to postpone vacination and poor skills in tailoring communication with parents. Opportunity: Drivers were sufficient time for adminstering vaccination and good availability of vaccines. Several barriers were evident: lack of implementation of mandatory vaccination, no uniform recall and reminder system or system for detecting under-vaccinated children, staff shortages and lack of time to discuss vaccination with parents. MOTIVATION: Drivers were a belief in the value, safety and effectiveness of vaccination and seeing that they have an important role to play. Barriers were a tendency to blame external factors e.g. anti-vax movement and a fear of being blamed for adverse events. CONCLUSIONS: The study identified complex and inter-related barriers and drivers to health worker positive vaccination practices. These insights will now inform a process to identify and prioritize interventions.

Epidemiology of measles cases and phylogenetic analysis of the virus circulated in the Federation of Bosnia and Herzegovina during 2018: implications for elimination efforts.

Aim To present combined measles cases data and phylogenetic analysis of the virus circulated in 2018 in the Federation of Bosnia and Herzegovina (FB&H, the entity of Bosnia and Herzegovina), in order to analyse endemic transmission patterns of circulating strains and its implications for elimination efforts. Methods The data were derived from epidemiological case investigations and laboratory diagnoses based on serology, molecular detection and genotyping of the measles virus. Results During 2018 16 measles cases were reported in FB&H, of which five were classified as laboratory confirmed cases, one was an epidemiologically linked case and 10 were clinically compatible cases. Among them 12 (75.00%) cases were unvaccinated or had unknown vaccination status. The most affected population was up to 14 years of age (13/16; 81.25%). None of the cases was fully vaccinated. Viruses of other genetic lineages had been introduced in FB&H in the recent period. Two virus lineages of genotype B3 were identified. Phylogenetic analysis indicated the presence of a unique sequence of measles B3 virus in FB&H (Sarajevo). Conclusion Further strengthening of measles surveillance system and renewed efforts to increase vaccination levels are necessary to prevent disease and for elimination setting.

Assessment of vaccine effectiveness during measles outbreak in the Federation of Bosnia and Herzegovina, 2014-2015.

OBJECTIVE: Between February 2014 and September 2015 a large measles outbreak (5,084 cases) occurred in the Federation of Bosnia and Herzegovina (FB&H). The aim of this study is to assess the effectiveness of routine measles vaccination in the FB&H. METHODS: We conducted an analysis of the resurgence period surveillance data and a retrospective cohort study involving primary school aged children in randomly selected schools. RESULTS: Measles cases occurred among all age groups, mostly among the unvaccinated. Among fully immunized, 2.1% contracted measles. Measles vaccine effectiveness was high. The study indicates that one dose reduced the risk for measles by 91.9% (95% CI: 81.4-96.4%), two doses reduced the risk by 97.3% (95% CI: 95.5-98.4%). No evidence of waning immunity was found. Our survey reveals that a significant number of children had no immunization status registered. CONCLUSIONS: The results of this study suggest that the resurgence was likely caused by an accumulation of measles-susceptible children not being vaccinated. This vaccine effectiveness study does not support possible vaccination failure as a contributing factor.

Association of adverse childhood experiences and health risk behaviors among young adults visiting a regional primary healthcare center, Federation of Bosnia and Herzegovina.

BACKGROUND: Many studies have linked adverse childhood experiences (ACEs) to long-term health outcomes, as well as health risk behaviors. In the post-war period in Bosnia and Herzegovina, many young people grew up in an environment of deteriorated living standards due to high unemployment and economic insecurity. The objectives of the study were to: 1) describe the health risk behaviors of young adults accessing primary healthcare; and 2) examine associations of these risk factors with adverse childhood experiences in this context. METHODS: This was a cross-sectional survey, conducted from April to October 2014. Participants were recruited from the Primary Healthcare Center Zenica. Patients between the ages of 18 and 24 were eligible for inclusion. The informed consent and self-administered questionnaire were offered to patients during clinic intake. The questionnaire contained questions on sexual and reproductive health, use of alcohol and drugs, dating violence, and adverse childhood experiences. RESULTS: During the study period 520 questionnaires were distributed, and 400 complete surveys were returned, for a response rate of 76.9%. Among the 400 respondents, 166 were males (41.5%) and 234 were females (58.5%). Our study showed that 48.7% of respondents had experienced some form of childhood adversity. Emotional neglect was the most common type of adverse childhood experience (25.6%) and was significantly more prevalent among females. Our study indicated that more than 15% of respondents had witnessed domestic violence. Overall, ACEs were associated with increased odds of early sex initiation, alcohol use, drug use, and dating violence, although some of these associations did not reach statistical significance. Emotional neglect was the exception, and reporting emotional neglect was associated with a significantly elevated odds ratio for all four of the health risk behaviors. Emotional abuse was associated with an increased odds of drug abuse (OR = 2.78; 95% CI = 1.31-5.90) and dating violence (OR = 2.31; 95% CI = 1.10-4.89). Sexual abuse was marginally associated with increased early sex initiation (OR = 3.2; 95% CI 0.93-10.8). Parental divorce was significantly associated with alcohol abuse. CONCLUSION: The results of this study demonstrated associations between adverse experiences in childhood and the probability of engaging in health risk behavior which has implications for health outcomes in the long-term.