South Eastern European Journal of Public Health

3

Authors: Peter Schröder-Bäck, Els Maeckelberghe, Miguel Ángel Royo Bordonada

Sometimes researchers and practitioners of public health are confronted with situations where it is not self-evident which option for action is the better choice. A decision about implementing a particular public health intervention can be difficult because there is a lack of scientific evidence that would speak clearly for or against its effectiveness. Moreover, a decision can be difficult because of moral values that are at stake. Indeed, taking a decision might sometimes feel like replacing one evil with another; or at least accepting some restrictions of liberty of individuals in the trade-off for another good, e.g. the health of others. Examples of difficult choices can be to implementing quarantines and isolations (like those being currently in place in relation to the Ebola outbreak in West-Africa), obligatory immunizations, prohibitions of risky behaviour or (re-)distributing resources.

7

Authors: Toni Yonkov Vekov

Aim: The aim of this study was to assess the economic performance of the application of the policy for negotiating discounts on drug products and agreements on the controlled access of patients in Bulgaria. Methods: The methodology involves comparison of the amounts of public spending on medicines in two periods – during the course of the analyzed drug policies (January 2007 – June 2009), and the period in which negotiations on the price of medicines and programs for the controlled access of the patients was discontinued (July 2009 – December 2012). Results: In Bulgaria, the government did not apply methods for controlling public expenditure on medicines bargaining price concessions from manufacturers and implementing agreements on controlled access of patients after June 2009. This led to an annual increase in the expenditures on drug products for home treatment (on average, 17% for the period 2009-2012). Conclusion: This trend in Bulgaria will continue in the future since expenditure control only through price control by means of a reference system and the positive list of medicines is ineffective. There is a need for implementation of combined drug policies in Bulgaria in the form of negotiations on rebates with manufacturers and agreements on controlled access of patients and reference pricing.

8

Authors: Katarzyna Czabanowska, Ulrich Laaser, Louise Stjernberg

The aim of this short report is to stimulate a discussion on the state of a public health profession in Europe and actions which need to be taken to authorise public health professionals based on their competencies. While regulated professions such as medical doctors, nurses, lawyers, and architects can enjoy the benefits of the 2005/36/EC Directive amended by 2013/55/EU Directive on the recognition of professional qualifications, public health professionals are left out from these influential (elite) professions. Firstly, we use the profession traits theory as a framework in arguing whether public health can be a legitimate profession in itself; secondly, we explain who public health professionals are and what usually is required for shaping the public health profession; and thirdly, we attempt to sketch the road to the authorisation or licensing of public health professionals. Finally, we propose some recommendations. Keywords: profession, professionalization, public health, recognition of professional qualifications.

10

Authors: Fitim Skeraj, Katarzyna Czabanowska, Gazmend Bojaj, Genc Burazeri

Aim: Family physicians and general practitioners are currently facing increasing demands to meet patients’ expectations and rapid technological and scientific developments. The aim of this study was to determine the self-perceived level of competencies of primary health care physicians in Kosovo, a post-war country in the Western Balkans. Methods: A cross-sectional study was conducted in Kosovo in 2013 including a representative sample of 597 primary health care physicians (295 men and 302 women; mean age: 46.0±9.4 years; response rate: 90%). A structured self-administered questionnaire was used in order to determine physicians’ competencies regarding different domains of the quality of health care. The questionnaire included 37 items organized into six subscales/domains. Answers for each item of the tool ranged from 1 (“novice” physicians) to 5 (“expert” physicians). An overall summary score (range: 37-185) and a subscale summary score for each domain were calculated for each participant. General linear model was used to assess the association of physicians’ self-perceived level of competencies with covariates. Results: The internal consistency of the whole scale (37 items) was Cronbach’s alpha=0.98. Mean summary score of the 37-item instrument and subscale summary scores were all higher in men than in women. In multivariable-adjusted models, mean level of self-perceived competencies was higher among older physicians, in men, those with >10 years of working experience, physicians serving >2500 people, specialized physicians and those involved in training activities. Conclusion: Our study provides useful evidence on the self-assessed level of competencies of primary health care physicians in post-war Kosovo. Future studies in Kosovo and other transitional settings should identify the main determinants of possible gaps in self-perceived levels of physicians’ competencies vis-à-vis the level of physicians’ competencies from patients’ perspective.

13

Authors: Jerneja Farkas, Mitja Lainscak, Andreja Kukec, Mitja Kosnik

Aim: Behavioural risk factors have a significant impact on health. We aimed to assess health-related behaviour, health status, and use of healthcare services among managers of Slovenian hospitals and institutes of public health. Methods: This was a cross-sectional study which included management (directors, scientific directors, directors’ deputies) of Slovenian hospitals and institutes of public health (63 respondents; 57% women; overall mean age: 51±7 years; response rate: 74%). Data were obtained using an anonymous self-administered questionnaire. Results: About 35% of respondents were directors. More than half of the respondents were overweight or obese (52%), the majority were not sufficiently physically active (59%) and overloaded with stress (87%). Hypercholesterolemia (36%), spinal disease (17%), and arterial hypertension (16%) were most common chronic diseases. Whilst only few participants visited their general practitioner due their health complaints, blood pressure (76%), cholesterol (51%), and glucose (54%) were measured within last year in most of the respondents. Conclusion: Our findings point to a high prevalence of overweight and obesity as well as workplace-related stress among Slovenian public health managers. Therefore, effective preventive strategies should be focused on stress management along with promotion of healthy behavioural patterns.

19

Authors: Vesna Bjegovic-Mikanovic, Katarzyna Czabanowska, Antoine Flahault, Robert Otok, Stephen M. Shortell, Wendy Wisbaum, Ulrich Laaser

With the growth and complexity of current challenges such as globalization, health threats, and ageing society, financial constraints, and social and health inequalities, a multidisciplinary public health workforce is needed, supported by new skills and expertise. It has been demonstrated that public health education needs to include a wider range of health related professionals including: managers, health promotion specialists, health economists, lawyers and pharmacists. In the future, public health professionals will increasingly require enhanced communication and leadership skills, as well as a broad, interdisciplinary focus, if they are to truly impact upon the health of the population and compete successfully in today‘s job market. New developments comprise flexible academic programmes, lifelong learning, employability, and accreditation. In Europe‘s current climate of extreme funding constraints, the need for upgrading public health training and education is more important than ever. The broad supportive environment and context for change are in place. By focusing on assessment and evaluation of the current context, coordination and joint efforts to promote competency-based education, and support and growth of new developments, a stronger, more versatile and much needed workforce will be developed. Keywords: public health competences, public health education, public health workforce.

3

Authors: Genc Burazeri, Slavenka Jankovic, Ulrich Laaser, Jose M. Martin-Moreno

The South Eastern European Journal of Public Health (SEEJPH) is an online, open-access, international, peer-reviewed journal, published by Jacobs Company in Germany. Starting from 2014, the journal will initially release two issues per year, at the end of June and the end of December, although articles will be immediately published online following acceptance – a unique advantage of open-access journals, whose relevance within the corpus of scientific literature has been growing in recent years.

7

Authors: Mariana Dyakova, Christian Drew, Nicola Wright, Aileen Clarke, Karen Rees

A large number of people, considered at increased risk of vascular disease, remain unidentified, untreated and not reached by lifestyle advice or intervention, despite public health and clinical efforts. This has prompted the initiation of national screening/systematic risk assessment programmes for vascular disease in healthy populations. These exist in addition to the more ad hoc opportunistic risk assessment initiatives undertaken worldwide. There is currently not enough indisputable evidence either showing clear clinical or economic benefits of systematic screening-like programmes over opportunistic risk assessment of cardiovascular disease (CVD) in primary care. We present the rationale and methodology of a Cochrane systematic review, assessing the effectiveness, costs and adverse effects of systematic risk assessment compared to opportunistic risk assessment for the primary prevention of CVD. Keywords: cardiovascular disease, Cochrane systematic review protocol, risk assessment.

8

Authors: Jolanda Hyska, Ehadu Mersini, Iris Mone, Entela Bushi, Edite Sadiku, Kliti Hoti, Arjan Bregu

Aim: the aim of this survey was twofold: (i): to assess medical students’ knowledge, attitudes and practices regarding nutrition in general, in order to identify their level of competences in the field of nutrition which will be useful in their future role of providers/health care professionals, and; (ii) to assess the knowledge, attitudes and practices regarding the discipline of public health nutrition in order to identify the needs for improving the curriculum of this subject in all the branches of the University of Medicine in Tirana. Methods: A cross-sectional study was conducted in June-July 2013 including a representative sample of 347 students at the University of Medicine in Tirana, Albania (61% females and 39% males; overall mean age: 23±2 years; response rate: 87%). A nutritional questionnaire, adopted according to the models used in previous international studies, was used to assess the level of knowledge, attitudes and practices among the university students. Results: Overall, about one third of the students was not satisfied with the quality and quantity of nutritional education and demanded a more scientifically rigorous curriculum. In general, students’ knowledge about infant feeding practices was adequate. However, there were gaps in the students’ knowledge regarding the commencement of breastfeeding, or the duration of exclusive breast-feeding. Furthermore, there was evidence of an insufficient level of knowledge among students regarding diet and nutrition in general and their health impact, especially on development and prevention of chronic diseases. Conclusion: This survey identified significant gaps in the current curriculum of public health nutrition at the University of Medicine in Tirana. Our findings suggest the need for intervention programs to improve both the quantitative and the qualitative aspects of nutrition curricula in all the branches of the University of Medicine Tirana, in accordance with the professional expectations of this teaching institution, as well as the urge for a movement towards a more integrated curriculum and problem-based learning approach.

9

Authors: Gazmend Bojaj, Katarzyna Czabanowska, Fitim Skeraj, Genc Burazeri

Aim: Besides the health professionals’ perspective, it is equally important to assess the perceptions of the users of health care services with regard to abilities, skills and competencies of their family physicians. Our aim was to assess the level of competencies of family physicians from patients’ viewpoint in transitional Kosovo. Methods: A nationwide survey was conducted in Kosovo in 2013, including a representative sample of 1340 primary health care users aged ≥18 years (49% males aged 50.7±18.4 years and 51% females aged 50.4±17.4 years; response rate: 89%). Participants were asked to assess the level of competencies of their respective family physicians regarding different domains of the medical encounter. The self-administered questionnaire included 37 items structured into six domains. Answers for each item of the instrument ranged from one (“novice” physicians) to five (“expert” physicians). An overall summary score related to family physicians’ competencies was calculated for each participant [range: from 37 (minimal competencies) to 185 (maximal competencies)]. Furthermore, demographic and socioeconomic data were collected. General Linear Model was used to assess the demographic and socioeconomic correlates of the overall level of family physicians’ competences according to patients’ perspective. Results: Mean value of the overall summary score for the 37-item instrument was 118.0±19.7. It was higher among the younger and the low-income participants, and in patients who reported frequent health visits and those not satisfied with the quality of the medical encounter. Conversely, no sex, or educational differences were noted. Conclusions: Our findings indicate a relatively high level of competencies of family physicians from patients’ perspective in post-war Kosovo. Future studies should comprehensively assess the main determinants of self-perceived competencies of family physicians among primary health care users in Kosovo.

11

Authors: Ermira Kola, Ermela Çelaj, Iliriana Bakalli, Robert Lluka, Gjeorgjina Kuli-Lito, Sashenka Sallabanda

Aim: Additional treatments for sepsis to be administered alongside the standard therapy recommended by the Surviving Sepsis Campaign have recently undergone evaluation. Due to its anti-bacterial, anti-inflammatory and immunomodulatory properties, intravenous polyvalent immunoglobulin M (IgM)–enriched immunoglobulins (IgM preparation) has been investigated as one of these potentially valid adjunctive therapies. The aim of this trial was to assess the efficacy of an IgM preparation as adjuvant therapy in the treatment of pediatric patients with sepsis. Methods: In our study, 78 septic patients admitted to a pediatric intensive care unit (PICU) at the University Hospital Center “Mother Teresa” in Tirana, Albania, were randomized into two groups (intervention and control). All patients were treated according to standard PICU sepsis guidelines. Additionally, patients in the intervention group received the IgM preparation Pentaglobin® while patients in the control group received standard sepsis therapy, but no immunoglobulin administration. Results: The survival rate was higher in the intervention group (87%, N=34) than in the control group (64%, N=25), and this difference was statistically significant (P=0.03). Length of stay (LOS) was also significantly shorter in the intervention group. Conclusion: In this study conducted in Albania, use of an IgM preparation, in addition to standard sepsis therapy, led to a significant increase in the survival rate as well as a significant reduction in LOS compared with placebo, when administered in PICU patients with sepsis.