South Eastern European Journal of Public Health

7

Authors: Petrit Gjorgji, Jera Kruja

Aim: Our aim was to describe the trend over time and the demographic distribution of hemorrhagic stroke in Albania in the past decade. Methods: This study included all patients diagnosed with hemorrhagic stroke and admitted during the period 2004-2015 at the University Hospital Center “Mother Teresa” in Tirana (988 cases overall; 34% women; overall mean age: 57.8±19.3 years). Information about selected demographic characteristics was also collected for all study participants. Results: The proportion of older patients (≥70 years) was slightly, but not significantly, higher in women than in men (32% vs. 27%, respectively; P=0.163). Furthermore, the proportion of Tirana residents was similar in both sexes (47% in men vs. 45% in women). Overall, there was evidence of a significant linear trend over time (Mann-Kendall test: P<0.01), indicating a gradual increase in the number of hemorrhagic stroke cases in Albania for the period 2004-2015. Conclusion: This study provides useful information about the increasing trend of hemorrhagic stroke in Albania, a transitional country in Southeastern Europe which is characterized by rapid changes including unhealthy dietary habits.

9

Authors: Julia Kollcaku, Artur Kollcaku

Aim: Our aim was to assess the association of rheumatoid arthritis with socio-demographic characteristics and lifestyle factors among women in transitional Albania. Methods: A cross-sectional study was carried out in 2012-2013 including a sample of 2198 women aged 30 years and above who attended the Rheumatology services at primary health care clinics in Tirana municipality (mean age: 60.2±9.7 years; overall response rate: 95%). The diagnosis of rheumatoid arthritis was based on the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) 2010 criteria. In addition, a structured questionnaire was administered to all study participants including information on demographic and socioeconomic characteristics and behavioral factors. Binary logistic regression was used to assess the association of rheumatoid arthritis with covariates. Results: Overall, 437 (19.9%) women were diagnosed with rheumatoid arthritis (both incident and prevalent cases). In multivariable-adjusted models, rheumatoid arthritis was positively and significantly related to older age (OR=1.8, 95%CI=1.3-2.6), a lower educational attainment (OR=1.4, 95%CI=1.1-1.9), smoking (OR=1.5, 95%CI=1.1-2.0), alcohol intake (OR=1.9, 95%CI=1.2-3.1) and overweight and obesity (OR=1.5, 95%CI=1.2-2.0 and OR=1.6, 95%CI=1.2-2.0, respectively). Conclusion: This study provides useful evidence about selected correlates of rheumatoid arthritis among women attending specialized primary health care services in Albania. Health professionals and policymakers in Albania should be aware of the magnitude and consequences of this chronic condition in the adult population.

14

Authors: Luz Arenas-Monreal, Lilian E Pacheco-Magana, Celina Rueda-Neria, Josue Carrillo-Estrada, Margarita Marquez-Serrano, Laura Magana-Valladares, Marta Rivera-Pasquel

Aim: To present the results of a community initiative focused on strengthening physical activity and the consumption of fruits, vegetables and natural water while discouraging the use of highly energetic food and sugary drinks in public schools of Morelos. Methods: A quasi-experimental study with an educational initiative focused on the school community of two primary schools and two junior high schools. Pre- and-post initiative measurements were made. The study took place in the municipality of Yautepec, Morelos, Mexico, in a rural area and an urban area, from August 2010 to July 2011. Results: Water consumption among school-aged children increased from 15.1% to 20.1% and soda consumption decreased from 21.4% to 13.2%. A slight increase in the consumption of fruits and vegetables was also measured (oranges, jicamas, bananas, tomatoes, prickly pear pads, lettuces), that are accessible in the region. It was found that the supply of fresh food is limited and that high energy density foods have an oversupply in both study areas. Physical activity increased with actions such as football and dancing, in accordance with the baseline measurement. No changes were observed in the nutritional condition of school-aged children (n=150; 13.3% with overweight and 7.3% with emaciation), or in adults who presented a body mass index higher than normal, 60.2% to 88.4%. Conclusion: In addition to educational activities, schools need to implement strategies to improve the access and availability of fresh foods while limiting the access of high energy-density foods.

18

Authors: Kristina Selli, Kasia Czabanowska, Lina Danusevičienė, Rūta Butkevičienė, Ramunė Jurkuvienė, Judy Overall

Aim: This study aimed to explore and describe the barriers that elderly Lithuanians experience with respect to going to court or other institutions to defend their right not to be discriminated regarding medical care. Methods: We used a mixed methods approach due to the scarcity of information in Lithuania. First, the review of laws was done using the e-tar database and court cases were searched using the e-teismai database followed by policy analysis. Additional sources of information were identified searching Google Scholar and PubMed, as well as Google for grey literature. The keywords used were: ageism in patient care, discrimination against elderly, elderly and health (English and Lithuanian: 2000-2015). Secondly, we conducted in-depth individual interviews with 27 clients of newly-established integrated home care services: 13 elderly patients, and 14 informal caregivers. Results: This study identified five groups of barriers explaining why Lithuanian elderly are hesitant to fight discrimination in the health system. The results of the study disclose the following barriers that the elderly in Lithuania face: i) the lack of recognition of the phenomenon of discrimination against the elderly in patient care; ii) the lack of information for complaining and the fear of consequences of complaining; iii) the deficiencies and uncertainties of laws and regulations devoted to discrimination; iv) the high level of burden of proof in court cases and lack of good practices; v) the lack of a patient (human) rights-based approach in all policies and in education as well as the lack of intersectoral work. Conclusions: This study disclosed the need to: encourage training of legists and lawyers in expanding knowledge and skills in human rights in patient care; encourage training of health care professionals – the burden of leadership for this has to be assumed by universities and public health professionals; incorporate a new article in the ‘Law on the rights of patients and compensation for the damage to their health’, clearly stating where to complain in case of discrimination; create a webpage and brochures with readable and understandable information for elderly persons and their families and caregivers; establish legal consultation and mediation cabinets in health care facilities; establish an older persons’ rights protection service under the Ministry of Social Security and Labour in close cooperation with the Ministry of Health; promote sustainable results by incorporating a human rights-based approach regarding elderly persons in all policies.

5

Authors: Ulrich Laaser, Peter Schröder-Bäck

Is the group of public health professionals consistent of other professions such as physicians, nurses, social workers and the like, or should public health professionals define themselves as a distinct profession in their own rights? As of today, in Europe, public health professionals do not build an own profession.

13

Authors: Maha Nubani-Husseini, Elliot Berry, Ziad Abdeen, Milka Donchin

Aim: This study aims to assess the Palestinian girls’ dietary habits and physical activity patterns as a baseline for intervention. Methods: A cross-sectional study of grade 4 and 5 pupils (mean age: 11 years) in 14 all-girl schools in East Jerusalem, of four different types of school ownership (overall N=897), was conducted, using self-administered questionnaires and height and weight measurements. Logistic regressions were conducted to determine predictors of healthy behaviours. Results: Only 36.6% of the pupils reported eating breakfast daily, with UNRWA schools having the highest rate of daily breakfast consumption (42.6%). About 28% reported eating the recommended daily quantity of five portions of fruits and vegetables. Only 15% of the pupils reported being active at least five days a week and more than one third of the schoolchildren viewed TV for ≥4 hours a day. The prevalence of overweight and obesity was 22.2% and 7.6%, respectively, with private schools having the highest rates, 29.6% and 12.8% respectively (P=0.001). Additional predictors of overweight and obesity were: being the first child in the family, watching TV for more than four hours a day, always eating while watching TV and being physically active less than five days a week. Conclusions: Most Palestinian pupils miss breakfast, eat less fruits and vegetables than recommended and have sedentary behaviours. These findings raise serious concerns and point to the urgent need for tailored interventions.

25

Authors: Vesna Bjegovic-Mikanovic

In order to promote awareness of factors that affect social services, their quality, effectiveness and coverage, the term “governance” is frequently used. However, there is no agreement on definitions, frameworks and how it relates to the health sector. In this overview, two interrelated processes in Serbia will be analyzed: governance and management at the macro-, meso-, and micro level. Key messages are as follows: i) Continue decentralization and support to an effective national decision-making body (Health Council of Serbia) with all relevant stakeholders; ii) Reduce the well-known implementation gap and agree on a binding time frame for reforms, and; iii) Establish obligatory schemes for education and training of managers and support sustainability of state institutional capacity to teach, train and advise on a scientific basis. Keywords: governance, health sector, management, Serbia.

7

Authors: Jadranka Bozikov

Health has never been an European Union (EU) priority like agriculture, research, ecology or food safety and still remains to be first of all, if not exclusively, the responsibility of member states (MS). From the EU perspective, health is the crosscutting policy sector dominated by many other policies, especially by the “hard law” regulations of the Internal Market. In the preceding two volumes, the South Eastern European Journal of Public Health (SEEJPH) published an admirable lengthy article by Hans Stein and equally splendid supplemented commentary by Bernard Merkel recounting and evaluating developments of the EU’s health policy from the 1992 Maastricht Treaty (and even from earlier) to the present-day state and future perspectives. Although health still has very weak basis in the EU legislation, it has evolved from “non-topic” into a key area of the EU economic policy, but despite a growing competence “the unfinished story of the EU health policy” is slowly moving from declarative to operational phase in developing framework for circulation of health goods and related items within Europe and beyond.

8

Authors: Toni Yonkov Vekov, Silviya Aleksandrova-Yankulovska

Aim: The objective of this study was to provide an analysis of the factors which have a significant impact on the growth of public expenditure on medical products in Bulgaria. Methods: This research work consists of a critical analysis of the data reported by the National Health Insurance Fund in Bulgaria on the stability of the healthcare insurance model and the implementation of the budget for 2014. Results: The results from the current analysis indicate that the growth of public expenditure is directly proportional to the number of reimbursed medical products and that the pattern of prescriptions including the innovative medical products mainly for the treatment of oncological and rare diseases has a significant impact on it. Conclusion: The reasons for the increase of public expenditure in Bulgaria include the non-transparent decisions in pricing and reimbursement of the products, the lack of guidelines for presenting pharmacological evidence and the lack of legislatively-defined drug policies for the management and control of the patterns of medical prescriptions.

9

Authors: Artur Kollcaku, Julia Kollcaku, Valbona Duraj, Teuta Backa, Argjend Tafaj

Aim: The aim of this study was to assess the association of lifestyle/behavioral factors with low bone mineral density in Albanian women, a transitional country in the Western Balkans. Methods: A cross-sectional study was conducted in Tirana city in 2010 including a population-based sample of 549 women aged 35 years and above (response rate: 92%). Low bone mineral density (osteopenia and/or osteoporosis defined as a bone mineral density T-score less than -1) was assessed with a bone ultrasound device which is simple and easy to use for screening of bone mineral density in population-based studies. Binary logistic regression was used to determine the relationship of low bone mineral density with behavioral factors in this study population. Results: The prevalence of low bone mineral density in this study population was 28.4% (156/549). In multivariable-adjusted logistic regression models, low bone mineral density was positively associated with smoking (OR=4.1, 95%CI=2.2-7.4) and coffee consumption (OR=2.3, 95%CI=1.3-4.1), but inversely related to overweight and obesity (OR=0.4, 95%CI=0.2-0.7 and OR=0.3, 95%CI=0.2-0.6, respectively). Conclusion: This study offers useful evidence about the lifestyle/behavioral determinants of low bone mineral density among women in this transitional South Eastern European population. Health professionals and policymakers in Albania should be aware of the major behavioral factors which increase the risk of low bone mineral density in order to provide correct treatment and control of this condition in the general population.

10

Authors: Musa Qazimi, Luljeta Cakerri, Zejdush Tahiri, Genc Burazeri

Aim: The objective of our study was to assess the association of reaction to political and socioeconomic transition with self-perceived general health status in adult men and women in a region of Kosovo, a post-war country in the Western Balkans which has proclaimed independence in 2008. Methods: This was a cross-sectional study carried out in Gjilan region of Kosovo in 2014, including a representative sample of 867 primary health care users aged ≥35 years (419 men aged 54.3±10.9 years and 448 women aged 54.0±10.1 years; overall response rate: 87%). Reaction to political and socioeconomic aspects of transition was assessed by a three-item scale (trichotomized in the analysis into positive attitude, intermediate attitude, and negative attitude towards transition), which was previously used in the neighbouring Albania. Self-reported health status was measured on a 5-point scale which was dichotomized in the analysis into “good” vs. “poor” health. Demographic and socioeconomic data were also collected. Binary logistic regression was used to assess the association of reaction to transition with self-rated health status. Results: In crude/unadjusted models, negative attitude to transition was a “strong” predictor of poor self-perceived health (OR=2.5, 95%CI=1.7-3.8). Upon multivariable adjustment for all the demographic factors and socioeconomic characteristics, the association was attenuated and was only borderline statistically significant (OR=1.6, 95%CI=1.0-2.6, P=0.07). Conclusion: Our findings indicate an important association between reaction to transition and self-perceived health status in the adult population of the newly independent Kosovo. Policymakers and decision-makers in post-war countries such as Kosovo should be aware of the health effects of attitudes towards political and socioeconomic aspects of transition, which is seemingly an important psychosocial factor.

8

Authors: Orjola Pampuri, Katarzyna Czabanowska, Bajram Hysa, Enver Roshi, Genc Burazeri

Aim: The aim of this study was to describe the current and the required leadership competency level of health professionals in Albania, employing a recently established international instrument. Methods: A nationwide cross-sectional study was conducted in Albania in July-December 2014 including a representative sample of 267 health professionals (162 men and 105 women; mean age: 44.7±10.3 years; overall response rate: 89%). A structured questionnaire was administered to all health professionals aiming at self-assessing the current level of leadership competencies and the required (desirable) level of leadership competencies for their current job position. The questionnaire included 52 items grouped into eight subscales/domains. Answers for each item of the tool ranged from 1 (“minimal competency level”) to 5 (“maximal competency level”). An overall summary score (range: 52-260) and a subscale summary score for each domain were calculated for both the current and the required leadership competency levels. Wilcoxon signed ranks test was employed to compare the overall scores and the subscale scores of the current and the required level of leadership competencies among health professionals. Results: Mean value of the overall summary score for the 52 items of the instrument was significantly lower for the current leadership competency level compared with the required leadership competency level (138.4±11.2 vs. 159.7±25.3, respectively; P<0.001). Most of the subscales’ scores were significantly higher for the required than for the current leadership competency level. Conclusion: Our study provides useful evidence about the current and the required level of leadership competencies among health professionals in transitional Albania. Findings of this study may help policymakers in Albania to identify the gap between the required and the current level of leadership competencies among health professionals. Furthermore, findings of this study should be expanded in the neighbouring countries of the South Eastern European region and beyond.

9

Authors: Julien D. Goodman

Aim: The aim of this paper is to investigate the history of accreditation of academic public health education and understand why there is a 65 year gap between the first system in America and the uptake of accreditation in Europe. The paper intends to search for parallels and dissimilarities between the development in America and Europe and then consider if any parallels could be used for determining the future role of accreditation in Europe. Methods: The paper draws heavily upon a literature review and analysis and the examination and interpretation of primary and secondary sources. Firstly there is an exploration of the American development which is complemented by an evaluation of the developments in Europe. Results: The paper demonstrates that there are two key features required for the development of accreditation: interstate collaboration and a liberalisation or opening up of the education market. Conclusions: Since the Second World War, Europe has embraced interstate collaboration which has led to a liberalisation of certain economic markets. The future for sector based accreditation of public health education will be determined by the extent Europe pursues liberalisation and whether a competitive environment will bring into question the transparency and trust in state sponsored accreditation agencies.

10

Authors: Wilfried Heinzelmann

During the thirties of the twentieth century, German medical doctors immigrated to Turkey. Among them, was the German-Jewish paediatrician Albert Eckstein. In this short biography, the richness of the literature, written by or about Eckstein, will be presented, and altogether combined. Starting from 1937 and further on, Albert Eckstein undertook scientific surveys on children’s state of health and health care in the most remote areas of Anatolia. The value of the social-hygienic approach could be recognized, even in this early stage, starting with epidemiological analysis and followed by basic comprehensive health care. Social hygiene, as a young branch of health sciences at the time, was in the position even then to model the health care system for large population groups, at least in countries actively developing health care, as was Turkey of that time. Albert Eckstein and his co-workers, such as Ihsan Dogramaci, stand out as founders of the modern Turkish health care system today and health sciences in this country. Keywords: Albert Eckstein, Anatolia, health sciences, Ihsan Dogramaci, paediatrics, public health, social hygiene.

13

Authors: Ishmael D. Norman1, Fred N. Binka2, Anthony H. Godi3

Aim: We investigated if Geophagia is restricted to only pregnant and lactating women in Ghana. We also investigated if the key driver of Geophagia is poverty and other socio-cultural factors. Methods: This analysis was part of a broader national study of resilience among the population of Ghana (N=2,000). Regional comparisons were made possible due to the stratified and random selection of representations that were similar in characteristics such as being urban or rural, ethnicity, religion and gender. Results: It was found that Geophagia was present among both females and males and was not restricted to pregnant and lactating women. Geophagia was not driven by poverty or the lack of formal education or the presence of gainful employment. Geophagia was practiced by both urban and rural residents irrespective of religious proclivities and devotion. The assertion that Geophagia was an instinctive primordial response to gastro-intestinal disturbances was not sustained by the data in this study, although the literature review suggested such in calves and lambs. Conclusion: In order to address the potential health threats posed by Geophagia, the key cultural drivers need to be studied and understood. We also need to appreciate the shocks and stresses that create such desires. It is not a case of mental illness and it cannot be concluded that Geophagia is driven by a psychiatric disorder. This paper would be disseminated to inform policy in Ghana and beyond.

13

Authors: Wolfram Laaser

The paper summarizes the actual debate about “massive open online courses” (MOOC), a concept that swept over like a “Tsunami” to European educators and universities since its first development in 2008. The definition of the so-called MOOCs, also referred to as a “disruptive educational innovation”, however, is not very precise and has led to some irritations and scepticism. Therefore, the ideas MOOCs rely on, will be described and the pedagogical and technological background will be explained by detailed descriptions of concrete examples. After setting the scene, the factors responsible for the initial hype about MOOCs will be analyzed as well as the upcoming criticism raised against the arguments of the MOOC proponents. The model of the Gartner hype cycle serves as a useful illustration of the ups and downs of expectations related to the introduction of educational innovations. The discussion will be supplemented by a brief flash back on prior developments in distance education. Furthermore, some recent empirical data retrieved from Google Trends are presented to underline that MOOCs are already on the descent. Finally, the conditions for a survival of some specific applications of MOOCs at “the plateau of the cycle of expectations” will be outlined. In conclusion, MOOCs seem to have promoted, especially in the US, the use of online teaching and learning as well as the reflection about open educational resources. However, the blurred definition of the term MOOC combined with exaggerated expectations turned down the initial hype about a “disruptive innovative concept of teaching and learning” to a more modest consideration of its potential. Keywords: connectivism, hype cycle, massive open online courses, MOOC, online learning.